AN INQUIRY 
INTO THE 
PATHOLOGY AND TREATMENT OF VARICES. 
BY JOHN WATSON, M.D. 
Surgeon to the New York Hospital. 
NEW YORK. OCTOBER 17, 1842- AN INQUIRY, &o- 
To determine the safest and most effectual mode of curing varices, is a 
question that of late has excited much attention. Prior to the experiments 
of Sir Everard Home by the application of a ligature to the veins, the 
pathology of these vessels had only begun to excite attention. Since that 
period the subject has been more thoroughly investigated, and has led to 
greater caution in interfering with the affections now under consideration. But 
notwithstanding the unfavourable results that have so frequently marked the 
various modes of treating varices, those most familiar with the sufferings, 
dangers, and sometimes fatal consequences attending these diseases when 
allowed to progress, still look upon the question of their treatment as one of 
absorbing interest. 
With a view to throw some further light upon this inquiry, it will be my 
object in this paper to offer some remarks upon the pathology of varices: 
to review in a summary way the various modes of treatment hitherto em- 
ployed for the cure of them; and to give the details of the operative proce- 
dures to which I have myself resorted. 
I shall pursue the subject in the order in which it has grown upon me; 
namely, by the study of individual cases. 
Part First.—Cases and Comments. Case I.—Mr. M., a teacher, about 
30 years of age, came to the city from Orange county, to be cured of a 
troublesome varicose affection in his left leg, of several years duration; and 
of late so painful and annoying, as to prevent him from attending to his 
usual occupation. 
The disease involved the whole of the great saphena, but was most 
marked in the internal saphena and its principal branches, many of which 
were excessively dilated, contorted, and nodulated. 
The operation proposed by Dr. Stevens, with whom I saw the patient, 
and which he performed May 27th, 1839, was the sub-cutaneous division 
of the saphena major, just below the middle of the thigh. The vessel was 
raised with the integuments covering it, and divided from beneath outward, 
without wounding the skin except at the point of puncture. A compress and 
roller were afterwards applied, and the patient was directed to keep the limb 
at rest in the horizontal position. 
June 3d. The dressings were removed for the first time. The wound 
had healed; there was still slight ecchymosis around it, but neither swelling 
nor inflammation. The varices, when the patient put his foot to the ground, Watson on the Pathology and Treatment of Varices. 
37 
instantly reappeared, and were as well marked as before the operation; 
although perhaps not quite so large. The course of the blood did not ap- 
pear to be interrupted at the point of incision. The edges of the wound in 
the vessel had in all probability united by adhesion, without obstructing its 
calibre; as they almost invariably do after ordinary venesection. 
4th. The patient being anxious for more effectual relief, Dr. S. at my 
suggestion, performed the following operation: 
An incision about an inch and a half long was carried through the skin, in 
the course of the vein, a few inches above the knee. After thus exposing 
the vessel it was raised on a probe and about half an inch of its calibre was 
excised. Free hemorrhage followed from both extremities of the cut. 
Slight pressure after a few moments put a permanent stop to the bleeding 
from the upper part of the vessel; that from the lower part was arrested by 
the application of a ligature. The edges of the wound were then drawn 
logether by adhesive straps, and a compress and roller were applied as on 
the former occasion. 
13th.. The ligature came away; the wound was suppurating slightly; the 
surrounding parts were free from inflammation. 
23(/. The wound had cicatrised; the bandage was entirely removed. The 
varices appeared to be effaced, except at the inner and upper part of the leg, 
where the principal swellings had existed. The bandage was replaced, and 
the limb again put in the horizontal position. 
28th. The patient returned to the country much relieved, but not entirely 
cured; the principal varix at the upper part of the leg being still apparent, 
and the blood filling the vessel even up to the level of the cicatrix. 
I saw this patient several months after the operation. The varices had 
reappeared in all the branches of the internal saphena; but were less dis- 
tended than they had formerly been, and gave him less uneasiness. 
The first point established by this case is,—that the simple subcutaneous 
division of a varicose vein, is not a certain means of obstructing the passage 
of the blood through the vessel. This fact might, indeed, have been de- 
duced from the results of ordinary phlebotomy. Every practitioner is aware 
that the arms of his patients may be marked by numerous cicatrices, the re- 
sult of repeated venesection in the same vessel, and almost all at the same 
point, without diverting the current of the blood from its natural channel, or 
diminishing the calibre of the vein; although many of these lancet wounds 
may have been free in the division of integument, and of sufficient depth 
and extent to have completely divided the vessel; and all of them, as in this 
case, followed by compression. 
The second deduction, and one perhaps of more importance, is that the 
excision of a considerable portion of a varicose vein, although it effectually 
interrupts the course of the blood at a given point, does not necessarily pro- 
duce an obliteration of the vessel, either above or below that point; and is 
not a certain means of curing varices, either in the vessel itself, or in any of 
its branches. 
Case II.—Z. P. Esq., of Green county, N. Y., a gentleman about 56 
years of age, tall and of spare habit, but accustomed to vigorous exercise, 
caine to the city for advice on account of extensive varices in all the superfi- 38 
Watson on the Pathology aad Treatment of Varices. 
[Jan. 
cial veins of his right leg. Having in a measure failed to effect a cure in the 
foregoing case, it was not thought advisable to repeat the operation; and as 
the starched bandage was much in vogue about this period, and had recently 
been tried in a few similar cases at the Bellevue Hospital, I took occasion to 
try it on this patient. The leg was accordingly encased with a moderate 
degree of tightness in the starched apparatus, and the patient was directed 
to walk about as usual, and to allow the bandages to remain upon the limb 
as long as they would retain their proper position, provided they gave him 
no uneasiness. 
I saw this gentleman about a year afterwards. He had worn the bandages 
about three months, during which time he had exercised much on foot, and 
had experienced much relief, and, as he said, comfort, in the use of the ap- 
paratus. But after its removal the varices were found to be as large and 
troublesome as ever. At thi3 time he applied to me for advice on account 
of a pruriginous eruption with which he had been long affected, and which 
appeared to have some connection with the varices. 
From the trial of the starched bandage in this case, I was induced to be- 
lieve that, as a palliative measure, it possesses some advantages ver the 
ordinary roller, as also over the military gaiter and laced stocking. When 
properly applied, the support rendered by this bandage is uniform; it is not 
readily disarranged, and may be worn without changing, for several weeks 
together. 
Case III.—Thomas Fitz Herbert, of Ireland, wire-worker, aged 40, was 
brought into the New York Hospital, late on the evening of May 17th, 
1841, in a state of extreme exhaustion from loss of blood. He had long 
been subject to varicose veins, accompanied with an ulcer on one of his legs. 
While passing along Water street in the dark, he struck his diseased leg 
against a cellar door. The injury though slight in itself, gave rise to he- 
morrhage from one of the enlarged vessels; and before his friends had time 
to bring him to the Hospital, (no measures having previously been taken to 
arrest the discharge), he had lost so much blood as to be beyond the power 
of recovery. He died in a few minutes after admission. 
The result of this case is sufficient to prove that varicose veins of the 
lower extremity constitute something more serious than “ a trifling inconve- 
nience;” and to justify the cautious and enlightened surgeon in further 
efforts to discover some certain mode of treating these affections, or to 
modify old modes in such a way as to render them more simple and effi- 
cacious. 
Case IV.—-Mr. W., of Plainfield, N. J., hatter, aged 35, had for several 
years been troubled with an ulcer on his right shin, and a varicose state of 
the veins of the leg. On the 27th of May, 1841, he called upon me for ad- 
vice. The integuments for some space around the sore were of a deep 
purplish hue almost black; the ulcer was small but irritable, and seated in 
the midst of an old cicatrix. The whole limb was somewhat swollen, and 
the external saphena, and its branches as low down as the foot, were en- 
larged, nodulated, tortuous, and painful to pressure: the internal saphena 
was unaffected. The varices were of more recent date than the ulcer, and 
appeared to have much influence in preventing it from healing. The disease 1843.] 
Watson on the Pathology and Treatment of Varices. 
39 
prevented the patient from pursuing his occupation, and he was anxious to 
submit to any treatment likely to afford him permanent relief. 
1 directed simple dressings to the ulcer, a roller to the limb, with repose 
in a horizontal position; and if at the end of a month the ulcer still per- 
sisted, I suggested the propriety of an operation upon the veins. The pal- 
liative treatment was pursued for the time specified, with little or no other 
effect than a slight diminution in the size of the ulcer. On the 17th of June 
l was summoned to Plainfield to perform the operation. 
The patient being in a recumbent position, a fillet was applied around the 
lower part of the thigh for the purpose of rendering the vessels turgid. An 
incision about an inch and a half long was then made in the course of the 
external saphena, near the outer and lower edge of the popliteal space, with 
a small straight bistoury. After exposing the vein it was elevated on a probe, 
and thus left for the instant. A second incision was next made over a large 
branch of the same vessel, at an anastomosing point near the middle of the 
leg, and a probe inserted beneath the vein as at the first point. The same 
procedure was repeated on an enlarged vein just below the ulcer, above the 
ankle, at another point of anastomosis; and lastly, on a dilated vein upon 
the dorsum of the foot. 
After thus completing the first steps of the operation, the fillet was re- 
moved. And while pressure was applied by the fingers of an assistant in 
the course of the vein, both above and below the last incision, with a pair 
of forceps I raised the vessel from the bottom of the wound, and with a pair 
of scissors removed about half an inch of its substance. No hemorrhage 
followed the excision of the vein. The same procedure was repeated on 
all the other portions of veins that had been exposed by the incisions, with- 
out giving rise to any bleeding. The edges of the wounds were then drawn 
carefully together by adhesive straps, and each wound covered with a com- 
press. Finally, the whole limb was enveloped in a roller from the foot to 
the middle of the thigh. The patient was now directed to remain on his 
back for at least a week, and for the first twenty-four hours to be kept 
under the influence of anodynes. On the day following the operation, the 
roller, giving him no uneasiness, was coated with paste; and another roller 
placed over it, and also pasted, so as to render the whole dressing firm, and 
to prevent it from wrinkling. 
The coats of the two uppermost pieces of vein that had been removed, 
were at least half a line in thickness. The inner tunic was of a pale flesh 
colour, and by the contraction of the vessel, thrown into longitudinal rugae,— 
giving it the appearance of muscular fibre. The middle coat, more hyper- 
trophied than the rest, was of a cartilaginous colour and consistence. The 
two lower pieces of vein, though dilated, were more nearly of a healthy 
structure; the inner lining, glossy and of its natural colour; the middle coat, 
sufficiently hypertrophied to prevent the vessel from collapsing. 
No untoward symptoms followed the operation. The bandages were re- 
moved on the eighth day. The incisions had already united, the varices 
had been effaced, and the ulcer had cicatrised. To prevent a recurrence of 
the disease, before allowing the patient to use the limb, the starched ban- 
dages were reapplied. He continued to wear them while attending to his 
business, for nearly three months, and then left off every sort of dressing. 
I last heard from this patient in April, 1842. He had had no return either 
of the ulcer or the varices; and the discolouration of the integuments around 
the cicatrix of the ulcer had nearly disappeared. 
The treatment in the case now described being somewhat original; its 40 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
simplicity, its efficacy, and the promptness and durability of the cure, gave 
me considerable satisfaction; and determined me to pursue the operation, or 
to improve upon it in other cases. I had been led by reflection to its adop- 
tion after perusing the able memoir of M. Bonnet on the subject of varices, 
in which he undertakes to show that in order to their effectual cure, it is 
necessary in most cases, to interrupt the course of the blood through the dis- 
eased vessels, at numerous points along the limb. The suggestion is not 
new, inasmuch as it had been practised upon at least as early as the days of 
Celsus; and in modern times by Hunter, Brodie, Davat, and others. But 
it is of more importance than would appear from the writings of any of these 
authors; and M. Bonnet has presented it in a manner so forcible, as almost 
to deserve the credit of originating it. 
Mr. Bonnet’s modes of treatment in detail, however, I did not feel justified 
in imitating, sufficiently aware that there are serious objections against the 
pins and twisted sutures, as well as against the caustic, employed and 
recommended by this author, and that without having determined the fact by 
experiment, the operation by numerous excisions appeared to have many 
advantages over these. 
In the first place it appeared to be more thorough and permanent in its 
effects; the pins as well as caustic often failing to obliterate the vessel, or to 
obliterate it permanently; and sometimes even failing to embrace it. 
Secondly, the immediate effects of the operation by excision did not appear 
likely to be serious, or attended with much pain; the wound usually healing 
by adhesion, or after slight suppuration. Whereas, by the other methods, 
sloughing and ulceration are necessary consequences. Thirdly, the cure 
appeared to be more rapid. Fourthly, by leaving the vessel in the same 
condition as after amputation or other ordinary operations involving a divi- 
sion of the veins; the process of excision, although it furnishes no immunity 
against either suppurative or erratic phlebitis, must almost of necessity be 
less frequently the cause of such accidents. 
Case V.—William Sutherland, of Canada, boatman, aged 21, was ad- 
mitted into tbe New York Hospital, May 5lh, 1842, with an ulcer about as 
large as a dollar on his left leg, produced three years previously by an in- 
jury; and with a varicose condition of the internal saphena and its principal 
branches, on the same leg, existing two years. 
After admission he was kept in bed, with simple dressings to the sore and 
a roller over the whole limb, for about two weeks; by which time the ulcer 
had cicatrised. On the 21st of May he underwent an operation for the cure 
of the varices. 
The steps of the operation were the same as those detailed in case fourth. 
The veins were exposed, and the exsection of a portion of the vessels was 
effected at four different points, commencing just below the knee, and pro- 
ceeding downward, as in the former case. The principal peculiarities met 
with in this instance, independent of the loss of blood to the amount, per- 
haps, of ten or twelve ounces, were, first, that the veins lay deeper and 
were covered with a much denser layer of fascia; second, that at the upper- 1843.] 
Watson on the Pathology and Treatment of Varices. 
41 
most incision, in the course of the internal saphena, there was a concomitant 
vein lying over the principal one, that this smaller vessel was first exposed 
and taken for the main trunk; and that the principal vessel was separated 
from it by a very dense fascia, and was not exposed until after the division of 
the concomitant vein. The coats of all the vessels were found to be even 
thicker than in the foregoing case; and their inner lining was also corrugated 
longitudinally, and redder than natural. 
The mode of dressing the wounds after the operation, and the subsequent 
treatment of the case, were in all respects the same as in the other case. 
The bandages were not disturbed until the end of the second week. On 
removing them we found the patient’s limb free from varices, and all the 
wounds united by adhesion. In a day or two afterwards the bandages were 
reapplied, and the patient was allowed to walk about. There was no ap- 
pearance of any return of the disease at the date of his discharge, June 19th. 
Any attempt to treat the foregoing case either by the use of pins or of 
caustic, must, as appears to me, almost of necessity have failed; first, from 
the fact that the internal saphena lay so deeply as not to have been readily 
discovered, and much less reached by either of these means; and secondly, 
from the fact that the concomitant vein which lay above it, and was at first 
mistaken for it, if obliterated by either of these modes of treatment, would 
have a tendency rather to increase than to diminish the amount of blood cir- 
culating through the principal vessel, and thus to aggravate the disease 
rather than to cure it. 
Case YI.—Catharine Fitzgerald, of Ireland, a cook, single, aged 46, was 
admitted in the New York Hospital, March 5th, 1842, with numerous 
varices on both legs, but mueh the worst on the left leg. The disease was 
attended with an cedematous condition of both limbs< and involved the 
smaller as well as the larger vessels. The minute veins of the integuments 
were in numerous patches so much dilated as to render the surface purplish 
and arborescent. The disease had existed about five years. In consequence 
of the oedema and the burning and heavy sensation in the limbs when she 
remained standing for any length of time, she was unable to attend to her 
occupation. Her countenance was sallow, she was of a lymphatic tempera- 
ment; and on closer examination I ascertained that for some months past she 
had suffered from a too frequent and profuse menstrual discharge, her 
periods returning noon her at the end of every second week. 
Deeming the case, from this circumstance, an improper one for surgical 
interference, I directed her to be transferred to the medical department of the 
Hospital. Here under an appropriate course of treatment, (of which, how- 
ever, 1 have no minutes), she was relieved of this difficulty; and about the 
first of May, she returned to the surgical department, to be relieved of her 
varices. 
