Manual of Surgery Volume I Part 31

We have met with a chronic form of arterial degeneration in elderly women, affecting especially the great vessels at the root of the neck, in which the artery is remarkably attenuated and dilated, and so friable that the wall readily tears when seized with an artery-forceps, rendering ligation of the vessel in the ordinary way well-nigh impossible. Matas suggests infolding the wall of the vessel with interrupted sutures that do not pierce the intima, and wrapping it round with a strip of peritoneum or omentum.

The most serious form of arterial _thrombosis_ is that met with _in the abdominal aorta_, which is attended with violent pains in the lower limbs, rapidly followed by paralysis and arrest of the circulation.

THROMBO-PHLEBITIS AND THROMBOSIS IN VEINS

#Thrombosis# is more common in veins than in arteries, because slowing of the blood-stream and irritation of the endothelium of the vessel wall are, owing to the conditions of the venous circulation, more readily induced in veins.

Venous thrombosis may occur from purely mechanical causes--as, for example, when the wall of a vein is incised, or the vessel included in a ligature, or when it is bruised or crushed by a fragment of a broken bone or by a bandage too tightly applied. Under these conditions thrombosis is essentially a reparative process, and has already been considered in relation to the repair of blood vessels.

In other cases thrombosis is a.s.sociated with certain const.i.tutional diseases--gout, for example; the endothelium of the veins undergoing changes--possibly the result of irritation by abnormal const.i.tuents in the blood--which favour the formation of thrombi.

Under these various conditions the formation of a thrombus is not necessarily a.s.sociated with the action of bacteria, although in any of them this additional factor may be present.

The most common cause of venous thrombosis, however, is inflammation of the wall of the vein--phlebitis.

#Phlebitis.#--Various forms of phlebitis are met with, but for practical purposes they may be divided into two groups--one in which there is a tendency to the formation of a thrombus; the other in which the infective element predominates.

In surgical patients, the _thrombotic form_ is almost invariably met with in the lower extremity, and usually occurs in those who are debilitated and anaemic, and who are confined to bed for prolonged periods--for example, during the treatment of fractures of the leg or pelvis, or after such operations as herniotomy, prostatectomy, or appendectomy.

_Clinical Features._--The most typical example of this form of phlebitis is that so frequently met with in the great saphena vein, especially when it is varicose. The onset of the attack is indicated by a sudden pain in the lower limb--sometimes below, sometimes above the knee. This initial pain may be a.s.sociated with s.h.i.+vering or even with a rigor, and the temperature usually rises one or two degrees. There is swelling and tenderness along the line of the affected vein, and the skin over it is a dull-red or purple colour. The swollen vein may be felt as a firm cord, with bead-like enlargements in the position of the valves. The patient experiences a feeling of stiffness and tightness throughout the limb. There is often dema of the leg and foot, especially when the limb is in the dependent position. The acute symptoms pa.s.s off in a few days, but the swelling and tenderness of the vein and the dema of the limb may last for many weeks.

When the deep veins--iliac, femoral, popliteal--are involved, there is great swelling of the whole limb, which is of a firm almost "wooden"

consistence, and of a pale-white colour; the dema may be so great that it is impossible to feel the affected vein until the swelling has subsided. This is most often seen in puerperal women, and is known as _phlegmasia alba dolens_.

_Treatment._--The patient must be placed at absolute rest, with the foot of the bed raised on blocks 10 or 12 inches high, and the limb immobilised by sand-bags or splints. It is necessary to avoid handling the parts, lest the clot be displaced and embolism occur. To avoid frequent movement of the limb, the necessary dressings should be kept in position by means of a many-tailed rather than a roller bandage.

To relieve the pain, warm fomentations or lead and opium lotion should be applied. Later, ichthyol-glycerin, or glycerin and belladonna, may be subst.i.tuted.

When, at the end of three weeks, the danger of embolism is past, douching and gentle ma.s.sage may be employed to disperse the dema; and when the patient gets up he should wear a supporting elastic bandage.

The _infective_ form usually begins as a peri-phlebitis arising in connection with some focus of infection in the adjacent tissues. The elements of the vessel wall are destroyed by suppuration, and the thrombus in its lumen becomes infected with pyogenic bacteria and undergoes softening.

_Occlusion of the inferior vena cava_ as a result of infective thrombosis is a well-known condition, the thrombosis extending into the main trunk from some of its tributaries, either from the femoral or iliac veins below or from the hepatic veins above.

Portions of the softened thrombus are liable to become detached and to enter the circulating blood, in which they are carried as emboli. These may lodge in distant parts, and give rise to secondary foci of suppuration--pyaemic abscesses.

_Clinical Features._--Infective phlebitis is most frequently met with in the transverse sinus as a sequel to chronic suppuration in the mastoid antrum and middle ear. It also occurs in relation to the peripheral veins, but in these it can seldom be recognised as a separate ent.i.ty, being merged in the general infective process from which it takes origin. Its occurrence may be inferred, if in the course of a suppurative lesion there is a sudden rise of temperature, with pain, redness, and swelling along the line of a venous trunk, and a rapidly developed dema of the limb, with pitting of the skin on pressure. In rare cases a localised abscess forms in the vein and points towards the surface.

