VARICOSE VEINS.
Palliative treatment is all that is required in most cases. Prolonged standing, the use of garters, chronic constipation, and anaemia or plethora should be guarded against, and everything calculated to improve the general health and diminish venous engorgement must he insisted upon.
Support to the dilated vessels by means of a properly applied rubber bandage affords the hest treatment for this condition. The bandage should be applied from the toes to the upper limit of the varix before the patient assumes the vertical position in the morning, and it should not be removed till he lies down in bed at night. Where the skin gets tender under its use a perforated rubber bandage may he employed, hut the elastic webbing described upon p. 1014 meets every requirement. These appliances are superior to the old-fashioned elastic stocking, which should never be recommended unless the patient refuses to take the trouble of employing a rubber bandage. The writer has obtained good results by the application of the elastic webbing or a pure rubber bandage over an ordinary silk or cotton stocking. Each morning the limb should be well douched or sponged with cold water and rubbed upwards before the bandage is applied.
On p. 1014 under Ulcer is described the use of the Gelatin bandage and the modified method of employing it as recommended by Jamieson and Low.
The supporting appliance made by Harris of Birmingham and known as the " Ambient " is a great advance on the old elastic stocking; it is easily and readily applied, the pressure being graduated by the tightness of the hieing. Tt is constructed on the principle of Murphy's Leg Corset, in which inelastic pressure is employed.
Surgical procedures are indicated when bandaging fails, when the varicosities are above the knee, and when recurring attacks of phlebitis have been experienced, or when the patient wishes to escape from the trouble inherent on constant need of bandaging.
The most efficient operation for the treatment of varicose veins is that practised by A. B. Mitchell. The insists upon the importance of removing the entire saphenous vein. Ile divides the internal saphenous
vein below the saphenous opening, after making a short transverse incision in the thigh, and applies an iodine catgut ligature to its proximal end. By pulling on the forceps attached to the distal end the line of the vessel beneath the skin is easily located by the index-finger of the other hand. A t-inch transverse incision is next made 5 inches down the thigh and the vein picked up and clamped with forceps; by drawing alternately on the upper and lower forceps in a see-saw fashion the vein is pulled up and down and its tributary branches torn. The upper forceps are now removed, and by traction on the lower the trunk of the vein is pulled out through the lower wound and cut off. Further in cisions are made and the above manceuyres executed till the knee is reached, when the wounds are sutured and sealed up with a mixture of Tr. Benz. Co. and Flexile Collodion to prevent infection whilst the leg is being operated on.
The vein is next pursued below the knee in a similar manner, the in cisions being closer together and vertical, but not exceeding inch, and made over every branch of dilated vein, great care being taken not to cut into the varices which here lie in contact with the skin. The entire vein is thus thoroughly eradicated down to the ankle, no intermediate portion lying between the incisions left.
The short vertical incisions below the knee require no suturing as a rule, but are closed by a firm bandage applied over sterile which will not require removal for a week.
Finally, after removal of the bandage, the leg and thigh receive a coating of Unna's Ichthyol Gelatin, a new bandage is applied, and the patient is able to leave his room within a fortnight after the operation. Mitchell claims for this operation the great advantages arising from no ligatures being left in the limb save the one on the proximal end of the saphenous trunk. The results are permanent. the recovery rapid, and the dangers of thrombosis nil, owing to the complete removal of the vein and its tributaries.