The operation was performed on the 21st of May, on the same day as in 
the preceding case. There were five different incisions, two of which were 
on the external saphena and its branches, and three on the internal saphena 
and the vessels going from it, at their anastomosing points; all of them below 
the knee. The veins, though much dilated, were not so much hypertro- 
phied as in either of the former cases, and their inner lining was smooth and 
of its natural appearance. They lay immediately beneath the skin, imbed- 
ded in adipose tissue, and without the dense fibres or cellular coverings 42 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
described in the former case. The patient lost little or no blood during the 
operation. The subsequent treatment was as before described. That is to 
say, the patient, in order to allay the pain of the incision, and to prevent 
constitutional excitement, was kept for the first twenty-four hours, under the 
influence of anodynes. About the fourth day, the patient having hitherto 
been free from pain or excitement, a small circumscribed swelling was ob- 
served about the middle of the thigh, attended with slight pain and redness, 
and lying in the course of the saphena major. A blister was applied over 
this; and after a dose of castor oil had operated, the patient was again put 
upon the use of anodynes. No further inconvenience ensued, the swelling 
gradually subsided, but left an indurated spot which continued for some 
weeks. 
The bandages were removed, and the incisions found to be cicatrised, at 
the close of the second week. The varices were now no longer visible, 
except that a few of the cutaneous venules were still apparent, giving to the 
skin the arborescent appearance already noticed. The bandage was again 
applied, and the patient allowed to use the limb. She remained in the 
hospital up to the 16th of July, using the limb every day without any dis- 
position to a return of the disease. She would have submitted to an opera- 
tion in the vessels of the other limb, had I thought the severity of the disease 
there sufficient to have required it. 
The main peculiarities of this case were, that both the internal and exter- 
nal saphena and their branches were involved; and that this circumstance, 
contrary to the opinion of Bonnet, gave rise to no inconvenience. Other 
circumstances more or less worthy of notice, were that the limb was free 
from ulceration; that vast numbers of minute venules in all parts of the leg 
and foot, were proportionally as much dilated as the principal vessels, if not 
more so; that though tortuous, lengthened, and dilated, the vessels were not 
proportionally thickened, their coats having apparently suffered from simple 
passive enlargement. From the number of vessels involved, and from the 
extension of the disease to the ultimate branches of the veins, the operation 
was undertaken with less confidence of ultimate success, than the result of 
the case would have justified. 
Case VII.—Michael Neale, of Ireland, seaman, aged 29, was admitted 
June 21st, L842, with a small ulcer on each shin, and varices on both legs. 
He stated that about five years previous, while in the East Indies, he had 
been confined to his bed by sickness for several months; after which, in at- 
tempting to walk, his limbs became swollen, and the varices soon afterwards 
appeared. Those on the left leg having been the largest from the first, were 
the first to give rise to ulceration. The ulcer on the other leg had existed 
about three years. Both of these sores had several times cicatrised and as often 
reappeared. Soon after the first occurrence of the varices on the left leg, an 
attempt was made to cure them by a deep longitudinal incision through the 
diseased veins near the upper part of the leg. The wound gave issue to 
very free hemorrhage, which returned every time the patient put his foot to 
the ground, for several days subsequently; but had no effect in diminishing 
the disease. Both legs have ever since continued swollen; the varices are 
gradually enlarging. The distress attending these frequently obliges him to 
remain on his back, and neglect his business. 1843.] 
Watson on the Pathology and Treatment of Varices. 
43 
After his admission he was for a few days confined to his bed, with 
simple dressings to the sore, and a roller over each leg; and with laxatives 
and low diet to relieve any inflammatory tendency, and prepare him for the 
operation. 
On the 25th of June, the operation was performed on his left leg. The 
varices were so numerous as to require nine different incisions; one of which 
was on the saphena major, a few inches above the knee, five upon the inter- 
nal saphena, between the knee and ankle; and three upon the external 
saphena and its branches, or the communicating vessels between it and the 
internal saphena, at their points of anastomosis. The veins though much 
dilated, were not generally as thick as usual; but in this respect they varied 
at the different points of incision. 
No unpleasant symptoms occurred. The dressings were removed at the 
end of the second week. The ulcer had healed and all the cuts but two had 
united by the first intention; and these two cicatrised soon afterwards. 
On the 20th of July, the disease in the left limb having been effectually 
cured, the patient underwent another operation on account of the varices on 
the right leg, the ulcer there having already disappeared. Three incisions 
only were required, all of them below the knee, the first in the internal sa- 
phena, the second on a branch of this, and the last on a mesh of varices at 
the posterior and lower part of the leg, in one of the main branches of the 
external saphena. 
At the end of a week the dressings were removed; the wounds had united, 
and the varices had disappeared. The patient was discharged, cured, August 
9th. 
The most striking peculiarity of this ease is, that in operating on the right 
limb, while attempting to pass the probe beneath the vein at the bottom of 
the second incision, the vessel was found in close contact with a cutaneous 
nerve of considerable size, which was indeed at first mistaken for the vein 
itself. The probe having passed beneath this, gave so much pain along the 
whole limb and down as far as the toes, that the mistake was at once detect- 
ed. In detaching the vein some caution was necessary to prevent this nerve 
from being injured. A similar complication by almost every other mode of 
operation, whether by subcutaneous section, by pins, or by caustic, might 
have led to serious consequences; whereas, by exposing the vessel, as in the 
mode described, the nerve may be avoided with scarcely any risk of danger. 
The other points of interest in this case, are—1st, the great number of 
incisions necessary in the first operation; and 2d, the interception of the 
blood through both the external and internal saphenas, in both limbs. 
Case VIII.—Mrs. Cohill, widow, a native of Ireland, aged 40, a washer- 
woman of full habit, but in feeble health; had suffered from extensive varices 
for six years, which, as she thinks, were originally caused by hard work. 
In June, 1838, she first came under my care, having at that time had seve- 
ral severe hemorrhages from a small ulcerated spot just below the knee on 
the left leg. The bleeding had recurred every day for eight or ten days in 
succession, and had reduced her excessively. Having no means of treating 
her conveniently elsewhere, I had her transferred to the hospital. On the 
evening of her admission, whilst in bed, and with a bandage on the limb, the 
hemorrhage started anew, and before the nurse had time to summon the 44 
Watson on the Pathology and Treatment of Varices. 
[Jain. 
house surgeon, the patient had lost, according to the reckoning of those 
about her, at least two chamber-potfuls of blood. A pin was immediately 
passed transversely beneath the bleeding vein at the point of ulceration, 
and compression effected by means of a thread, adhesive straps, a compress 
and roller. The limb was kept elevated for several days afterwards. The 
wound healed; there was no recurrence of hemorrhage from this point; and 
the patient in a week or ten days left the hospital, with the varicose condi- 
tion of her limbs as bad as at the time of her admission. 
In August, 1841, she had a return of hemorrhage from another minute 
point of ulceration at the upper and outer part of the right leg. This was 
arrested by compression, aided by a few days repose in bed. From that 
period up to the 13th of August, she had no return of bleeding; but the 
varices were continually increasing, giving her much pain, causing her feet 
and legs to swell, frequently preventing her from attending to her work, and 
oftentimes confining her to her bed. 
She called upon me, much alarmed, on the morning of the 15th of August, 
1842, stating that on the night of the 13th, while engaged in ironing clothes, 
one of the diseased veins near the outer ankle of the right limb suddenly 
burst with so much force as to throw the blood to the distance of several 
feet from her, and that before it was arrested she had lost at least a quart. I 
found the veins in both limbs exceedingly enlarged; but those on the right 
leg, in respect to the number and size of the varices, in a worse condition 
than I had ever before witnessed, presenting by their elevations and numer- 
ous convolutions, the appearance of a cluster of small snakes winding around 
the limb in all directions. The enlargement and varicose convolutions ex- 
tended throughout the whole length of the saphena major, involved all the 
superficial veins of the leg—and probably many of the venules in the sub- 
cutaneous cellular tissue, as well as in the skin. The irritation of the varices 
had excited a chronic pruriginous papular eruption, which formed large 
patches on different parts of the legs, but most extensive about the feet and 
ankles. She had often attempted to wear a bandage on the limbs; but, as 
she stated, it caused the veins to swell and to become very hard and painful, 
so that of late she has not ventured to use it. For some days prior to each 
recurrence of hemorrhage, she had observed a small red sore spot over the 
vein from which the bleeding at length issued. The point from which the 
last bleeding issued was not larger than a pin’s head, and had already ceased 
to be swollen or inflamed. I applied a compress over this part, and secured 
it with a roller, which was carried over the whole leg as tightly as the sen- 
sitive integument would bear it. On her way home, the pain of walking 
obliged her to rest at the house of a friend; and while there the blood again 
started with violence from the same point. The loss of blood at this time 
was greater than at any former period, and was arrested by the syncope 
which it induced. I saw her in the course of the afternoon. She was still 
in a state bordering on syncope. The varicose enlargement had to all ap- 
pearance been entirely effaced by the bleeding. The compress and roller 
were again adjusted. A slight oozing again occurred during the night. On 
the following morning she was admitted into the hospital. 
In a few days after admission, she complained of nausea, loss of appetite, 
and slight headache, and was somewhat depressed in spirits. She was con- 
fined to her bed, and put on low diet and laxative medicine. The cathartic, 
however, rather aggravated her symptoms, irritated her stomach and bowels, 
and excited vomiting. These unpleasant feelings were relieved by small 
doses of Dover’s powder. She could not at first bear much pressure on the 1843.] 
Watson on the Pathology and Treatment of Varices. 
45 
right leg—the veins being somewhat tender. An evaporating lotion was 
applied to them, which relieved the soreness. 
On the 20th of August, her unpleasant symptoms having subsided, 
(although her tongue was pale and glossy, and her spirits still somewhat de- 
pressed,) the operation was performed on the right leg. Seven sections 
were necessary; one of which was on the saphena major, just above the 
knee; all the rest were on the internal saphena and its branches, the lowest of 
them being just above the inner ankle, in a mass of varices with which the small 
vein that had given issue to the recent hemorrhages communicated, by wind- 
ing from below the outer ankle upwards and backwards, behind the tendo 
Achillis. 
The vessels were unusually thin, and when once exposed and separated 
from their cellular attachments, they suddenly contracted, apparently to their 
natural size. In consequence of their tenuity, much caution was necessary 
to prevent them from being injured before isolating them. One of them was 
in fact perforated with a director by one of my colleagues, in attempting to 
pass the instrument under a thin layer of fascia which I was about to divide. 
At the bottom of one of the incisions, after passing the probe beneath a su- 
perficial vein, it was found that several other veins, still larger, lay some- 
what deeper, and were yet covered by dense cellular tissue. This was 
divided, and these deeper veins lying immediately upon the sheath of the 
muscles, were taken upon the probe with the other, and in due time divided. 
The dressings and treatment immediately after the operation, were the same 
as in former cases. 
About seven hours afterwards the patient became somewhat feverish, with 
headache, nausea, disposition to vomit, with pains in her back and lower 
part of the bowels. Her pulse was slow, however, and the appearance of 
her tongue as before the operation. A small dose of solut. sulph. morph, 
was administered and followed occasionally through the night with effervesc- 
ing mixture. The excitement was somewhat increased on the two follow- 
ing days; but it was soon ascertained that the patient’s menses had appeared 
immediately after the operation, and her state of excitement was attributed 
to that circumstance. 
On the 23d the febrile symptoms had mostly subsided, but the patient had 
some soreness in the limb. The bandages were at first loosened, and at the 
end of a week entirely removed. Some of the incisions had closed by adhe- 
sion, one or two were suppurating slightly; but two of them had become 
more inflamed than usual, and threatened to excite severe inflammation in 
the loose cellular tissue of the calf of the leg. One or two small abscesses 
did in fact appear. At the close of the second week, the inflammation had 
entirely disappeared, and in the course of a few days aftenvards, all the in- 
cisions had healed, and the patient resumed the use of the limb entirely free 
from varices except in the venules of the skin. But some of the convolutions 
of the veins were still visible by their bluish colour. She was discharged 
cured of the disease in the right limb, Sept. 16th, 1842. The patient was 
anxious to undergo the operation for the cure of the disease in the other leg, 
but the state of her family at home required her presence, and she was 
obliged to leave. 
The peculiarities of this case are—the number and extent of the varices; 
their complication with a pruriginous eruption; the frequency and alarming 
severity of the hemorrhages; the thinness of the coats of the vessels and 
their marked disposition to contract the calibre of the veins after being ex- 
No. IX.—January, 1843. 46 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
posed and detached from their cellular envelopes; and finally, the febrile symp- 
toms and suppurative inflammation, following the operation. 
Thus far the operation by repeated exsections had been attended with 
uniform and marked success. Before proceeding to relate my two remain- 
ing cases, which terminated unfavourably, I shall offer some observations 
on the most striking peculiarities of six others, in which the operation was 
seven times performed by my colleagues; all with complete success. 
Case IX.—On the 7th of June, 1842, Dr. J. Kearney Rodgers operated 
on a patient, making six exsections in the course of the internal saphena 
and its branches, either over large varicose masses, or at distinct anastomos- 
ing points. His mode of operating consisted in cutting boldly down upon 
the veins, and removing portions of them, without previously elevating 
them on a probe, and finishing the exsection at one point before commencing 
the incisions at the points below. This method has the advantage of being 
more expeditious than the other; but, on the contrary, it exposes the patient 
to a greater loss of blood. 
In this case the disease had existed six years, and was complicated with a 
chronic ulcer. The patient, a currier, aged 24, had been operated upon 
about three years previously, by a physician in Connecticut, who applied a 
ligature upon the saphena major about one-third way up the thigh. The 
ligature was cut away on the fifth day: the wound healed by suppuration, 
and as soon as he began again to use the limb the varices were found to be as 
large and troublesome as ever. About a year after this he submitted to a 
second operation in the Massachusetts Hospital. Here caustic potassa was 
applied along the course of the vessel, on the skin, just below the point of 
the first operation. The result of this second operation was as ineffectual 
as that of the first. The vessel appeared to be as large and full at the point 
of the primary ligature as at any other place, and, as far as I could judge, the 
caustic had not produced an eschar of sufficient depth to reach the vein 
at all. 
After the third operation, the limb was dressed as before described; no 
unpleasant symptoms ensued. The bandages were removed at the close of 
the second week, by which time the ulcer had closed; the varices had disap- 
peared; almost all the incisions had cicatrised; one or two remaining open a 
few days longer. The patient was discharged cured on the 1st of July. 
On the 23d of June, Dr. R. operated on two other cases. The first of 
these, 
Case X., was an Irish porter, aged 38, who was brought to the hos- 
pital in a state of insensibility, and sinking from sudden and profuse flow 
of blood. The point from which the blood had issued was a small indurated 
and elevated ulcer over a varicose vein, at the upper and inner part of the 
leg. About seven years previously he had had a similar bleeding from a 
ruptured varix near the same point; and about two years ago a second 
bleeding from an ulcerated spot similar to the present. The first attack 
came on soon after heavy lifting; the second whilst he was getting out of 
bed in the morning; and this last, in which the loss of blood was more pro- 
fuse than in either of the others, came on whilst he was descending a flight 
of stairs. The varices had existed many years; were originally caused by 
hard labour. He had never had any large ulcer on the leg, and no other 1843.] 
Watson on the Pathology and Treatment of Varices. 
47 
sore than the small indurations that occur over the varicose swellings, and 
from which, by sudden giving way of the skin at a very minute point, all 
the hemorrhagies have issued. 
In this case there were seven incisions made in the internal saphena and 
its branches, and about an inch of the vein removed from each. The band- 
ages were removed at the end of a fortnight, by which time the cure had 
been effected. The patient was discharged on the 26th of July. 
Case XI.—Dr. R.’s third case had been several months in the hospital 
under treatment for varicose ulcers on both legs. The ulcers had preceded 
the varices, and these had existed about two years; and were, worse on the 
left leg, whence they extended to the common saphena. The superficial 
epigastric vein on the right side was also slightly varicose. The ulcers had 
nearly healed at the time of the operation, which was performed only on the 
left leg. Four incisions were necessary, all on the internal saphena: three 
above and one below the ulcer. The progress and result in this case were 
the same as in the foregoing instance. The patient was discharged, cured, 
on the 25th of July. 