_Treatment._--Attention must be directed towards the condition with which the phlebitis is a.s.sociated. Ligation of the vein on the cardiac side of the thrombus with a view to preventing embolism is seldom feasible in the peripheral veins, although, as will be pointed out later, the jugular vein is ligated with this object in cases of phlebitis of the transverse sinus.

VARIX--VARICOSE VEINS

The term varix is applied to a condition in which veins are so altered in structure that they remain permanently dilated, and are at the same time lengthened and tortuous. Two types are met with: one in which dilatation of a large superficial vein and its tributaries is the most obvious feature; the other, in which bunches of distended and tortuous vessels develop at one or more points in the course of a vein, a condition to which Virchow applied the term _angioma racemosum venosum_.

The two types may occur in combination.

Any vein in the body may become varicose, but the condition is rare except in the veins of the lower extremity, in the veins of the spermatic cord (varicocele), and in the veins of the a.n.a.l ca.n.a.l (haemorrhoids).

We are here concerned with varix as it occurs in the veins of the lower extremity.

_Etiology._--Considerable difference of opinion exists as to the essential cause of varix. The weight of evidence is in favour of the view that, when dilatation is the predominant element, it results from a congenital deficiency in the number, size, and strength of the valves of the affected veins, and in an inherent weakness in the vessel walls.

The _angioma racemosum venosum_ is probably also due to a congenital alteration in the structure of the vessels, and is allied to tumours of blood vessels. The view that varix is congenital in origin, as was first suggested by Virchow, is supported by the fact that in a large proportion of cases the condition is hereditary; not only may several members of the same family in succeeding generations suffer from varix, but it is often found that the same vein, or segment of a vein, is involved in all of them. The frequent occurrence of varix in youth is also an indication of its congenital origin.

In the majority of cases it is only when some exciting factor comes into operation that the clinical phenomena a.s.sociated with varix appear. The most common exciting cause is increased pressure within the veins, and this may be produced in a variety of ways. In certain diseases of the heart, lungs, and liver, for example, the venous pressure may be so raised as to cause a localised dilatation of such veins as are congenitally weak. The direct pressure of a tumour, or of the gravid uterus on the large venous trunks in the pelvis, may so obstruct the flow as to distend the veins of the lower extremity. It is a common experience in women that the signs of varix date from an antecedent pregnancy. The importance of the wearing of tight garters as a factor in the production of varicose veins has been exaggerated, although it must be admitted that this practice is calculated to aggravate the condition when it is once established. It has been proved experimentally that the backward pressure in the veins may be greatly increased by straining, a fact which helps to explain the frequency with which varicosity occurs in the lower limbs of athletes and of those whose occupation involves repeated and violent muscular efforts. There is reason to believe, moreover, that a sudden strain may, by rupturing the valves and so rendering them incompetent, induce varicosity independently of any congenital defect. Prolonged standing or walking, by allowing gravity to act on the column of blood in the veins of the lower limbs, is also an important determining factor in the production of varix.

Thrombosis of the deep veins--in the leg, for example--may induce marked dilatation of the superficial veins, by throwing an increased amount of work upon them. This is to be looked upon rather as a compensatory hypertrophy of the superficial vessels than as a true varix.

_Morbid Anatomy._--In the lower extremity the varicosity most commonly affects the vessels of the great saphena system; less frequently those of the small saphena system. Sometimes both systems are involved, and large communicating branches may develop between the two.

The essential lesion is the absence or deficiency of valves, so that they are incompetent and fail to support the column of blood which bears back upon them. Normally the valves in the femoral and iliac veins and in the inferior vena cava are imperfectly developed, so that in the erect posture the great saphena receives a large share of the backward pressure of the column of venous blood.

The whole length of the vein may be affected, but as a rule the disease is confined to one or more segments, which are not only dilated, but are also increased in length, so that they become convoluted. The adjacent loops of the convoluted vein are often bound together by fibrous tissue.

All the coats are thickened, chiefly by an increased development of connective tissue, and in some cases changes similar to those of arterio-sclerosis occur. The walls of varicose veins are often exceedingly brittle. In some cases the thickening is uniform, and in others it is irregular, so that here and there thin-walled sacs or pouches project from the side of the vein. These pouches vary in size from a bean to a hen's egg, the larger forms being called _venous cysts_, and being most commonly met with in the region of the saphenous opening and of the opening in the popliteal fascia. Such pouches, being exposed to injury, are frequently the seat of thrombosis (Fig. 66).

[Ill.u.s.tration: FIG. 66.--Thrombosis in Tortuous and Pouched Great Saphena Vein, in longitudinal section.]

_Clinical Features._--Varix is most frequently met with between p.u.b.erty and the age of thirty, and the s.e.xes appear to suffer about equally.

