3.

In sacular aneurism it is often possible to suture the wall of the sac, obliterating it without interfering with the circulation of the artery.

4. It is also possible to cure fusiform aneurism in some favorable cases similarly by suturing the enfolded walls of the sac without interfering with the current of blood in the affected vessel.

5. In the Matas operation the surrounding structures in the operative field are undisturbed, especially the satellite veins and the nerves which are frequently adherent to the sac, thus obviously lessening the danger of gangrene, or of atrophic changes in the extremity or distal parts.

VARICOSE VEINS AND THEIR SURGICAL TREATMENT.

BY SAMUEL GILBERT GAY, M. D., OF SELMA.

Grand Senior Counsellor of The Medical Association of the State of Alabama.

When we glance at the anatomy of these veins, with their thin walls and largely up-hill return of blood to the heart, assisted by their many valves, we can readily understand the frequent and extensive disease of these vessels.

Varicose veins occur most frequently in the female, between the ages of twenty and forty years. They are usually easy to recognize, for they are found chiefly in the superficial vessels, but may be difficult when the deep vessels only are involved. In spite of its frequency, the etiology is still rather obscure. An abundant amount of blood being forced into the veins or some impediment to its return flow, such as an occupapation requiring much standing, tight garters, heart and lung diseases, tumors in the pelvis and abdominal cavities, ascites, pregnancy, heredity, and racial peculiarities, may be determining factors in this disease.

The writer recently saw a case in consultation, where a railroad accident, received some months before, was the predisposing cause. The patient a gentleman-and his physician, stated positively that no such condition existed before the accident.

Syphilis and tuberculosis, directly or indirectly, must be seriously considered as etiological factors in this disease.

Varicose veins are often associated with, or are a sequel to, phlebitis thromosis or emboli of the large venous trunks, these being often complications of the acute infectious diseases, as typhoid fever, sepsis following surgical operations, and childbirth.

At first, the veins are uniformly dilated, but as the disease advances they become elongated and sometimes very tortuous. The greatest dilatation is situated just above the valves, they being often destroyed or rendered incompetent to perform their functions on account of dilation.

The vein walls are very much thinned, but may be thickened or fibroid degenerations may occur. The outer coat sometimes becomes extremely thin, and allows the internal coat to protrude in more or less lobulated masses. The coverings to these masses become so thin that rupture may take place in the deep or superficial veins, causing, sometimes, alarming hemorrhages, especially when superficial vessels are ruptured. The writer saw this take place in a stout, elderly lady, after she had retired for the night; and also the same condition in a male of small stature. In these cases, the walls were so thin that rupture took place while they were at rest.

Dilation may be fusiform or sacculated, the sluggish circulation or temporary stasis in their dilation conduces to coagulation. The clot may organize and the nodules become obliterated. Calcium salts may be deposited to form the so-called phleboliths often felt as hard masses under the skin.

Beck calls attention to the occurrence of osseous degeneration or calcification of the veins, and to the fact that real osseous degeneration of the venous walls does not seem to have received previous attention, demonstrating a case by a skiagraphic illustration. Frequently their irritation causes extensive coagulations, commencing from a single nodule, and extending through the diseased trunk.

Large areas may be thrombosed, sometimes involving the entire internal saphenous, or femoral vein.

It was my opportunity to observe a case where thrombosis of the entire internal saphenous vein took place; this was a case of a white male, 28 years of age, farmer; as a result of this, he was practically an invalid. Operation was advised and accepted. I first dissected down upon the internal saphenous, just below its ring or opening, keeping in mind the great danger

of embolism from a disturbed thrombus. I ligated well above that condition. The vein was dissected out from the point of ligation en masse, to just above the ankle of the left leg. This long incision healed by primary union, the patient returned to his home in two weeks, since which time he has enjoyed good health and has been able to do his usual amount of farm work for more than a year.

Trophic disturbances gradually develop from the effects of the retarded and obstructed venous circulation, leading to the most frequent sequences of edema, hemorrhage, thrombosis, eczema and ulceration. The muscles become relaxed and flabby so that the patient is easily fatigued, being unable to walk or stand for any length of time.

The writer recalls a case of a gentleman who was more than fifty years of age, whose occupation (as a repairer of saws for a large lumber mill) required his standing constantly during his working hours. On account of the pain and discomfort caused by these varicose veins in both legs, he was becoming very despondent, fearing he would soon be required to give up his position. An operation was done more than two years ago, and in a conversation with him recently, he stated that he was now able to stand all day and do his work with comfort.