On minute examination of the exsected portions of veins in these two 
cases, I found them contorted, nodulated, and dilated, as usual. Their coats 
irregularly hypertrophied, were at some places nearly the tenth of an inch 
thick, and the outer coat in various points almost as hard as cartilage. The 
inner coat was corrugated into longitudinal folds of a pale pinkish colour, 
which changed after a few minutes exposure to a deeper red, giving the 
corrugated surface the appearance of muscular fibre. The valves were nei- 
ther thickened nor irregular; so far as I could judge, they appeared to be 
perfectly healthy. Besides the longitudinally folded appearance of the inner 
coat, there were also numerous transverse folds involving all the coats of 
the vessels, puckering them and throwing their sides into little pouches 
and irregular convolutions, which could not be effaced or straightened out, 
even after the vessels had been separated from the dense cellular bands on 
their outer surfaces that appeared to hold them in these irregular positions. 
The coats of the vein at the concave side of these convolutions, were usually 
thicker and harder than at other parts. These morbid appearances in the 
vessels, as well as in their cellular investments, appeared to have been the 
result of chronic inflammation. The vessels, after their removal and longi- 
tudinal division, appeared to contract considerably in their transverse mea- 
surement. 
Case XII.—On the 23d of July, 1842, Dr. Hoffman operated on the 
right leg of a patient for the cure of varices complicated with an ulcer and 
with a chronic eczematous eruption, the result of the varices. The patient 
lost considerable blood. There were four points of incision; three on the 
inner saphena and its branches, and one on the outer. The dressings were 
removed on the 9th day: all the cuts, with one exception, had then been 
cicatrised and the varices had disappeared. 
Case XIII.—In this patient, (a German seaman of middle age and good 
general health,) Dr. Buck operated on both legs: on the right leg, August 
I8th, 1842; and on the left, September the 17th, following. The varices 
were so prominent on the right leg, as to enable the operator to dispense 48 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
with the use of the fillet around the lower part of the thigh. Saven inci- 
sions were necessary over the internal saphena and its branches. Subse- 
quent to the operation, the patient had an attack of inflammation of the ab- 
sorbents along the thigh, which soon subsided; but in the progress of the 
case he had considerable inflammatory reaction, and several of the incisions 
suppurated. In the second operation, (which was not performed until all 
the former cuts had closed and the patient was able to walk about,) there 
were four incisions: three on the internal saphena and its branches, one on 
the external. In the upper cuts on the former vessel, great masses of varices 
were exposed and found to be so convoluted and concatenated as to render 
the isolation of a single convolution less easy than the removal of the mass. 
No unpleasant symptoms followed this operation. The cure on both limbs 
was effectual. 
In this case the disease had existed since boyhood. The varices were of 
an enormous size, so much so, especially on the left leg, as to render the 
limb deformed. He had for years been subject to small indolent ulcers on 
different parts of his legs, usually in the course of the veins. At the time 
of the first operation his limb was studded with several small indurated 
swellings in a state of chronic inflammation, with dark spots in the centre, 
like the eschars resulting from dry gangrene, and these were seated in the 
integuments immediately covering varices more tender than the rest, and 
apparently adhering to the skin. The convolutions at some of the points 
of incision were so short as to give the veins the spiral and twisted appear- 
ance of a cork-screw. The veins in the right leg were much thicker and 
more numerous and convoluted than in the left. When divided their coats 
were found to be nearly the eighth of an inch thick, uniformly hypertro- 
phied and free from nodules: their inner coat presenting the appearance of 
pale and dense muscular fibres running longitudinally; and transverse ridges 
and depressions extending through both coats as in former cases. The 
valves of the veins were healthy. The fascia investing the vessels and 
binding the convolutions to one another, was very thick and strong, and 
appeared to be the result of long continued chronic inflammation in the cel- 
lular investment of the vessels, by which it had been contracted and con- 
solidated. 
Case XIV.—This was a patient with a chronic ulcer in the leg, which 
had given rise to varices in the course of the limb. The operation for the 
cure of these was performed as before described, by Dr. Cheesman. The 
vessels were divided at four different points. In consequence of undue ten- 
sion of the bandages, it was found necessary to remove them on the third or 
fourth day. The cure was as rapid and effectual as in the preceding cases. 
Case XV.—Susan Hyde, a negro woman, aged 33, a servant, was sent 
to me by a medical friend on account of varices on her right leg. The dis- 
ease had existed five years. In the interval she had had a chronic ulcer on 
the shin of the same leg, which is now cicatrised; had suffered from an 
attack of bilious fever, and within the past year, from what was supposed to 1843.] 
Watson on the Pathology and Treatment of Varices. 
49 
be a disease of the liver. But, although somewhat emaciated, she stated 
that she had recently enjoyed tolerable health. On the 9th of September I 
had her admitted into the Hospital. After a few days preparatory treatment 
she appeared to be in a favourable condition for the operation, which was 
performed on the 15th. 
A small ulcerated spot from which the hemorrhage had issued, as she 
stated, had first become sore about a month before admission, in conse- 
quence of a slight blow. It was seated in front of the ankle, on one of the 
terminal branches of the internal saphena. Just before the hemorrhages oc- 
curred she had suffered very acute pain in this part; the pain appeared to 
extend in the course of the veins all the way up to the thigh, and was fol- 
lowed by a sudden rupture of the vein at the point already mentioned, and 
the immediate loss of at least a pint of blood. A second hemorrhage oc- 
curred in three or four days afterwards, whilst she was in a recumbent posi- 
tion, and was much more profuse than the first. When I first saw her the 
varices were very numerous, and the veins greatly enlarged; but in conse- 
quence of the repose of the limb and the pressure of the bandage, at the 
time of the operation, they were greatly reduced so that the main trunk of 
the saphena in the thigh, and its continuation on the inner side of the knee 
downwards to the ankle, were the only vessels prominent beneath the skin. 
These to the finger were exceedingly resisting, and appeared to be consoli- 
dated. The application of the fillet was unnecessary, except for raising the 
vein at the lowest incision, and then it was applied around the leg just above 
this. There were but three incisions made, all of them on the main track 
of the internal saphena between the knee and ankle. The operation gave 
rise to scarcely sufficient hemorrhage to stain the instruments. About half 
an inch of the vein was removed at each incision, the last of which was at 
two inches above the point of ulceration. The vessels were absolutely 
empty, very much thickened, the inner coat corrugated as usual, and the 
calibre so contracted before the division, as scarcely to have admitted the 
smallest probe. 
Sept. 16th. Patient had passed a comfortable night, and was still some- 
what under the influence of the anodynes which she had taken subsequent 
to the operation. Skin warm, pulse 120. The pain in the leg caused by 
the incisions had nearly subsided. No tension or tenderness either of the 
foot or of the thigh, above the bandage. 
17th. The anodyne taken last night had not procured her much sleep. 
Her tongue was thickly coated, and rather broad and swollen; pulse 140, 
small and rather weak. Had recently taken a dose of castor oil, which was 
still operating. She complains of thirst, and has no desire for food. No ten- 
derness in the limb. She was permitted to drink weak lemonade. To-day 
for the first time, the starched bandage was applied over the simple roller. 
During its application she had some chilliness, which was attributed to the 
cool air from an open window near her, and was very transient. An ano- 
dyne was administered at night, consisting, as usual, of the solution of 
the sulphate of morphia, gtt. xxx. 
18th. Had passed a watchful night without pain. Her general condition 
precisely as on the preceding day, except that there was some oedema of 
the foot, which when pressed was found to be rather tender; she spoke of a 
slight headache. The frequency of the pulse was the only symptom that 
appeared to indicate much constitutional excitement. I questioned her 
closely in respect to her history and previous state of health, but could elicit 50 
Watson on the Pathology anil Treatment of Varices. 
[Jan. 
nothing further from her than that her last menstrual period had just passed 
at the time of her admission into the Hospital; and that she had long been 
habituated to the use of opiates. The tenderness of the foot appeared to be 
caused by the tightness of the bandage. This was divided for a few inches 
upwards, and a looser one applied on the part. In the afternoon the patient 
had a rigor, which was followed by increased tension of the limb. The 
whole of the bandage was now divided, and a looser one applied. In the 
afternoon and until bed-time, the nurse informed me the patient appeared to 
be more comfortable than at any period within the two or three days past; 
but about midnight she began to moan and appeared to be in considerable 
pain. About 3 o’clock in the morning, supposing the patient required her 
assistance, the nurse arose, and to her surprise found her in a state of col- 
lapse. The house-surgeon was instantly summoned. He had scarcely 
time to see the patient, and administer a few tea-spoonfuls of brandy, be- 
fore she expired. 
Post mortem examination, between eight and nine hours after death. 
The body was rather emaciated; the parietes of the abdomen corrugated as 
if by utero-gestation. The upper incision of the leg was in process of union 
by adhesion; but the two lower cuts were gaping and filled with dark fluid 
blood. The integuments for an inch or two around them, appeared to have 
been in a state of gangrenous inflammation, the cuticle being detached from 
the skin. The cellular tissue of the foot was partially infiltrated with serum, 
and the veins below the last cut were filled with dark fluid blood, and free from 
coagula. The portion of vein between the two lower cuts, which were per- 
haps three or four inches apart, was the only part of the venous system 
that appeared to be at all inflamed, being of a brighter red colour than the 
fluid blood contained in it; but free from coagulum, and from every thing like 
fibrinous or purulent deposits. Above the middle incision, the internal sa- 
phena vein was empty, and of the same colour as the small sections that 
were removed during life. There had existed a very large mass of varicose 
contortions in the saphena major at its upper third. The vein here was 
also found of a deeper colour than usual, being of a dingy brownish purple; 
and its inner coat had the muscular appearance so often noticed in other 
cases during life; but gave no unequivocal evidences of recent inflammation. 
The inner coat of the vessel throughout was hypertrophied, and could be 
raised in large strips from the outer coat, to which, however, it adhered 
rather firmly, and when raised and examined, did not appear vascular. The 
large veins between this point and the heart gave no evidence of disease 
whatever, except that they had assumed, probably by imbibition, the precise 
shade of the dark fluid blood contained in them. The only coagulum found 
in the veins, was a small mass in the external iliac vein, which did not ad- 
here to the coats of the vessel. The inner lining of all the large veins was 
perfectly smooth and elastic, and all the valves were healthy. 
The heart presented no morbid appearances, with the exception of a 
fibrinous polypus, which extended from the right ventricle into the pulmo- 
nary artery. The upper lobe of both lungs was consolidated, and studded 
with numerous tuberculous deposits, mostly small. Some of these had de- 
generated into bone; and some of these bony tubercles were as large as peas; 
all of them of an irregular shape, and extremely hard. The right lung 
adhered firmly to the chest. The lower lobes of both lungs were free from 
tubercles, but were somewhat injected with mucus. In the midst of the 
tuberculous masses of the left lung there were two small deposits of laudable 1843.] 
W atson on the Pathology and Treatment of Varices. 
51 
pus; in all amounting to about half a tea-spoonful; probably the result of a 
softening tubercle. There was an old cicatrix on the surface and near the 
upper extremity of the right lung. 
The liver was nearly twice as large as natural, and congested with fluid 
blood; as were all the large veins in its neighbourhood. The texture of the 
liver did not appear to be abnormal, either in colour or consistence. 
The vagina was filled with a sero-purulent fluid, which issued from it in 
profusion in the attempt to separate the uterus from it. The uterus itself 
appeared to be larger and heavier than natural. There was a small fibrous 
tumour projecting from its fundus. The uterine veins were numerous, 
dilated, and convoluted, as in ordinary varices. The left ovary was as large 
as a hen’s egg, and had degenerated into numerous cy3ts, which, when 
opened on the following day, were found filled, some of them with a trans- 
parent yellowish gelatinous fluid, others with what appeared to be grumous 
blood coagulated. The inner surface of the uterus, when laid open on the 
following day, was found to have been in a state of inflammation. Its 
mucous lining was of a bright red colour, extremely vascular; the vascu- 
larity greatest at the fundus, and at the openings of the Fallopian tubes; 
and terminating below, within half an inch of the neck, in a small pro- 
jecting vascular growth, like an incipient polypus, about as large as a 
pea. The os tincae was puckered, fissured, and slightly gaping; and there 
was an old cicatrix just external to it, round, about a quarter of an inch in 
diameter, probably the result of a chancre long since healed. No other 
morbid appearances were detected. 
From the foregoing history it is evident that this patient must have con- 
cealed some of her symptoms prior to the operation, a circumstance by no 
means unusual in hospital practice; when, partly from the ignorance and 
inattention of the patients to their own feelings, and sometimes from a de- 
sire to deceive, we are often forced to draw our conclusions, both as to the 
nature and the causes of disease, rather from what we should expect, than 
from what we ascertain. 
The most striking features of this unfortunate case then are,—a vitiated 
condition of the general health prior to entering the hospital, consisting in 
tuberculous deposits in the lungs, probably of long duration; an enlargement 
of the liver, also of long continuance; an inflammatory disease of the uterus, 
of recent date. Upon which supervened, after a trifling and almost blood- 
less operation, obscure febrile movements, characterised principally by a 
rapid feeble pulse, with heavily coated tongue, wakefulness, anorexia, and 
slight headache, which, after continuing for three days and a half, were sud- 
denly followed by collapse, terminating in death; the fatal issue probably 
hastened, if not actually induced, by the formation of a fibrinous concretion 
in the heart, which must have materially interfered with the circulation 
through the pulmonary artery. The blood in most of the large vessels was 
in a fluid state; neither of the wounds had suppurated, and there were no 
evidences of phlebitis, except in a small portion of the internal saphena be- 
tween the two lower incisions, which must have prevented the blood in this 
part of the vein from entering the general circulation. 52 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
Case XVI.—Thomas Donahoe, of Ireland, a labourer, aged 30, was 
admitted into the N. Y. Hospital, August 30th, 1842, with extensive varices 
on the left leg and thigh, existing ten years, and a chronic ulcer on the shin 
existing six years. For the last few years the disease had troubled him so 
much that he was obliged to remain idle about half the time. He was of a 
sanguine temperament, had since his youth been subject to frequent attacks 
of epistaxis, and at the time of admission was somewhat plethoric, but was 
otherwise apparently healthy. 
'I he saphena major, from the groin downward, was very prominent, 
about as broad as the patient’s thumb, and the whole of its lower third 
thrown into irregular serpentine convolutions. Below the knee the varices 
were still more prominent, involving all the branches of the internal saphena, 
the main trunk of the external saphena, and numerous communicating 
veins, above and below the patella, as well as on the back of the leg. The 
whole limb was deformed by them; and the dilatation in the minute veins 
was such as to produce a general engorgement of the leg, a spongy state 
of the subcutaneous cellular tissue, and spots of arborescent blotches in 
the skin. The varices had never given issue to free hemorrhage; but he 
was subject to frequent extravasation of blood beneath the skin from the 
slightest bruise. The purplish spots thus produced often occupied the 
space of several inches square, continuing for two or three weeks, and then 
gradually disappearing. He had long been in the habit of wearing a roller 
on the leg, at first with partial benefit, but of late with no advantage. 
After admission he was put on spare diet and placed on his back, with a 
roller applied tightly over the diseased limb, and a saline cathartic was ad- 
ministered. Notwithstanding the continued pressure of the roller, and strict 
observance of the recumbent posture, the vessels at the day of the operation, 
September 3rd, were still as prominent as ever, enabling me to operate 
without the use of the fillet. The veins were divided at five different points; 
the first above the knee, one in the upper part of the external saphena; all 
the rest on the internal saphena and its branches, the largest of which ran 
along the calf of the leg. The incisions were rather freer than usual, and the 
veins were raised by a thread, instead of the probe, as in former cases. 
About two inches of the main trunk of the vein were removed at the incision 
above the knee, and a large mass of convolutions, intimately interlaced, from 
the inner and upper part of the leg. No bleeding of any account occurred 
until after completing the last two exsections in the upper part of the leg and 
above the knee; but before applying the straps and compresses here the 
patient lost perhaps more than a pint of blood. 