The amount of discomfort bears no direct proportion to the extent of the varicosity. It depends rather upon the degree of pressure in the veins, as is shown by the fact that it is relieved by elevation of the limb. When the whole length of the main trunk of the great saphena is implicated, the pressure in the vein is high and the patient suffers a good deal of pain and discomfort. When, on the contrary, the upper part of the saphena and its valves are intact, and only the more distal veins are involved, the pressure is not so high and there is comparatively little suffering. The usual complaint is of a sense of weight and fulness in the limb after standing or walking, sometimes accompanied by actual pain, from which relief is at once obtained by raising the limb.

Cramp-like pains in the muscles are often a.s.sociated with varix of the deep veins.

The dilated and tortuous vein can be readily seen and felt when the patient is examined in the upright posture. In advanced cases, bead-like swellings are sometimes to be detected over the position of the valves, and, on running the fingers along the course of the vessel, a firm ridge, due to periphlebitis, may be detected on each side of the vein.

When the limb is dematous, the outline of the veins is obscured, but they can be identified on palpation as gutter-like tracks. When large veins are implicated, a distinct impulse on coughing may be seen to pa.s.s down as far as the knee; and if the vessel is sharply percussed a fluid wave may be detected pa.s.sing both up and down the vein.

If the patient is placed on a couch and the limb elevated, the veins are emptied, and if pressure is then made over the region of the saphenous opening and the patient allowed to stand up, so long as the great saphena system alone is involved, the veins fill again very slowly from below. If the small saphena system also is involved, and if communicating branches are dilated, the veins fill up from below more rapidly. When the pressure over the saphenous opening is removed, the blood rapidly rushes into the varicose vessels from above; this is known as Trendelenburg's test.

The most marked dilatation usually occurs on the medial side of the limb, between the middle of the thigh and the middle of the calf, the arrangement of the veins showing great variety (Fig. 67).

There are usually one or more bunches of enlarged and tortuous veins in the region of the knee. Frequently a large branch establishes a communication between the systems of the great and small saphenous veins in the region of the popliteal s.p.a.ce, or across the front of the upper part of the tibia. The superficial position of this last branch and its proximity to the bone render it liable to injury.

[Ill.u.s.tration: FIG. 67.--Extensive Varix of Internal Saphena System on Left Leg, of many years' standing.]

The small veins of the skin of the ankle and foot often show as fine blue streaks arranged in a stellate or arborescent manner, especially in women who have borne children.

_Complications._--When the varix is of long standing, the skin in the lower part of the leg sometimes a.s.sumes a mahogany-brown or bluish hue, as a result of the _deposit of blood pigment_ in the tissues, and this is frequently a precursor of ulceration.

_Chronic dermat.i.tis_ (_varicose eczema_) is often met with in the lower part of the leg, and is due to interference with the nutrition of the skin. The incompetence of the valves allows the pressure in the varicose veins to equal that in the arterioles, so that the capillary circulation is impeded. From the same cause the blood in the deep veins is enabled to enter the superficial veins, where the backward pressure is so great that the blood flows down again, and so a vicious circle is established.

The blood therefore loses more and more of its oxygen, and so fails to nourish the tissues.

The _ulcer_ of the leg a.s.sociated with varicose veins has already been described.

_Haemorrhage_ may take place from a varicose vein as a result of a wound or of ulceration of its wall. Increased intra-venous pressure produced by severe muscular strain may determine rupture of a vein exposed in the floor of an ulcer. If the limb is dependent, the incompetency of the valves permits of rapid and copious bleeding, which may prove fatal, particularly if the patient is intoxicated when the rupture takes place and no means are taken to arrest the haemorrhage. The bleeding may be arrested at once by elevating the limb, or by applying pressure directly over the bleeding point.

_Phlebitis and thrombosis_ are common sequelae of varix, and may prove dangerous, either by spreading into the large venous trunks or by giving rise to emboli. The larger the varix the greater is the tendency for a thrombus to spread upwards and to involve the deep veins. Thrombi usually originate in venous cysts or pouches, and at acute bends on the vessel, especially when these are situated in the vicinity of the knee, and are subjected to repeated injuries--for example in riding.

Phleboliths sometimes form in such pouches, and may be recognised in a radiogram. In a certain proportion of cases, especially in elderly people, the occurrence of thrombosis leads to cure of the condition by the thrombus becoming organised and obliterating the vein.

_Treatment._--At best the treatment of varicose veins is only palliative, as it is obviously impossible to restore to the vessels their normal structure. The patient must avoid wearing anything, such as a garter, which constricts the limb, and any obvious cause of direct pressure on the pelvic veins, such as a tumour, persistent constipation, or an ill-fitting truss, should be removed. Cardiac, renal, or pulmonary causes of venous congestion must also be treated, and the functions of the liver regulated. Severe forms of muscular exertion and prolonged standing or walking are to be avoided, and the patient may with benefit rest the limb in an elevated position for a few hours each day. To support the distended vessels, a closely woven silk or worsted stocking, or a light and porous form of elastic bandage, applied as a puttee, should be worn. These appliances should be put on before the patient leaves his bed in the morning, and should only be removed after he lies down at night. In this way the vessels are never allowed to become dilated. Elastic stockings, and bandages made entirely of india-rubber, are to be avoided. In early and mild cases these measures are usually sufficient to relieve the patient's discomfort.