Discomfort varies greatly, and does not always correspond to the amount of visible disease. Extensive involvments of large areas of the finer veins produce more discomfort, apparently, than dilatation confined to the larger branches. This was observed in the case mentioned above.

When we find the patient has more pain than external appearances indicate, especially if muscular cramps are complained of, we should suspect and look for involvement of the deep veins. We should also keep in mind secondary neuritis and acute inflammation. The latter is usually accompanied by thrombosis, and it is not always possible to determine which is primary. The inflammation usually disappears, but may advance to suppuration. Under rest and ice, or cold applications, until the acute symptoms disappear, after which the removal of a section or sections of involved vein, we should expect recovery.

It is easy for the functions of the veins to become partially or wholly destroyed beyond the possibility of relief or cure by other than surgical treatment. The only treatment to be considered, save in exceptional cases, is the surgical.

Before considering this, we should make a systematic and

thorough examination of the patient, in order to discover if there are any other causes that may bear directly or indirectly upon this disease. If deemed necessary, we should improve the general health of the patient by tonics, rest in open air, with good and nutritious diet. Proper attention should be given to the bowels and suitable treatment to any other organ that may be impaired. All obstruction to the return circulation should be removed, if possible.

We should remember, when dealing with varicosity, that we have a diseased condition of these vessels and sometimes septic infection; therefore, we should be more careful in the details of asepsis, if possible, than in abdominal work. The operation, if aseptically done, is not generally a serious one, but should sepsis occur, it may become most serious.

The cases in which it is considered justifiable to operate, are: I. When the veins give rise to pain and inconvenience. 2. When hemorrhage takes place, or is threatened. 3. When ulceration threatens, or is present. 4. When a patient's occupation is, in any way, interfered with, or if he wishes to enter public service. It has been found, after extensive experience among the troops in the Russian army, that new recruits with even slight degrees of varicose veins in the legs, are not accepted for military service if the saphena magna is painful from this cause; for such a condition is liable to become acute, and finally severe and chronic, necessitating the dismissal of the recruit. Another reason for rejection is, that varicose veins are usually a sign of some constitutional affection, or tendency to arteriosclerosis, or neuritis. 5th and last cause; when the patient becomes sensitive about the disease, and develops a melancholic condition.

The writer recalls the case of an energetic young man whose business aspirations were much hampered from this condition in both legs, with ulceration of the right. He came to me and requested that something be done for his relief, stating that he preferred death to his condition, and that he had considered self-destruction if he could not be benefited. Operation was suggested and accepted, first on his right leg, it being more extensively involved. The internal saphenous was ligated just below its opening and removed for about six inches. The skin and all fascia down to the muscles were divided for about twothirds of the circumference of the calf, and both ends of the vessels ligated. The ulcer was excised and immediately skin grafted. The leg was put at absolute rest in a plaster cast.

The recovery was good, the ulcer healed and remained healed for the first time in years. His mental condition rapidly improved and he returned to his work with renewed interest. His relief was so great that he returned later and had an extensive excision done on the left internal saphenous. After a prompt recovery he enjoyed good health for more than a year. I received a most cheerful letter from him recently, expressing a willingness to come to this meeting (more than a hundred. miles) and present himself.

In speaking of operations, I refer only to the open method. All other methods of surgical interference should be considered from historical interest only. For special operations, I refer my hearers to any of the recent text books on surgery. The operation which gives best and most permanent results, is that in which not only the varices are removed, but also the trunk of the internal saphenous in the thigh. The result will more.certainly be permanent if this portion of the vein is very extensively resected. No doubt, re-currencies may develop even after the operation, on account of anastomoses gradually developing from the upper end of the internal saphenous, which is allowed to remain. But results have not, hitherto, shown a case of recurrence. Some operators prefer to tie the veins in

many places.

The writer's personal experience has been, that the more extensive the resection, and the fewer ligatures applied, the less is the danger of sepsis, and the results are more satisfactory. Some surgeons report that ligation alone has given twenty-one per cent. of successful results, while resection gave seventyeight per cent. We can more easily locate the veins at the time of operation, if we, on the previous day, while the veins. are distended, mark them with nitrate of silver to allow of darkening.

It will be noted that nothing has been said about treatment by elastic pressure, or support, the writer taking the position that such treatment should not be recommended, except as a temporary relief, or in cases which cannot, or will not, come to operation; or when operation from some cause is contraindicated, as in severe heart or kidney diseases and varicosity of the deep veins. After the operation, an elastic stocking should be worn for a few months to equalize the blood pressure in the remaining vessels.

In conclusion, allow me to insist that more of these cases be given the benefit of a cure by operation. You can never prom