The points of interest observed in connection with the operation and exami- 
nation of the portions of the veins removed, were— 
1st. That the coats of the enlarged veins were not of equal thickness at 
the different points of incision, and that the thickening bore no relation to 
the degree of dilatation. Thus, the vessels in the thigh, enormously dilated, 
were but slightly hypertrophied; the thickness of its parietes was trifling in 
comparison to that of the large branches of the internal saphena below the 
knee. 
2d. That the points at which the convolutions were the most numerous 
and agglomerated, were the points at which the greatest degree of hyper- 
trophy existed in the coats of the veins. 1843.] 
Watson on the Pathology and Treatment of Varices. 
53 
3d. That the thickening at each point in the course of the vein was regular 
on all sides, and free from the small nodules of lymph or cartilage, as well 
as from small irregular thin pouches in the coats of the vessel, as witnessed 
in former cases, especially in such as had given issue to several hemorrhagies. 
4th. The anatomical changes in the two coats were, as observed in other 
cases. The inner coat was marked by fleshy looking longitudinal fibres, and 
mottled at the various points of anastomosis with small purplish spots, as if 
by extravasation of blood between the two coats. The outer coat had the 
appearance of a thick and uniform layer of semi-diaphanous cartilage. The 
cellular investment beyond this was dense, and bound the vessels closely to 
the fascia and looser cellular tissue surrounding them. 
5th. A fact worthy of remark was the very great contractile power of the 
vessels when freed from the cellular envelopes by which they were held in 
a state of dilatation. Thus, the saphena major, before exposing it, appeared 
to be nearly an inch in diameter; and, when exposed, and before it was 
separated from the surrounding tissues, its diameter was still the same. But 
after isolating it from these, and before it was divided, the isolated portion 
contracted so much as to lead me to suspect that I had fallen upon a small 
collateral vessel; it was not more than one-fourth its former size, if indeed so 
much. The same fact was observed in the lower branches; but owing to 
the greater thickness of the parietes of these, the degree of contraction after 
isolating them was by no means so great as in the saphena major. 
6th. The subcutaneous extravasations, that had been of frequent occur- 
rence, must have issued from venules too minute to be secured, as these 
vessels, in numerous patches, were very much dilated without any apparent 
increase in the thickness of their parietes. 
About three hours after the operation the starched bandage was applied, 
without any instructions from me to that effect, the usual practice having 
been to apply this on the day following the operation, after having allowed 
sufficient time for swelling. In the evening I found the patient complaining 
of pain over the tibia. lie had already taken a full anodyne; another was 
ordered and instructions given for dividing the bandage if the pain con- 
tinued. 
Sept. 4th. The patient had been in pain all night, and had slept little or 
none. Early in the morning he became sick at his stomach and vomited. 
The house-surgeon now slit the bandages over the seat of pain. At 8 
o’clock A. M. I found him comparatively free from pain but with a rigor upon 
him. There was some tenderness at the left groin, which he attributed to 
the effort at vomiting. The lymphatic glands here were evidently enlarged, 
without any corresponding tenderness or swelling along the thigh. There 
appeared to be a distended vein under the integument at the point of the leg 
where the bandages had been cut, and the skin over them was slightly 
chafed. Another anodyne of solution of sulphate of morphia (gtt. xxx.) was 
administered, to be followed with spirit, minderer. every second hour. 
At 2 o’clock, P. M. the patient was free from pain and disposed to sleep, 
pulse 80, tongue moist and clean. At 8 o’clock, P. M. he had taken another 
anodyne of half the former strength, and had continued the use of the dia- 
phoretic. He had been free from pain all day, with his skin moist and 54 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
natural. He had an attack of epistaxis, but no return of nausea or vomiting. 
I found him asleep, with pulse at 100. A blister that had been applied in 
the morning over the enlarged glands at the groin, had drawn well. The 
chafed spot on the leg was now rather swollen and injected, but the enlarged 
vein had disappeared. 
5/A. The patient had slept well. In the morning had a cathartic of castor 
oil which operated freely. In the evening had a rigor which soon subsided. 
The circulation was free in the limb, he had no pain, but a small circum- 
scribed swelling, like an enlarged lymphatic gland, had appeared on the 
track of the saphena at the middle of the thigh. A small blister was applied 
over this, and the other treatment continued. Hitherto, although with little 
relish, he had taken his regular meals, which were of the simplest kind. 
6/A. Had slept as usual, and was free from pain; pulse about 100, tongue 
clean; still on the anodyne and diaphoretic treatment. In the course of the 
day he had sickness of stomach and occasional vomiting after eating, or 
after the effervescing draught which had been substituted for the spirit, 
minderer. At night he had another rigor, which was slight, and followed by 
no excitement. No tenderness or unusual swelling in the limb. The ten- 
derness and swelling in the lymphatic glands had been relieved by the 
blisters. 
7th. He had vomited once or twice in the early part of the night, but 
rested as usual. Disposed to wander in his sleep, but intellect clear at other 
times; pnlse 102. 
9th. General condition as at last report. The bandages were partly 
removed. Over the tuberosity of the tibia, owing to irregular pressure, a 
small slough had taken place, and at the seat of the old and partly cicatrised 
ulcer on the shin the integuments had also given way, leaving a sore larger 
than the original one. 
10/A. The rest of the bandages removed. All the cuts, except one near 
the calf of the leg, were quite dry, and in process of healing. From this 
one there wras a healthy purulent discharge. Simple dressings to the sores, 
dry lint to the cuts, and a many-tailed bandage over the whole. 
12/A. General condition gradually improving. No pain except at the calf 
of the leg where the adhesive straps exert an irregular pressure. The 
integuments here are inflamed, and a small abscess is about to form below 
the suppurating cut. The patient rests well, has no further irritability of 
stomach, and very little general excitement. A poultice was applied to the 
leg. The anodyne and diaphoretic course was still continued. 
14th. A small abscess that had formed in the back part of the leg was 
opened; the foot and lower part of the leg for a day or two had been some- 
what oedematous. He has little or no appetite, and is “ romancing in his 
sleep.” His skin is moist, and his pulse about 90, less full than formerly; 
and his tongue is heavily coated. 
15/A. Less inflammation, but more oedema in the limb. Pulse 88, soft 
and feeble; tongue moist and less heavily coated; romancing while asleep; 
skin moist and flaccid; slight emaciation. Patient has no pain, but speaks 
of inability to move the right leg. Simple dressings and a roller were sub- 
stituted for the poultice, and the patient was put on the use of bitter infusion, 
with a more generous diet. 
16/A. Patient has eaten with more relish, has slept well, is free from pain, 
and speaks of soon being able to get about. 
17th. General condition as at last report, but in the course of the day he 1843.] 
Watson on the Pathology and Treatment of Varices. 
55 
took a dose of castor oil which sickened him, and in the evening the nausea 
and vomiting returned. 
18th. I had not an opportunity of seeing him. The nausea and disposi- 
tion to vomit continued unchecked either by anodynes or the effervescing 
mixture. 
19th. A pulse at 120 and very small, countenance anxious, skin bathed in 
perspiration, stomach still irritable. He spoke of severe pain in his hips. 
The discharge from the leg was rather free. He could not turn in bed 
without assistance. A sinapism was placed over his stomach, and he was 
put on the use of sulphate of quinine, about three grains daily, with wine 
whey, broth, and beef tea, as much as he was disposed to take. 
20th. Stomach quiet since the application of the sinapism; tongue dry and 
brown. The ulceration over the shin has extended and left a part of the 
tibia bare. 
2lst. Increased prostration, and increased pain in the hips. This morn- 
ing 1 observed the first joint of his right index finger much swollen and the 
integuments red, evincing the formation of what I supposed to be a secondary 
abscess. He attributed this to the habit of keeping the hand under his head 
while asleep. In the evening his tongue w'as dry and almost black, and he 
had slight subsultus, with muttering delirium during sleep; pulse still more 
frequent. He was put on brandy toddy. 
22cl. Had taken nearly half a pint of brandy during the night. Prostra- 
tion in the morning less marked. The conjunctiva of the right eye engorged 
with blood. The stimulants were continued freely during the day, but 
towards night he began to sink rapidly, and he died about half past 7 
o’clock, P. M.; rather more than nineteen days after the operation. 
Jiutopsic examination, 20 hours after death. Some of the cuts made 
during the operation had cicatrised; the others were all far advanced in the 
process of healing. There were two small openings that had been made for 
the discharge of matter, near the calf of the leg, communicating with an 
abscess there that contained a few ounces of purulent matter. With the ex- 
ception of a small part of the saphena major, all the veins of the limb, as 
well as those in every other part of the body, appeared to be free from 
inflammation; few or none of them even presenting the reddened appearance 
of their coats, so frequently the result of imbibition. The saphena major, 
for about fire inches and a half above the uppermost incision, was thickened 
and adhering by lymphatic effusion to the surrounding tissues. It was dis- 
coloured internally, and blocked up with adherent and partially organised 
bloody lymph. But these morbid appearances terminated abruptly above, 
and were arrested here by an intervening valve. This valve itself was 
healthy, as were all the others above it. 
A small bloody and fibrinous coagulum was found extending from the 
right ventricle of the heart into the pulmonary artery. The heart in other 
respects presented no abnormal appearances. The lungs and the abdominal 
viscera were healthy. 
The principal seat of disease had evidently been the lymphatic system. 
The absorbent vessels running in vast numbers along the inner side of the 
thigh were thickened, consolidated, and opaque; in size and firmness 
resembling minute cords of catgut. The lymphatic glands were equally 
diseased. One of these, at the middle of the thigh, lay immediately upon 
the saphena vein, to which it adhered by firm fibrinous attachments. It was 
about an inch and a half long, oval, firm, and had numerous enlarged and 56 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
at the groin, both superficial and deep-seated, were also enlarged, indu- 
rated, and agglomerated. The disease in the absorbents and lymphatic glands 
above this part had probably given rise to the most striking lesion in the 
consolidated absorbent vessels entering it from below, imbedded in condensed 
cellular tissue, and others extending from it upward. The lymphatic glands 
body, and one which elucidated many of the symptoms that occurred in the 
progress of the case. 
This consisted in an immense abscess extending in the course of the left 
psoas muscle, external to the iliac fascia, from the diaphragm to the groin, 
and passing at the groin under Poupart’s ligament, on the inner side of the ves- 
els, downwards on the thigh, where it was arrested by the pectineus and adduc- 
tor muscles. The whole of the pelvic surface of the os ilium, as well as the 
portion of the os pubis forming the floor of this abscess, was exposed, bathed 
in purulent matter, but smooth and free from disease. The muscles lying in 
the course of the abscess, viz., the psoas, pectineus, and adductor femoris, 
were discoloured, softened, and approaching to a state of decomposition. 
The abscess, at its upper part, advanced close upon the vertebral column 
without actually reaching it. The vertebrae, so far as I could detect, were 
healthy. 
There was a large concomitant vein running nearly parallel with the 
saphena major in front of the thigh, with numerous branches extending ex- 
ternally and downwards. It anastomosed with the saphena, first, just above 
the valve by which the adhesive inflammation had been arrested, and again 
just before its entrance into the femoral vein at the groin. This concomitant 
branch was about one-fourth the size of the saphena major, and nearly, if 
not quite as large as the saphena itself, as seen in some subjects. It was 
healthy, but contained blood partially coagulated, as did also the deeper veins 
in the limb, and the large veins in other parts of the body. This vessel had 
probably enlarged subsequent to the operation, and must have been of mate- 
rial assistance to the deeper veins, in returning the blood from the limb. 
The details of this unfortunate case, which, towards its close, was looked 
upon as one of erratic phlebitis, throw much light upon some of the symp- 
toms that follow operations upon varices, and serve to show that other cir- 
cumstances, equally as important as phlebitic inflammation, must hereafter 
be taken into account in determining the propriety of any operation upon 
the veins. The fatal issue was evidently induced by inflammation of the 
absorbents, and not by phlebitis. 
The signs in the early part of the case, which subsided after the loosening 
of the bandage, were probably owing to the extension of irritation in the 
course of the absorbent vessels, as indicated by the swelling and tenderness 
at the groin, and by the enlarged lymphatic glands in the middle of the thigh. 
It is difficult to say how far this irritation was the result of the irregular and 
painful pressure of the bandage on the leg, or how far the direct effect of a 
division of the absorbent vessels themselves during the operation. The sub- 
sidence of most of the constitutional symptoms for a few days before the 
close of the second week, shows that the inflammation of these vessels could 
not, at that period, have progressed above the groin. But the loss of power 
in the limb, the inability of the patient to turn himself in bed, the severe pain 
in the hips, the recurrence of rigors and sickness of stomach, the dry and 1843.] 
Watson on the Pathology and Treatment of Varices. 
57 
heavily-coated tongue, the emaciation, and the rapid and feeble pulse, all of 
which came on rather suddenly about the close of the fifteenth day, may be 
looked upon as indicating, at this period, a rapid extension of inflammation 
in the course of the absorbents, to the loose cellular tissue of the left lumbar 
region, eventually terminating in the recent abscess, which exhausted the 
patient, and was the immediate cause of death. 
Before closing these observations on individual cases, I may remark that 
they constitute only the seveier instances of varices that have fallen under my 
notice, and that, during their occurrence, I have had the management of nu- 
merous other cases. Some of these were the result of local injury, some of 
chronic ulcers, some accompanied tumours both simple and malignant, and 
some appeared to depend not so much upon an undue determination of blood 
to the lower extremities, from disease, severe labour, or the long observance 
of the erect position, as upon a natural laxity of fibre, either in the coats of 
the veins themselves, or in the tissues surrounding them. In several instances 
of this last class, the varices were less marked in the larger veins than in 
those of smaller calibre. They were nearly all observed in females of lym- 
phatic temperament, with superabundance of fat in the limbs; one of them, 
however, was a youth of twenty years of age. These cases were mostly 
treated with the roller and by keeping the limbs elevated. In a few, 
I pencilled the integument over the veins with tincture of iodine, but 
with no appreciable advantage. I shall close the report of cases with the 
following: 
Case XVII.—A coloured woman, aged 28, had for eight years suffered 
from a varicose swelling on the saphena major, just below the knee, which 
she stated to have been produced by an inflammation at the upper part of the 
leg, caused by resting on her knees in scrubbing. For six years the varicose 
swelling appeared to remain stationary; but some time since, after having 
placed her feet in cold water, she was suddenly affected with severe pain and 
stiffness of the limb, and ever since the varices have been increasing. They 
now involve numerous branches of the saphena major on the leg, and extend 
around either ankle to the foot. She is subject to occasional attacks, during 
which the pain and turgescence of the limb are almost unsufferable. During 
these attacks she has been in the habit of puncturing the veins with a needle, 
in order to unload them. She has in this way often drawn half a pint of 
blood, or more, at a time. She has occasionally employed the common 
roller as a palliative, but from soon slipping and falling into irregular folds, 
it has given her so much uneasiness, that she can no longer resort to it. She 
was desirous of submitting to an operation for relief. From this, after the 
ill success above stated, I considered it my duty to dissuade her. I therefore 
resorted to another expedient. Requesting her to keep her bed for twenty, 
four hours with a common roller on the limb, in order to overcome the swelling, 
on the following day I applied several small portions of a common wax bougie, 
some longitudinally, others transversely, along the limb, over the course of 
the varices; I secured them in these situations, and then enveloped the limb 
in a starched bandage. On the succeeding day she was walking about; the 
bandage gave her no uneasiness except in ascending a flight of stairs. At 
the end of two weeks the dressings were still undisturbed. The patient ex- 58 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
periences no inconvenience from the varices, but it is too soon yet to antici- 
pate the permanent result of the experiment. 
Part Second. I. Pathology.—The term varix has been employed in a 
manner altogether too indefinite. By some writers it is applied to a sort of 
thrombus or pouching tumour in the walls of a dilated vein, holding the same 
relation to the vein as an aneurism to an artery.* Others, using it in this 
sense, apply it also to varicose tumours formed by an agglomeration of con- 
volutions, either in a single dilated vein, or in a congeries of veins intimately 
entangled.t The true import of the term, as used by the ancients and 
others, is still more comprehensive. A varix, according to Galen,f is a vein 
tumefied or dilated with blood. In this sense it is also used by Paulus iEgi- 
neta,§ Pare,|| J. Cloquet, and others. It may be defined to be a vein mor- 
bidly dilated, and usually elongated, convoluted, and nodulated. 
II. Seat of Vances.—Varices may occur in almost any part of the body. 
They have been observed on the head, on the arm; in the jugular veins, the 
subclavian, the vena cava, the azygos, the intercostal veins, the veins of the 
abdomen and pelvis, and the veins of the thoracic and abdominal parietes. 
They are most frequent in those parts of the body from which the blood 
returns with greatest difficulty to the heart, as in the superficial veins of the 
lower extremities, the spermatic, the hemorrhoidal veins. 
On the head and face the disease is of rare occurrence. I have seen it 
on the lips, and in one instance in the minute veins of the conjunctiva. In 
this case the vessel ruptured spontaneously, and produced a diffuse ecchy- 
mosis. Asa secondary affection, it is occasionally seen here among the re- 
sults of chronic ophthalmia. The morbid growth on the conjunctiva, called 
pterygium, in some instances is evidently the result of a varicose enlarge- 
ment of the veins of this membrane. According to ffEtius,** the disease may 
* Hodgson (on tlfe Arteries and Veins, p.538,) says, “A small portion of a vein is occa- 
sionally more dilated than the rest, and forms a prominent tumour, which is denominated 
a varix.” On the same subject M. Monfalcon (Diclionnaire des Sei. Med.) says, “elles sont 
b. ces vaisseaux ce qu’est aux arteres l’anevrisme qu’on appelle vrai.” 
t “Varix, xips-oj. Tumeur formee par la dilatation plus ou moins considerable et per- 
manente des veines.” Begin, (Dictionnaire de Med. et de Chirurg. Prac.) Mr. S. Cooper 
gives the word this sense in his definition of it, whilst in his article on varicose veins, he 
gives it the more liberal application. 
t As given by Fcetius, (QEconomia Hippocratis, appended to his Latin version of Hip- 
pocrates); also by himself, “varices venae dilataUe sunt.”—(Epitome Galeni Operum, fob, 
Lugduni, 1643, p.459.) 
§ As adopted by Fabricius ab Aquapendente. 
II The small tumours, by some modern writers called varices, Pard distinctly charac- 
terises under the name of Thrombus. (Les GEuvres d’Ambrose Pard, fob, Paris, 1579, 
p. 484.) 
IT Dictionnaire de Medecine. 
** As stated by the translator of Hippocrates. 1843.] 
AVatson on the Pathology and Treatment of Varices. 
59 
occur upon the eyelids; others have noticed it on the temples. Alibert* has 
found almost every vein of the head affected with varices. Portal* has dis- 
covered varices in the meningeal veins of the head; and, according to Mon- 
falcon,* they occur in the vessels of the pharynx and upper part of the (Eso- 
phagus, and bursting here, give rise to extensive hemorrhage. 
In the veins of the arm, varices, as a primitive affection, are exceedingly 
rare. In a case recorded by J. L. Petit,* the disease occurred at the flexure 
of the arm. The patient was fat, and no other vein being apparent, M. 
Petit, wishing to bleed the patient, was obliged to puncture the varix with a 
lancet. M. Rouxt saw a case under the care of Sir A. Cooper, in which 
the superficial veins of the fore-arm were immensely distended. As a se- 
condary affection, however, varices are as frequent on the arm as on other 
parts. I have seen them here in connection with malignant tumours. Mon- 
falcon quotes a case from M. Cartier, in which all the superficial veins of the 
upper extremity were affected. The disease was congenital, but increased 
with the growth of the patient. At the age of twelve, “the varices were 
separated from one another by considerable depressions; the skin was bluish 
and livid, in a word, the arm and fore-arm appeared to be full of nodosities.” 
This, I suspect, was an instance of aneurism by anastomosis, a disease in its 
origin very different from the one under consideration, but which, as is well 
known, may extend in the course of the large vessels, and in the end pro- 
duce all the appearances of simple varices, Aneurismal varix, or that variety 
of the disease which is produced by the passage of arterial blood from its 
proper vessel, through an unnatural opening into a vein, is of more frequent 
occurrence on the upper extremity than on any other part of the body, owing 
to the fact that the operation of venesection is now almost exclusively per- 
formed on the vessels of this part. 
In the veins of the neck the disease has been observed by Morand,f 
Cline,§ Portal,|| and M. Cases similar to that recorded by Morand 
are not unfrequently the result of obstructed circulation through the heart. 
The jugular veins in this instance were of the thickness of a man’s thumb. 
The woman had suffered from palpitation, faintings, and continual pulsation 
in the jugular veins—“The right auricle of the heart was almost filled with 
a polypous concretion, the branches of which reached through the neighbour- 
ing veins quite to the jugular.” In Mr. Cline’s case, the patient was also 
a female, who had a large pulsating tumour in the neck, which burst, and 
proved fatal by hemorrhage. “A sack proceeded from the internal jugular 
* Dictionnaire des Sciences Medicales. 
t Medico-Chirurgical Review for July, 1832, p. 184. From Journal Hebdom. 
t As quoted by Morgagni, Letter xviii, article 9. 
§ Hodgson. Treatise on the Arteries and Veins, p. 539. 
|| Dictionnaire des Sci. Med. 
T Medico-Chirurgical Review for July, 1832, vol. xvii., new series, p. 184. 60 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
vein; the carotid artery was lodged in a groove at the posterior part of the 
neck.” 
“A man, aged 23, entered the Hopital de la Charite under the care of M. 
Roux. There was a tumour situated immediately above the clavicle, of the 
size of a pigeon’s egg, which was at first supposed to be an encysted tumour; 
it w-as firm, elastic, and did not pulsate. The patient had noticed it for about 
two years, but it xvas only within the last two months that it had given him 
any annoyance. Its true nature was not ascertained before the operation; 
when cut into, a quantity of coagulated black blood flowed out.” The swell- 
ing was now discovered to be formed by the dilatation of a venous branch 
communicating between the two jugulars. We are not told which jugulars, 
probably the deep and superficial of the same side. M. Roux put a ligature 
round it, and also around several thoracic branches. Fortunately the wound 
healed perfectly in a fortnight.” 
Varices in the subclavian vein are extremely rare. M. Hodgson and others 
refer to a case of this recorded by Portal: the dilatation was excessive in the 
right subclavian vein, and terminated fatally by bursting into the cavity of the 
chest. 
In the veins of the thorax varices have been observed by several authors. 
Morgagni,* on the authority of other writers, refers to several cases of 
varices of the vena cava, and other large veins attached to, or in the imme- 
diate neighbourhood of the heart, and gives the particulars of a case from 
Manfredi, of a varix of the vena azygos, which ruptured and terminated 
fatally. The vein, though contracted by the effusion, “ had retained so much 
of its breadth, that it might be well compared to the vena cava. This dila- 
tation had extended itself to about the length of a span, and about the mid- 
dle of that length a foramen lay open, in the form of an ellipsis.” Portalf 
has recorded three instances of this same condition of the vena azygos. In 
one of these the disease had also extended to the inferior intercostal veins, 
one of which was open. 
In the veins of the abdominal and pelvic viscera,\arices occasionally occur. 
Internal abdominal hemorrhages, according to Monfalcon, are frequently caus- 
ed by the rupture of vavices. In one of the preceding cases I have noticed a 
varicose condition of the veins of the uterus and its appendages. An instance 
occurred to M. Cruveilhier4 in which a varicose condition of the veins of 
the round ligament was found in connection with a strangulated hernia: the 
nature of the disease was made evident after the operation. The internal 
surface of the bladder is sometimes affected with varices, which rupture and 
give rise to hasmaturia; but the veins in the neighbourhood of this organ 
most frequently affected, are those that surround the prostate gland. In a 
* Letter xxvi, articles 28 and 29. 
t Monfalcon. Diclionnaire des Sei. Med. 
t Medico-Chirurgical Keview, vol. viii., new series, p. 543. 1843.] 
Watson on the Pathology and Treatment of Varices. 
61 
patient who had suffered from a tumour of the luette vesicale, which had 
given rise to hypertrophy of the bladder, to calculous deposits, disease of the 
kidneys, &c., I found some of the plexuses of veins around the neck of the 
bladder and base of the prostate gland larger than ordinary goose quills. The 
vagina and vulva are occasionally the seat of varices. During parturition 
they are exposed to injury, and when ruptured, may lead to fatal hemorrhage. 
Cases of this sort have been recorded by Dr. Elsasser and others.* The 
veins of the urethra are sometimes affected in the same way, giving rise to 
symptoms analogous to those of stricture, and on the introduction of cathe- 
ters or bougies, giving rise to profuse and alarming hemorrhage. Such, I 
have reason to believe, was the fact in the following case: 
Mr. C., a Smyrnese, aged 40, had long suffered from a slight obstruction 
in the urethra, which was supposed to be an ordinary stricture. A few slight 
applications of lunar caustic had been made with apparent benefit. On the 
26th of March, 1842, the caustic was applied with as much caution as usual 
at the supposed seat of stricture, between five and six inches from the mea- 
tus urinarius. The amount of caustic dissolved was scarcely appreciable. 
The patient experienced no unusual symptoms until Sunday night, March 
27th, about thirty-two or thirty-three hours after the introduction of the in- 
strument. But feeling a disposition at this time to evacuate his bladder, he 
arose from bed, and, after some effort, began to evacuate clotted blood. 
During the night he was frequently aroused to repeat the same procedure, so 
that before the morning he passed nearly a chamber-potful of this clotted 
blood, mixed with fluid blood and urine. The discharge recurred about once 
an hour until the afternoon of the 28th, at which time I first saw him. He 
was pale, cold, agitated, and frequently shivering. He complained of throb- 
bing in his head, and sighed frequently and deeply. His pulse was weak, 
disposed to intermit, and ranging at sixty in a minute. His physician had 
administered rhatania extract internally, and had applied cold wet cloths to 
the perineum. The patient informed me that he could continually feel the 
blood, as he lay on his back, dropping, as he expressed himself, “ goutte par 
goutte” against the has fond of the bladder. A solution of acetate of lead, 
fifteen grains to the ounce of water, was thrown into the urethra through a 
silver canula, previously introduced about four inches and a half into the 
passage. After injecting about four ounces of the solution into the bladder, 
and withdrawing the instrument, a compress was applied to the posterior 
part of the perineum, and directions were given, in case the hemorrhage re- 
turned, to introduce a tampon of ice into the rectum. The patient had no 
evacuation of the bladder for several hours afterwards. About midnight he 
again voided a small quantity of clotted blood and urine; the tampon of ice 
was then introduced. On the following morning he voided healthy urine, 
free from blood. He had no subsequent return of the hemorrhage. 
In the veins of the thoracic and abdominal parietes.—On the chest and 
upper part of the body varices are rarely observed, except as the effect of 
tumours and of carcinomatous diseases. In their simpler form they are not 
unfrequent on the walls of the abdomen. In one of the foregoing cases 
there existed a varix of considerable size in the superficial epigastric vein. 
* American Journ. Med. Sci. vol. xvi. p. 233—234. 
No. IX.—January, 1843. 62 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
Varicose tumours of immense size sometimes form on the lower part of the 
abdomen, especially in women who have borne several children, cases of 
which have been recorded by Severinus,'* Boyer,t Bordeu,J and other wri- 
I have observed extensive varices on this part of the body in con- 
nection with ovarian tumours; and on the hips and loins, in connection with 
bony tumours. 
In the hemorrhoidal and spermatic veins.—These vessels, next to those 
of the lower extremities, are the most frequent seat of varices. In the veins 
of the rectum and anus, the disease receives the specific name of the piles, 
or hemorrhois, and is'of too much importance, and attended with too many 
peculiarities, both in a pathological and therapeutical point of view, to be 
spoken of incidentally. It may, perhaps, be the subject of a future essay. 
The same remark will apply, but not so forcibly, to the disease in the veins 
of the testicle and spermatic cord, where it constitutes varicocele, or, as it is 
still occasionally, and more properly called, cirsocele. 
In the veins of the lower extremity.—This part of the body is beyond all 
comparison the most frequent seat of varices. The main object of the cases 
reported at the commencement, is to illustrate the disease as it affects this 
part. Leaving then the history of varices as they occur in other parts of the 
body, we have now to speak of them in the vessels of the leg and thigh. 
III. Stages in the progress of varices.—When this disease in the veins 
of the lower extremity is the result of local injury, or of any morbid influ- 
ence acting directly on the limb, the varicose enlargements usually appear 
first in the neighbourhood of the affected part, or in the vessels that receive 
the blood directly from it. But they most frequently commence just below 
the inner side of the knee, and again in the vessels ramifying through the loose 
cellular tissue just above the heel, on either side of the tendo Achillis. The 
great saphena and its branches are more frequently affected than the saphena 
minor, owing to the shorter course and peculiar termination of the latter. 
The deeper vessels are but rarely involved. They are not, however, ex- 
empt. In the auto psieexamination of Case XVI., I observed a very exten- 
sive varix behind the knee, in one of the deep veins, just before its entrance 
into the femoral. 
The changes produced in the vessels by the progress of the disease are, 
first, simple dilatation, which, though it may result from mere physical dis- 
tension, soon leads to a proper interstitial development, in the same way that 
morbid, and even healthy developments, are sometimes effected in other or- 
gans, as in hypertrophy of the muscles by healthy exercise of them; hyper- 
trophy of the heart, by mechanical distension and over-action; morbid deve- 
lopment of the bones of the head and face, and of the soft parts connected 
* De Recondita Abscessuum Natura, Cap. ix., § 13. 
t Maladies Chirurg., tome ii.,p. 359. 
§ Medico-Chirurgieal Review, vol. xix., p. 213. 
t Monfalcon. Diet, des Sci. Med. 1843.] 
Watson on the Pathology and Treatment of Varices. 
63 
with them in some cases of chronic hydrocephalus, and from tumours in their 
neighbourhood. 
The next important change is an increase of length. This is in a still 
more marked degree the result of interstitial growth, and not of physical dis- 
tension. As the vessel grows in length, it falls into folds and serpentine con- 
volutions, and these occur most readily at points within which the vessel is 
under least restraint from fascias or dense cellular tissues, or other resisting 
envelopes. The walls of the vein about this period occasionally yield irre- 
gularly to the pressure of the blood, and form the small pouches which some 
have compared to aneurisms, and to which Pare gives the name of throm- 
bus. These several irregularities in the shape and course of the vessel, at 
first appear to be easily effaced; they disappear under certain movements of 
the limb; but by degrees they become fixed. The vessel contracts intimate 
adhesions to the surrounding tissues, which in their turn take on a diseased 
action, and become condensed into firm bands, extending from one fold or 
convolution of the vein to another, holding the vessel in its irregular shape, 
preventing it from exercising its proper elastic force for diminishing its cali- 
bre, and as the folds and convolutions at a particular point increase, binding 
them into one mass in the form of a varicose tumour. At this stage of the 
disease, by forcing the blood from the vessels, they may be made to collapse, 
so as to be no longer visible externally. A few days’ repose, or the pressure 
of a bandage, may so far relieve the varices, as to lead us for a time to sup- 
pose that they have been entirely obliterated. The mistake, however, is cor- 
rected as soon as the pressure is removed, and the blood is allowed to de- 
scend into the limb. 
The next stage in the progress of the disease is an increase of thickness 
in the elastic coat of the vessel. This, in its healthy state, is always deli- 
cate, and never so firm as to prevent the vein from collapsing when deprived 
of blood. 13ut in the progress of morbid development, it may become, even 
in the terminal branches of the saphena, thicker and tirmer than the corre- 
sponding coat in the largest arteries. When examined under these circum- 
stances, it is found to have a pale bluish, grayish, or sometimes yellowish- 
white appearance, a cartilaginous hardness, and considerable contractile force. 
The cellular tissue surrounding it is also consolidated, sometimes nearly as 
firm and compact as the elastic coat itself. In some cases, especially in the 
early stages, the hypertrophy is uniform in the whole circumference of the 
vessel, though never so throughout its whole extent, being generally greatest 
at the point where the varix first appeared, or where it has been subjected to 
the greatest irritation. But in other cases, especially where the convolutions 
are short, numerous, or intimately involved, the elastic coat is thrown into 
nodules, and transverse prominences and depressions; the prominent points 
on the inner face of the vessel being usually the seat of nodules, or of an 
undue degree of hypertrophy, whilst at the depression on the opposite part 
of the vessel the parietes may be but little, if any, thicker than natural. 64 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
Sometimes these nodules are so numerous in the course of the vessel, when 
felt beneath the skin, as to give a sensation similar to what might be produced 
by a chaplet of beads, or by a hard knotted cord. This feeling, however, is 
no evidence that the calibre of the vessel has been obliterated or obstructed 
with fibrinous coagula. Pressure, the horizontal position, or any other mode 
of emptying the vessels, may at this stage diminish the size of the varices, 
but will not even temporarily obliterate them. 
The inner coat appears to be the last to suffer. This at first is found 
smooth, shining, and diaphanous; at a later period it is thrown into reticu- 
lated depressions, and afterwards into minute longitudinal folds, giving it, 
with the reddish tinge which it has now acquired, the appearance of delicate 
muscular tissue. At this stage, though the inner membrane adheres closely 
to the elastic coat, and follows it through all its transverse ridges and de- 
pressions, it may, nevertheless, readily be torn in large patches from the 
latter, and these patches, when thus removed, show the membrane to have 
been thickened; the longitudinal folds disappear, the reddish tinge continues, 
but no vesssls are visible in its texture to the naked eye. 
In varices resulting from tumours and malignant growths, the coats of the 
veins are rarely or never thickened as above described, but are subject to the 
diseases of the surrounding tissues, and when inflamed, the blood coagulates 
within them, and may in this way prevent the loss of blood, on the super- 
vention of ulceration or sloughing. More frequently, however, their parie- 
tes give way before the blood coagulates, causing copious hemorrhage, which 
continues to recur as the disease progresses, and is the immediate cause of 
anasarcous swellings, sinking of the vital powers, and finally of death. But 
the coagulation of blood in ordinary varices is a rare occurrence. I have never 
had occasion to witness it independent of inflammation. As a result of inflam- 
mation, however, it is as likely to occur in varicose veins as in any other. 
Cases of spontaneous phlebitis supervening on varices, and terminating fa- 
tally, are reported by Mr. Lawrence and others. The strings and shreds of 
coagulable lymph mentioned by some writers as occurring in varicose veins, 
I have never witnessed on first opening into these vessels. In the autopsic 
examination of Case XVI. I noticed them, but only in the parts of the vein 
from which the circulation had been previously intercepted by the operation, 
and which were already in the process of obliteration. In short, the spon- 
taneous closure of varices, independent of acute phlebitis, is rarely or never 
noticed. The knotted and cord-like character of the vessel, when felt be- 
neath the skin, even if accompanied with a marked diminution of size, or 
following a previous state of unusual swelling and excitation, is not to be taken 
as proof of the closure of the vein. In Case XV. all these circumstances 
were observed before the operation, and in some of the vessels afterwards; 
but in the autopsic examination the diseased veins were found pervious, and 
most of them apparently as much dilated as they had ever been. 
Varices accompanying ossific and osteo-sarcomatous tumours, are some- 1843.] 
Watson on the Pathology and Treatment of Varices. 
65 
times found imbedded in grooves upon the surface of these tumours. Mr. 
Hodgson states that similar grooves are sometimes found on the surfaces of 
healthy bone in cases of ordinary varices. This I have not witnessed; but 
the induration of the tissues on either side of a varix, may give the finger 
when pressed upon the vessel, a sensation similar to what might be pro- 
duced by a depression in the bone. 
IV. Complications.—Often before the walls of the veins take in the state 
of hypertrophy above described, the languid circulation and increasing 
turgescence in the capillaries, lead to swelling of the limb. The skin and 
subjacent tissues are engorged with venous blood, infiltrated with serum, or 
consolidated with lymph. Ulcerations difficult to heal break out sponta- 
neously, or after the slightest injury, around the ankles or lower part of the 
leg; or pruriginous eruptions in the form of lichen, or chronic eczema, 
attack the flexures of the joints, the natural folds of the skin, or those parts 
of the limb upon which the varices are most troublesome. The cellular 
tissue is occasionally the seat of small indolent swellings that rarely suppu- 
rate, but occasionally take on gangrenous inflammation. These form imme- 
diately over varices, to which they adhere; and which, indeed, give rise to 
them. They usually bind the diseased vessel to the skin, and after ulcerat- 
ing or sloughing, give rise to sudden hemorrhage. The subcutaneous tissues 
are also occasionally the seat of sanguineous effusions, sometimes from the 
minute vessels, at other times from those of greater size, occurring either 
spontaneously or after trifling injuries. The varices themselves, already in 
a state of excitation, are peculiarly subject to sudden attacks of erethism 
bordering on subacute inflammation. This in turn leads to extension of the 
disease to vessels not previously affected, or to its more rapid development 
in those that have already suffered; or it induces ulceration in their coats 
which sooner or later progresses to the surface, and gives rise to sudden 
hemorrhage. Finally, acute suppurative phlebitis may supervene sponta- 
neously in the progress of varices, and lead to fatal consequences; as in a 
case of Mr. Lawrence’s, reported in the Lancet, (Jan. 20th, 1827, p. 527.) 
and in others, reported in the same journal, (Sep. 10th, 1825, p. 305.) from 
the Archives Generates. 
Among these various complications the ulcers are the most frequent; and if 
not the most dangerous, are at least among the most troublesome. Of these 
there are three kinds: first, the ordinary indolent ulcer, occurring about the 
ankles and lower part of the leg, indeterminate as to size and form, but al- 
ways obstinate. Independent of its connection with varices, and of its in- 
tractable nature, it has no characteristics to distinguish it from other ordinary 
ulcers. The second form is a minute perforating ulcer not much larger 
than the head of a pin, never larger than a pea, and is produced by the ex- 
tension of ulcerative action from the vein outward. It is surrounded with 
little or no swelling or induration: it gives rise to hemorrhage which may 66 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
recur a few times before the ulcer closes. Finally, it cicatrises, and is not 
likely to reappear. The third form is also small, occurring in the centre of 
one of the small indolent tumours already noticed, either after an abrasion of 
this, or after the separation of a slough. It gives exit to hemorrhage, as in 
the second form; heals up spontaneously soon afterwards; but is likely to 
reappear during intervals of excitement in the vein beneath it, or after 
injury. 
It has been remarked, perhaps correctly, that the loss of blood from 
varices, when moderate, has not the same prostrating effects as other he- 
morrhages. The blood in these vessels is habitually in excess, and the 
whole system often in a state of plethora, as indicated by attacks of epistaxis 
and hemorrhage from organs remote from the diseased veins. The function 
of sanguification appears to be exalted either to supply the loss caused by 
frequent bleedings from the varices, or to repair the deficiency in the rest of 
the body caused by the recession of blood to the dilated veins, in which it 
remains shut off, as it were, from the general circulation. This plethoric 
condition is strongly shown in those cases in which the simple application 
of a roller to the limb, or any other measure calculated to force the blood out 
of the varices into the general circulation, has led to congestion or inflamma- 
tion of distant organs, to haematemesis, diseases of the lungs, and other alarm- 
ing consequences. Madame Boivin, says Velpeau,* cites the case of a girl 
who when pregnant, could bring„on an abortion at any time, by bandaging 
her legs, which were varicose. Mr. Freer’s case, reported by Mr. Hodg- 
son,t in which a ligature applied to the saphena vein gave rise, within four 
hours afterwards, to violent pain in the left side of the chest, quick and la- 
borious respiration, inability to speak, and at length to vomiting of blood; 
and in which the alarming symptoms subsided on the removal of the liga- 
ture; and reappeared on repeating the operation several weeks afterwards;— 
is evidently another striking example of the same sort. 
V. Causes.—Without entering minutely into the special causes of varices, 
we may remark that they most frequently occur during the middle periods 
of life, and almost invariably after the age of puberty, in persons of both 
sexes habituated to severe labour, or protracted exercise on foot; or who 
have suffered from other affections determining an undue quantity of blood 
to the lower extremities, or preventing the blood already there from return- 
ing freely to the heart. 
In reference to their causes, then, varices are either primary or secondary. 
The hist occur in persons of lax fibre, of lymphatic or sanguineous tempera- 
ment; the coats of whose veins are naturally delicate, who have a supera- 
bundance of fat in the limbs, whose superficial veins lie loose in the midst 
of soft cellular tissue, free from the restraint of sheaths or dense surrounding 
* Medecine Operatoire, tome 2d, p.262. Paris, 1839. 
t Treatise on the arteries and veins, p. 551. 1843.] 
Watson on the Pathology and Treatment of Varices. 
67 
textures. The second may result from chronic ulcers, from cutaneous erup- 
tions, morbid growths, local injuries, spontaneous inflammation, or they 
may occur after long confinement to the recumbent position, or in the train 
of other diseases, especially of the abdomen; as in disorders of the portal 
system, ovarian and other tumours, the gravid uterus; and, as some believe, 
from obliteration of the larger veins. It should be remarked, however, that 
mere mechanical obstruction is never of itself sufficient to give rise to varices. 
The blood when impeded in its course through its natural channels, is almost 
immediately diverted into others, so that obstructions of this sort, instead of 
producing varices, are, in fact, among the most efficacious means of curing 
them. 
Mr. Hodgson has intimated that varices may be the result of rupture of 
the valves of the veins; and Sir Everard Home thinks that in varices the 
valves are thickened and contracted. I am not aware of any facts on record 
to establish these points. In every instance in which I had an opportunity of 
examining the veins, the valves were perfectly healthy. Nor have I been 
able to confirm an observation made by Boyer, that varices are most apt to 
appear immediately above the situation of the valves. The truth is, valves 
are not often found in the midst of varicose enlargements, except in the 
saphena major above the knee. Even in healthy veins their number and 
position are indeterminate. I have at times been led to suppose that they 
are less numerous in persons subject to varices than in others. But if dis- 
ease in the valves has not been shown to give rise to varices, the impairment 
of their function after the varicose dilatation has commenced, evidently tends 
to aggravate it. In Case XVI. after the saphena major had been divided, 
pressure applied immediately above the incision, instantly arrested the he- 
morrhage; but when applied at the distance of three inches above this point, 
it only served to aggravate it. The autopsic examination showed that a 
healthy valve situated between these two points, had not been able to pre- 
vent the regurgitation of the blood entering the saphena from a large col- 
lateral branch that opened into this vein above the valve. 
VI. Diagnosis.—Varices may be overlooked or confounded with other 
diseases. In the thorax of persons dying of phthisis they have been found, 
where no such complication had been suspected.* We have no means of 
forming even a probable diagnosis of their existence, during life, in any of 
the natural cavities; except so far as they may occur in connection with 
other varices in vessels leading immediately into these cavities. Even in 
the superficial vessels they are sometimes overlooked. In the feet and lower 
part of the legs of adipose women, they may give rise to considerable swell- 
ing, which may be attributed to serous infiltration, or to irregular deposi- 
tions of fat. At the groin, in the upper part of the saphena major, in the 
* Morgagni, loc. citat. 68 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
superficial epigastric veins, or in the femoral vein, &c., they occasionally 
give rise to tumours, which may be taken either for aneurisms or for hernial 
protrusions. Instances of this sort have been noticed by Sir Astley 
Cooper,* I)upuytren,f Cruveilhier,J and others. The diagnosis in such 
cases is readily effected by pressing on the disordered veins, at the distal 
side of the tumour. In the lower part of the neck the veins are sometimes 
observed to pulsate, and when varicose may be mistaken for aneurisms. 
Morgagni in reference to these, says, “ we may distinguish the veins I am 
speaking of from the carotid arteries, if we attend to their external situation, 
and the softness of their parietes; and especially if with Morand we observe 
that upon pressing the finger upon them, that part of the vessel which is 
below the finger shall, according to the laws of the circulation, subside; and 
that part which is above is increased, or at least preserves its former disten- 
Dupuytren also described a pulsating varicose tumour at the groin, 
that might have readily been confounded with aneurism of the femoral 
artery.|| Again, erectile tumours or aneurisms by anastomosis, when sub- 
cutaneous, may at times be mistaken for varices. Such I suspect was the 
fact in a case of reputed varices of the fore arm, quoted by M. 
from M. Cartier. For the peculiar characteristics of these tumours I must 
refer to my essay on Telangiectasis.** 
VII. Terminations.—I have already had occasion to speak of the dispo- 
sition of varices to occasional attacks of turgescence or erethism, during 
which the hypertrophy of their coats progresses with rapidity. On the 
subsidence of this state, the undue amount of blood which it attracts towards 
the veins, forsakes them; they contract somewhat upon themselves, and 
may diminish their calibre so much, as in future to contain even less blood 
than naturally belongs to them. This same mode of termination also proba- 
bly goes on in a more protracted manner in the ordinary process of the dis- 
ease, where neither erethysm, inflammation, nor ulceration, supervenes to 
interfere with the gradual hypertrophy of the coats of vessels. In persons 
who have recovered from one or two attacks of the venous erethysm above 
mentioned; and in others who have long relinquished the laborious habits 
that gave rise to varices; and again, in very aged people who had formerly 
suffered from these, we occasionally find that their former varices have so 
far diminished as to give them no uneasiness, and to be distinguished only 
by their corded and irregular feeling under the skin. 
The calibre of the vessels under the foregoing circumstances, is simply- 
reduced in size; the second mode of favourable termination, is in absolute 
closure of the veins. This mode of termination I suspect, is effected only 
* Lectures. 
t Ibid. vol. viii., new series, p. 543. 
t Medico-Chirurg. Rev. March, 1829. vol. x., new series, p. 575. 
§ Letter 18th, section 11th. 
|| Medico-Chirurg. Rev. March 1829, p. 575. 
IT Dictionnaire des Sci. Med. 
** American Journ. Med. Sci. vol. xxiv. p. 24. 1843.] 
Watson on the Pathology and Treatment of Varices. 
69 
by the supervention of active inflammation. When inflamed, the inner 
membrane of the veins throws out coagulable lymph, which interrupts the 
course of the blood through them; the blood itself coagulates, and adheres to 
the parietes of the vessel; the vessel itself adheres to the surrounding tissues, 
and if the inflammation is arrested in this its adhesive stage, the fibrinous 
effusion within the vein gradually becomes organised, the coagulated blood 
is absorbed; and the vessel is converted into a ligamentous cord, which at a 
still later period is finally resolved into its primitive cellular tissue. But if 
the inflammation proceeds to suppuration, and is still limited to the varices, 
fibrinous effusions, and purulent collections form both on their inner and 
their outer surface; the integuments ulcerate, and after the evacuation of the 
pus the inflammation subsides, and the varices are finally obliterated, as 
under the former circumstances. 
Finally, varices may terminate spontaneously in death. The fatal result 
may be induced, first, by suppurative phlebitis, as in two cases already re- 
ferred to; the one in the practice of M. Ribus, the other in that of Mr. Law- 
rence.* This mode of termination, occurring but seldom as a spontaneous 
result, is the most common in fatal cases after operations. The symptoms 
and anatomical characteristics of traumatic phlebitis, I have sufficiently illus- 
trated in another place.f 
Secondly, Varices may lead to fatal consequences by the direct loss of 
blood, as in Case III. A similar case is mentioned by IIeister,j in which 
the patient bled to death in his bed. I have already referred to Morand’s 
case, of rupture of a varicose jugular terminating fatally, and to Mr. Cline’s 
case of a varix in the same vessel terminating in the same manner. In three 
cases reported by Dr. Elsasser,§ the patients, during labour, bled to death 
from the rupture of varices in the vulva. Four others are cited in the Ameri- 
can Journ. Med. Sci. (vol. xvi. p. 234.) in which women under similar cir- 
cumstances died of loss of blood from varices in the vagina and external parts 
of generation. Many writers, speaking of varices on the lower extremities, 
without reporting cases, allude to instances of fatal hemorrhage. It is incor- 
rect, observes M. Velpeau,|| to say that varices are unattended with danger. 
The contrary of this was sufficiently proved by M. Girod in 1814. Petit has 
demonstrated the serious effects of ruptured varices. Two patients, mentioned 
by Lombard, died of these. Chaussier cites an instance of ruptured varix in a 
pregnant woman terminating fatally. Murat has given an account of a washer- 
woman who died suddenly of the same accident. In 1827 a similar case 
was mentioned at the Academy of Medicine. I saw, continues M. Velpeau, 
a countryman, in 1819, die of hemorrhage twenty-four hours after the burst- 
ing of a varix. The death of Copernicus was owing to this cause. MM. 
* London Lancet, Sep. 10th, 1825, p. 305; and Jan. 20th, 1827. 
t See my essay on secondary abscesses. Amer. Journ. of Mud. Sci. v. xxi. p. 37. 
t System of Surgery, vol. ii. p. 344. 
|| Medccine Operatoire, tom. ii. p. 262. 
§ American Journ. Med. Sci. vol. xvi. p. 233. 70 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
Reis, Lacroix, and Lebrun have published similar facts. A pregnant woman 
under the care of M. Forestier, from the same cause, was reduced to the 
same extremity. To this list of M. Velpeau’s I may add, that in Cases VIII. 
and X., already reported, the danger from hemorrhage was equally as immi- 
nent as in the pregnant woman last cited. 
Again, after operations the disease may terminate fatally, independent of 
phlebitis, by the extension of inflammation to the absorbents, with or with- 
out the concomitant formation of abscesses in the course of these vessels. 
The absorbents are, indeed, intimately involved in most of the diseases of 
the veins, whether spontaneous or traumatic. In cases of spontaneous 
obliteration of the veins, attended with dropsical effusions, M. Bouillaud* and 
others! have attributed the effusions to the obstruction in the veins, the real 
cause of which, however, was more probably owing to simultaneous diseases 
in the absorbent vessels accompanying the veins. For, there are numerous 
cases on record to show that veins even of the largest size, and many of 
them together, may be completely obstructed without giving rise to oedema 
or dropsical effusions. “I have already observed,” says Mr. Brodie,! in 
speaking of varicose veins of the lower extremity, “ that there are some 
reasons for believing that the venous branches are less liable to be inflamed 
in consequence of mechanical injury than the trunks in which they termi- 
nate.” The observation is correct, so far as it refers to the occurrence of 
inflammation, and is probably owing to the fact that the trunk of the saphena 
is surrounded by an immense number of absorbents, that suffer under every 
operation upon this vessel, and participate in most of its diseases. In Cases 
VI. and XIII. the absorbents were evidently inflamed after the operation, as 
shown in the one by the enlargement of a lymphatic gland over the saphena 
major in the middle of the thigh; and in the other, by linear inflammation in 
the integuments and enlargement of the glands at the groin. In Case XVI. 
the fatal result was evidently induced by the extension of inflammation along 
the absorbents, and from them to the loose cellular tissue in their course along 
the psoas muscle. Such, also, was probably the cause of death in one of 
the cases given by Mr. Hodgson, the symptoms of which were analogous to 
my case, and the autopsic examination of which evinced enlargement of the 
inguinal glands, without any visceral disorder, and with evidences of phle- 
bitis, to say the most, equivocal, and by no means sufficient to account for 
death. “ The whole of the vein above the wound, as far as its junction 
with the femoral vein, was removed. Its internal coat was redder and more 
vascular than natural; no coagulable lymph or pus was effused into its cavity, 
nor was any other preternatural appearance observed in it.Ӥ 
In the fourth place, death may be induced after operations, as in Case XV., 
* Lancet, June 26th, 1824, p. 407, from Archives Generates for May 1824. 
f American Journ. of Med. Sci. vol. ix., p. 204, from Arch. Geri. for April 1831. 
t Medico-Chirurgical Transactions, vol. vii., p. 201. 
§ Diseases of the Arteries and Veins, p. 557. 1843.] 
Watson on the Pathology and Treatment of Varices. 
71 
by the excess of reaction, and subsequent collapse, in persons already much 
reduced by previous or existing disease. Here the fatal result falls into the 
general category of those from all other operations upon persons whose gene- 
ral health is equally depraved. I have known the same result from the re- 
moval of a toe, and in three instances from the application of ligature to small 
hemorrhoidal protrusions. It is worthy of remark, that in persons dying 
under these circumstances, we usually find firm fibrinous concretions in the 
heart. Are these the cause or the consequence of the collapse? To attri- 
bute them to phlebitis, without other evidences of phlebitic inflammation ac- 
companying them, is neither philosophical nor correct. 
Lastly, Death may ensue, after operations, independent of phlebitis, by 
the recession of blood from the varicose vessels into the course of the general 
circulation, a result most likely to occur in persons of plethoric habit, and 
immediately produced by the sudden engorgement or inflammation of one or 
more of the vital organs. Death, under these circumstances, is preceded by 
such symptoms of constitutional disturbance as would otherwise characterise 
congestion or inflammation of the organs upon which the onus of disease is 
fixed. The organs, perhaps, most frequently affected in this way, are the 
lungs. Hence the occasional detection of pleuritic effusion, pneumonia, and 
pulmonary engorgement in the bodies of those supposed to have died of phle- 
bitis, but in whom the veins are either healthy, or but triflingly affected. 
Some of the older surgeons were sufficiently aware of the dangers resulting 
in this way from meddling with extensive varices. “II est meilleur,” says 
Pare, “ de ne toucher aux inveterees, parce qu’elles preservent de plusieurs 
maladies, a cause que le sang regare aux parties nobles, dont s’ensuit ulceres 
et chancres et suffocations.”* This observation, however, was not original. 
Galen, before him, had made the same remark: “ Quod si venas illas turgen- 
tes melancholico humore quis moliatur excidere, periculum imminet, ne 
homo corripiatur melancholia: id quod fieri ssepius est visum, non in varicibus 
modo, verum etiam in haemorrhoidibus, quae ex hujusmodi humore consis- 
tent.”! 
Part Third. Treatment. I. General Indications.—In the treatment of 
varices surgical interference may be requisite; first, on account of the ulcers 
and inveterate eruptions, induced by, or accompanying them; secondly, on 
account of the repeated and alarming hemorrhage occasioned by them; and 
not unfrequently on account of other annoyances, as pain, turgescence, and 
rigidity of the limb; conditions, it is true, not often compromising life, but 
sufficient, nevertheless, to prevent the patient from following his usual occu- 
pation, and to render life uncomfortable. 
The modes of treatment of which we are about to speak, it should be here 
remarked, have reference, principally, to the disease as it affects the lower 
extremities. Some of them are, indeed, applicable to the disease in the 
* Les CEuvres, fol., p. 484. t Epitome Galeni Operum. Fol. Lugduni 1743., p. 341. 72 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
spermatic and hemorrhoidal veins; but varices in most other parts of the 
body either call for palliative treatment only, or are so situated as to be 
beyond the reach of art. A mere enumeration of the writers and surgeons 
whose names are connected with special modes of treating varices, would be 
no inconsiderable undertaking. Such of them as have given most attention 
to the subject, will be noticed as we proceed. 
There are three distinct groups of indications to be fulfilled in the treat- 
ment of varices. The first of these is to prevent engorgement of the limb, 
and without undertaking to cure the disease, to keep it from increasing, or 
from exciting ulceration, or other concomitant affections; or to relieve these, 
when existing. The second is, to render more effective relief by reducing 
the size of the vessels, without suddenly obliterating them. The third is, to 
obliterate the varices at once, and to force the blood into new channels. The 
means employed for effecting the first of these are purely palliative measures. 
Those for the second are not always successful, and are sometimes dangerous. 
Those for the third are more efficacious than the others; but, at the same 
time, painful in their application, and still less exempt from danger. 
II. Special Treatment. First. To prevent engorgement of the limb; to 
keep the disease from increasing, or from exciting ulceration, or other con- 
comitant affections; or to relieve these when existing. 
The most effectual mode of fulfilling these indications is by moderate and 
equal compression over the affected part, aided, as occasion requires, by ele- 
vation of the limb, simple dressings to the sores, specific applications for 
arresting hemorrhage; detergent, anodyne, or cooling applications to the 
eruptions. 
Compression.—The credit of introducing gradual and equal pressure over 
the whole of the affected limb, for the relief of varices, has been awarded to 
Avicenna. The practice is probably of more ancient origin. The caliga, 
or legging, of the lloman soldiery, may have been employed, among other 
purposes, for relieving or preventing varices. Fabricius employed it, made 
of dog skin, for this purpose. In more modern times it has given place to 
the laced stocking, or gaiter, either of chamois leather or of cloth. The 
common roller has long been used for the same purpose. For these Mr. 
Travers has substituted adhesive straps. Tire starched bandage may be at 
times advantageously substituted for either of them. 
Local Depletion.—Punctures, scarifications, or small incisions into the 
veins, for the purpose of unloading them, is a practice mentioned several 
times by Hippocrates,* and by some of the other ancient writers; and recom- 
mended by Pare,f Petit,f and other modern surgeons. In Case XVII. it was 
employed by the patient herself, suggested to her by her own sufferings, and 
* Sect. I. De Medico; also, Sect. VI. De Ulceribus. 
f Les CEuvres, fol. Paris, 1579, p. 484. 
t As stated by Hodgson and others. 1843.] 
Watson on the Pathology and Treatment of Varices. 
73 
frequently repeated, during states of unusual fulness of the vessels, with 
temporary benefit. As a means of treatment it is rarely advisable. The 
object for which it is recommended by Petit, viz., the evacuation of coagula, 
is frequently hypothetical. And the punctures and incisions, small as they 
are, when practised upon diseased vessels, subject the patient to all the 
dangers of more important operations, without offering him an equal chance 
of cure. 
Second. To diminish the size of the vessels gradually and permanently. 
—Varices, as already stated, may in some cases be gradually reduced, if not 
actually obliterated, by a change from the habits or modes of life that give 
rise to them. This result will be more likely to ensue, when, to the change 
of habit, is superadded permanent and well regulated compression, with 
other adjuvants. But varices may be more rapidly, yet still gradually, 
reduced, by special modes of applying pressure, by exciting inflammation in 
the tissues surrounding them, or by other special modes of acting on the 
veins without dividing them. 
Direct pressure on the veins.—Fabricius wras in the habit of applying a 
compound astringent paste along the course of the varicose vessels, covering 
this with a reed, the hollow of the reed corresponding with the convexity of 
the paste; and binding on this dressing with ligatures, or with a roller drawn 
tightly round the limb. “ Thus,” says he, “ by the pressure, first of the 
roller, then of the reed, and by the astringency of the medicament, the 
varices have so far diminished as to appear to have been dried up.” 
In Case XVII. I resorted to a process somewhat less complicated, which 
may be applied as follows:—Take a common wax bougie, somewhat larger 
than the medium size, cut it into pieces of an inch or two in length; secure 
these at the detached points along the course of the varices, (longitudinally 
where the vein is straight, transversely where it is thrown into tumours,) by 
means of small adhesive straps. Then secure the whole with a common 
roller, laced stocking, or starched bandage, which should be applied as 
tightly as the patient can conveniently bear; the ordinary bandage, or stock- 
ing being the best for the first few days; and the more permanent application 
afterwards, as soon as the swelling which usually accompanies the varices 
has subsided. 
Mr. Travers succeeded in obliterating a varicose cyst of the saphena, 
behind the inner condyle of the knee, by means of adhesive plaster, applied 
in strips around the limb with as much tightness as could be borne. “ The 
vein took on inflammation, and the cyst became a perfectly solid tumour, 
which afterwards shrunk, and was perfectly obliterated. The inflammation 
was severely painful, and accompanied by extreme tension of the part, and 
with considerable fever.”* 
Local irritants.—With a view to reduce the varices without obliterating 
* Surgical Essays. Philad., p. 190. 74 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
the vessels, Mr. Mayo* recommends the application of an escharotic, com- 
posed of equal parts of soft soap and potassa, to the integuments. More 
recently MM. Laugier,f Berard,f and a few of the English surgeons,§ have 
employed the Vienna paste, a compound of equal parts of quick lime and 
potassa, for the same purpose. These applications, whatever be the special 
mode of using them, may give rise to diffuse phlebitis, to hemorrhage, and 
even to fatal consequences; and, if not carried so deeply as to excite adhe- 
sive inflammation in the vessel, they necessarily fail. Mr. Brodie,|| with the 
same view, has advocated the application of blisters along the course of the 
diseased vessel; a measure, from what I have seen of it, less likely to suc- 
ceed than it is to prove injurious. 
I do not find that electricity has ever been employed by any of the sur- 
geons wdio have written on the subject of varices. A case is reported in the 
Lancet,Tf of a midwife who employed it for the cure of the disease in the 
vessels of her own limbs, as she states, with much relief. 
The tincture of iodine, first introduced, I believe, by Mr. Herbert Finch** 
for the cure of varices, has recently found some favour with the profession. 
When applied of sufficient strength to act as a caustic to the integuments 
over the varices, it may perhaps be attended with some benefit. 
Third. To obliterate the varices at once, and to force the blood into new 
channels.—The anastomosis between the superficial veins of the lower 
extremity, as, indeed, between the veins in every other part of the body, are 
exceedingly numerous. Several of the largest vessels of the leg, including 
both saphenas, may be totally obliterated, without impeding the circulation. 
The blood, under these circumstances, is returned, at first, mostly by the 
deeper vessels, but, soon after the interruption, by numerous superficial 
anastomosing branches, as shown in Case XYI. Before these superficial 
vessels are sufficiently enlarged, the blood, indeed, has to seek the deeper 
channels; but the contraction of these from the action of the muscles obliges 
it to seek another course, external to the fascia lata, through which it can 
move at all times, free from the impediment of muscular pressure, to which 
the deeper veins are continually subjected, and which renders them, for the 
most part, empty during moments of active exertion. 
Aware of the ease with which the blood is returned by new channels after 
* Medico-Chirurg. Rev. vol. x. new series, p. 250. 
t Bulletin Chirurgica!, 1839, quoted by Dr. Scratchley in Lancet, May 14th, 1842. p. 
225. 
§ Dr. Scratchley, and Mr. Clay of Manchester. Lancet, July 18th, Aug. 29th, Oct. 
17th, Dec. 12th, 1840, and July 24th, 1841. 
t Gazette Medicale de Paris, Jan. 22, 1842. 
|| Lancet July 5th, 1828, p. 44G. 
** Lancet Aug. 24, 1833, p. 707. 
V Lancet April 5th, 1834, p. 44. 1843.] 
Watson on the Pathology and Treatment of Varices. 
75 
its proper veins have been obstructed, surgeons have long been in the habit 
of attempting the obliteration of these veins when diseased; and for this pur- 
pose they have employed a great variety of measures. Among these may 
be enumerated laceration, cauterisation, excision, erosion, ligature, incision 
and its modifications, the seton, and special modes of compression between 
folds of the skin, with a vice or clasp, or with pins and twisted sutures. 
Laceration. This barbarous mode of treatment was in use among the 
early Romans, and was practised, as we are told, on Cains Marius, who, 
after submitting to it on one leg, refused to have it tried on the other. It 
was performed, according to Paulus, by elevating the varicose veins, and 
tearing them forcibly from their attachment. 
Cauterisation. The actual cautery is recommended by Celsus; but like 
the foregoing treatment, it has long since been rejected. 
Excision. The removal of varices by excision, was also practised by the 
ancients, as we learn from Celsus,* Galen,f and Paulus iEgineta.j: 
ls7. By multiplied incisions. This the Celsean method, is performed by 
dividing the skin, drawing the lips of the wound apart with small hooks, 
laying the vein bare with a scalpel and passing a blunt hook under it. After 
thus exposing the vessel at one point, the operation is to be performed at 
intervals of four fingers breadth along the whole extent of the varix. The 
first hook is then to be raised, and the portion of the vein resting upon it, is 
to be excised; and so with the rest, until all the exposed portions are re- 
moved. The lips of the wounds are then to be approximated, and covered 
with agglutinating plaster. 
2(7. Preceded by ligatures. Galen operated in two ways; first, when the 
varix was small, by simply excising it; and again, where the vein was likely 
to bleed freely when divided, by first placing ligatures upon it, and then 
dividing it between these.§ 
3d. With temporary compression and subsequent ligature. Paulus 
iEgineta describes the operation on the saphena major above the knee. He 
commences by binding the upper part of the thigh with a cord, and directing 
the patient to walk about, in order to render the varix prominent. He then 
traces its course with ink upon the skin. He now directs the patient to lie 
* Lib. vii. Cap. xxxi. t Epitome Galeni Operum. De Methodo Medendi. Lib. xiii. 
§ The early introduction of the ligature as a means of arresting hemorrhage from both 
arteries and veins, appears to have been forgotten of late. The following is the whole of 
the passage in which it is spoken of by Galen. “Quod si inter nudandum appareat tibi 
vas magnum, aut magnum exhibere pulsum, tulius fuerit vinculo id prius excipcre, mox 
quod in medio est, prsecidere. Sunto autem ejusmodi vincula ex materia aliqua minimd 
putrescibili, polissimum si iis arterise sint excipiendte. Etenim quae caro in abscissis 
vasorum partibus coalescit, ea pro operculo est, atque ipsorum oscula claudit. Quod 
quidem ubi factum jam eernimus, decidere tunc tutd vincula possunt. Ac sic etiarn 
varices curamus, quse dilatatae sunt venae, potissimum circa crura et testiculos.”—Epitome 
Galeni Operum fol. Lugduni, 1643, p. 459. 
t On the authority of Pare and Fabricius. 76 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
down, and ties a second cord just above the knee. Then, with a scalpel, 
he divides the skin over the part marked with ink; he next detaches the ves- 
sel from its membranous envelopes, seizes and elevates it with a hook, cuts 
it off, unties the cord, allows a certain amount of blood to flow when this 
can be done with safety, and then applies the ligatures above and below, 
which he passes beneath the vessel by means of a needle, and perhaps, also, 
through the skin, making them at the same time serve as sutures, for closing 
the lips of the wound.* 
Erosion. We have already spoken of the potential cautery, as recom- 
mended by Mr. Mayo, for partially obliterating the diseased vein. The 
difference between this mode and that long since recommended, (as we are 
told,)f by Pare and Guillemeau, is scarcely appreciable, except that the 
older surgeons applied the caustic so deeply, as at once to erode the coats of 
the vein, leaving a space between the open orifices, to be filled up by cicatri- 
sation. As a means of radical cure even this bolder use of the caustic is liable 
to failure, unless applied as recommended by Mr. Bonnet,J along the course of 
the veins, at intervals of three or four inches; and even repeated, where the 
first application fails to reach the vessel. The dangers attending this mode 
of practice are numerous. It gives rise to abscesses along the course of the 
vessels, to alarming hemorrhage, to diffuse phlebitis, and has resulted fatally. 
Simple Ligature. To Sir Everard Home we must attribute the institution 
of this practice. The ancients, as already shown, employed the ligature in 
connection with other means; but only for the purpose of arresting hemorr- 
hage. Home was the first to publish any account of it as a means, by itself, 
for removing varices.§ Supposing them mainly to depend on thickening 
* It is remarkable that several recent writers give the credit of the operation here de- 
scribed to Ambrose Par6, whilst Pare himself as shown by his marginal note, has evi- 
dently given the credit of it to Paulus. The mode of applying the ligature, however, as 
given by Pare, is more after the manner of Galen. Fabricius, from whom I have taken 
the operation, seems to have some doubt as to the exact mode in which Paulus applied the 
ligature. 
t Several authors attribute to Pard the first employment of the potential eauterj? in the 
treatment of varices. In the copy of his works to which I have access, I find no men- 
tion of this practice; at least, none in the chapter devoted to the subject of varices: and I 
am still more surprised that in another chapter to which M. Bonnet refers, (livre 13, chap, 
xx. p. 315,) he does not even so much as mention varices. The following, however, is the 
passage, cited by several writers, in which he speaks of the caustic, and which I am 
obliged to give on the credit of M. Bonnet. “Autre moyen de couper les varices, e’est 
d’appliquer un cautbre potentiel qui rcyifge et coupe la veine, puis se retire en haut et en 
bas. Par ce moyen, il y demeure un espace vide oh apr6s s’engendre de la chair, et puis 
la cicatrice qui sera dure et epaisse empGchera la fluxion en bouchant le passage de ladite 
veine, ct, par ce moyen, la veine variqueuse sera gudrie.”—Archives Gdndrales, Mai, 1839, 
p. 48. 
t Memoire sur la Traitement dcs Varices. (Archives G6n<SraIes, Mai et Juin, 1839.) 
§ Practical Observations on the Treatment of Ulcers on the Legs, &c., chap. ix. 1843.] 
Watson on the Pathology and Treatment of Varices. 
77 
and rigidity of the valves, which prevented these from occupying the whole 
area of the vein, it appeared to him no small object to take off a part of the 
pressure of the column of blood, by establishing an artificial valve; and this 
he did by applying a ligature to the saphena major near the inner side of the 
knee, just above the point at which the branches from the leg unite to form 
the common trunk. He appears, however, to have borrowed the practice 
from Mr. Hunter, who, in one case, operated in this way on several branches. 
As a means of cure, the simple ligature is frequently effectual, but not uni- 
formly so. It has frequently proved fatal; and the dangers attending it are 
so numerous, that it has for the most part been abandoned. 
Incision.—lsf. Longitudinal Incision. This plan of treatment, intro- 
duced by Mr. Richerand* in 1823, has had but few advocates. It consists 
in making a longitudinal incision of some inches in length, through the in- 
teguments and diseased vessel; and after unloading this by the escape of 
blood, filling the wound with lint; and allowing it to heal by granulation. 
2d. Transverse Incision.—This practice originated, so far as I can ascer- 
tain, with Mr. Brodie,t who in speaking of it, observes: “ I found it to be 
preferable to the use of the caustic, as the operation occasioned less pain, 
and as (in consequence of there being no loss of substance) the wound was 
cicatrised in a much shorter space of time.”J He soon, however, relinquished 
it for his simpler and safer operation, viz: 3d. The Subcutaneous Inci- 
sion.—This he performs with a narrow convex bistoury, which he introduces 
through the skin on one side of the varix, and passes in between the skin 
and vein, with one of the flat surfaces turned forwards and the other back- 
wards, until it reaches the opposite side. He then turns the cutting edge of 
the bistoury backwards, and in withdrawing the instrument the division of the 
varix is effected. He recommends this operation only when there are but 
few varices in the limb; and performs it on the branches, but never upon 
the main trunk of the saphena. I have already shown its liability to failure. 
It was at first looked upon as entirely free from danger. We are told, how- 
ever, that such is not the fact. “ Division of the vein with a valvular 
wound of the integument is surely no violent injury to the vessel, and yet it 
is occasionally followed by fatal inflammation.Ӥ 
The Seton. This operation, invented by M. Fricke, is performed by 
transfixing the vein with a needle, armed with a single thread, leaving the 
thread in the wound, traversing the vein; and allowing it to remain there 
long enough to excite adhesive inflammation, in the varix, and thus to con- 
solidate the vein. The procedure is to be repeated at two or three points 
* Philadelphia Med. and Physical Journal, vol. viii. p. 449, from Medico Chirurg. Rev. 
March, 1824. 
t In other hands it has terminated fatally. See Velpeau, (Medecine Operatoire, vol. ii. 
p. 259. 
t Medico-Chirurgical Transactions, vol. vii. p. 195, et seq. 
6 Medico-Chirurg Review, vol. x. p. 251. December, 1828 
No. IX.—January, 1843. 78 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
along each of the vessels affected. This operation too, like most of the 
others, has been attended with fatal consequences.* 
The Elastic Truss. This is spoken of by Sir Charles Bell,t and Mr. 
Colies.1 The latter is said to have used it with considerable success. He 
applies the pad of a circular truss over the saphena major at the groin, with 
force sufficient to prevent the passage of blood through the vessel. 
The Vice, or Screiv Forceps. This instrument, applied by its inventor, 
M. Breschet,§ for the cure of varicocele, was afterwards used by M. Sanson 
in the treatment of ordinary varices. It consists of two parallel iron plates, 
cushioned on their inner face, which are approximated, or separated, by 
means of screws. For applying it, the vein must be elevated on a fold of 
integument, and then embraced between the two plates of metal, which are 
approximated by means of the screws, until they are sufficiently close to 
interrupt the circulation, or even to excite a slough, in all the parts em- 
braced between them. The application of this instrument is attended with 
much pain. The surgeon is obliged to shift it frequently from point to 
point, along the track of the vein. If not applied with sufficient force to 
cause a slough of the skin, it is not likely to produce a permanent closure of 
the vessel. From the trials which I have seen with this instrument, in the 
practice of M. Sanson, I should never dream of using it. 
Subcutaneous Stricture. There are several distinct modes of interrupting 
the circulation through the vessel, by pins and ligatures, without exposing 
it; all of them of recent origin. 
1 st. M. Davat's Method.|| This surgeon commences by applying a tem- 
porary bandage just above the knee, and then requiring the patient to walk 
about for a few moments, in order to distend the varices. The patient then 
sits down; and the surgeon elevating the saphena major in a fold of integu- 
ment, passes a needle transversely through the skin, beneath the vessel, and 
so on out at the opposite side. A second needle is next to be carried 
through the skin and the coats of the vein, under the first pin, and at right 
angles with it; and then brought again through the vessel and integuments 
to the surface, thus puncturing the vein at four points; and pressing it so 
firmly against the first pin, which lies under the vessel, as to arrest the 
course of the blood through the vein. These pins are now to be secured by 
a thread, in the form of a twisted suture, which is not to be applied very 
tightly; and allowed to remain until they become loosened by the ulcerative 
process, and then removed. If the first operation do not remove the whole 
* Velpeau, Mddecine vol. ii. p. 269. 
+ Lecture, in London Medical Gazette, vol. xiii. p. 428. 
t Velpeau, ut supra, p. 266, and Library of Practical Medicine, 2d edition, Phila. vol. 
ii. p. 625. 
§ American Journ. Med. Sci. vol. xvii. p. 234. 
II Du Truitement Curatif des Varices. Par Davat, 8vo. Paris, 1836. See also review 
of the work in American Journ. Med. Sci. vol. xx. 460. 1843.] 
Watson on the Pathology and Treatment of Varices. 
79 
of the varices, he repeats it afterwards at a few points in the branches of 
the saphena, lower down. This operation is less dangerous than that by the 
seton; but it has, nevertheless, led to fatal results.* 
2d. M. Velpeau's Method.f This surgeon uses but a single pin for 
strangulating the vessel at a given point. This he passes transversely be- 
neath the vein without puncturing it, precisely in the same way as that prac- 
tised by M. Davat for the passage of the first pin. But he repeats the pro- 
cess at two or three points upon the saphena above the knee, and upon all 
the dilated branches on the leg and foot; using eight, ten, or even fifteen 
pins upon the same limb. Sometimes, however, says he, two or three ap- 
plications are sufficient. After thus inserting the pins, he embraces the ex- 
tremities of each of them in a circular ligature, which is to be tied with 
sufficient force to strangulate the portion of integument and vein resting upon 
the pin, and to cause it to slough. With this practice M. Velpeau was at 
first remarkably'successful, having had more than a hundred cases before 
he met with an instance in which it terminated fatally. Of late, however, 
his success has not been so great; and it is now conceded that this opera- 
tion is as dangerous as the rest. In one case that terminated fatally, it was 
found that the pin had been so placed as not to interrupt the track of the 
vessel.;): Such indeed is likely to be often the case, especially among the 
lower branches of the saphena, where, in consequence of the induration of 
the tissues, it is sometimes impossible to raise the vein sufficiently to allow 
the pin to be passed transversely under it. 
3d. M. Regnaud's Method.§ This consists in passing a thread, by 
means of a needle, transversely under the vein; applying a roll of basilicon, 
or of wax, or a small graduated compress, on the integuments immediately 
over the vessel, and then drawing the ends of the thread tightly over this, 
and tying them in a slip knot. The ligature in this way may be tightened 
or loosened at pleasure. It is not so likely to be efficacious in obliterating 
the varix as either of the two former methods. 
4/A. M. Ricord's Method.]] This process has been more particularly used 
in reference to varicocele; but it is also applicable to varices on the lower ex- 
tremity. It consists in passing two ligatures transversely; the one beneath, 
and the other above the level of the vein; but both below the skin, and 
traversing the integuments through the same openings. When thus applied 
they are to be tightened, by tying their extremities together with sufficient 
force to strangulate the vessel. 
III. Appreciation.—The foregoing summary of operations constitutes a 
formidable list, sufficient in itself to show the difficulties and dangers both of 
the disease itself, and of the measures that have been devised for overcoming 
it. Severe as some of these measures are, they are all subject to failure; 
* Velpeau, loco citat. p. 270. 
$ Medico-Chirurg. Review, vol. xxxvi. N. S. p. 556. 
t Loco citnt. p. 271. 
§ Ibid, p. 275. 
I! Amer. Journ. of Med. Sci. vol. i. new series, 1841, p. 516 80 
Watson on the Pathology and Treatment of Varices. 
[Jan. 
and with the exception of simple compression, and one or two other means, 
even less efficacious than this, there is not one of them thus far practised to a 
sufficient extent to prove its efficacy, that has not led to fatal consequences. 
Nay, even pressure itself is not practised at all times with impunity. Some 
of these operations are, doubtless, intrinsically more dangerous than others. 
But their danger is in proportion neither to their efficacy, nor their apparent 
severity. It holds a more exact relation to the susceptibility of the veins 
already diseased, to an aggravation of their morbid action; to the state of 
these veins before the operation; and to the patient’s general health at the 
time of submitting to it. 
It is to be regretted that we have no statistics worthy of the least depend- 
ence, for establishing the proportionate mortality that has attended opera- 
tions upon diseased veins. Those who have published the results of their 
own experience, have almost invariably presented us with a striking array of 
successful cases, in order to set off some new or favourite invention, leaving 
the counter-stroke of failures and fatal consequences, to be either guessed at 
or heard of accidentally from others. 
A principle of much importance, one upon which any operation, to be 
successful, should be founded, is the necessity of interrupting the circulation 
at more points than one in the course of the varicose vessels, and of multi- 
plying these interruptions in proportion to the extent of the varices and the 
freedom of their anastomoses. This, though evidently the principle upon 
which the operation of Celsus was founded, appears to have been forgotten 
for a time, until the attention of the profession was again called to it by M. 
Bonnet. Impressed with the importance of it, and believing, as I still do, 
that a vein is less likely to become inflamed after a clean section, than after 
any other operation upon it; and rejecting the caustic, as recommended by 
M. Bonnet, I undertook the operation as detailed in the foregoing cases. 
But if the result of these bears out the importance of this principle, they 
also show that a clean cut cannot be made through a diseased vein without 
endangering the life of the patient. 
Still the disease is a dangerous one; or, if not dangerous, troublesome 
and distressing. What then is to be done for it? 
If called upon to treat a varicose limb, free from complication either with 
ulcers, eruptions, local inflammation, or constitutional disturbance; until 
some means is discovered more simple and efficient than any yet employed, 
I should treat it with the view of fulfilling the second indication, as I have 
described under the head of direct pressure, and as practised in Case XVII. 
If there be an ulcer, I would elevate the limb; dress the ulcer as any other 
under similar circumstances, independent of the complication; apply a 
simple roller to the limb; and after curing the ulcer, treat the varices as be- 
fore. Are there eruptions; are the veins turgid and painful; or is there any 
local inflammation complicating the varices? Treat the one or the other of 
these as independent affections; by elevating the limb; applying deter- 
gent, anodyne, or antiphlogistic lotions, or other similar applications; and 1843.] 
Watson on the Pathology and Treatment of Varices. 
after curing or relieving these, attend to the varices. Is there hemorrhage? 
Elevate the limb; keep the patient quiet on his back; apply a compress and 
roller until the ruptured vein has healed; and afterwards attend to the varices. 
In a word, whatever be the complication, palliate the disease until this is 
overcome; and then undertake the treatment of the varices, by attempting to 
effect their gradual and permanent diminution. 
81