REGIONS OF THE LEG. 



superficial veins are without this important 

 help. Their sides are supported, on one hand, 

 by the yielding layer of the fascia and muscles, 

 and, on the other, by the integument. When, 

 therefore, any impediment presents itself to 

 the free transmission of the blood through the 

 femoral, popliteal, or iliac veins, or even by 

 the mere weight of the ascending column of 

 blood, in persons who stand much, it is the 

 superficial veins that suffer most, and a perma- 

 nently dilated state is the frequent result. 



The pathology of varicose veins has not re- 

 ceived the attention which it deserves, and 

 hence the conflicting opinions as to the precise 

 nature of their origin ; we must even now con- 

 fess with Delpech that the nature and causes 

 of the disease are unknown. It is quite clear 

 that that state of disease of the veins commonly 

 termed varicose comprehends more than one 

 pathological condition, and probably has more 

 than one mode of origin. Every instance of 

 an enlarged vein cannot be considered as a 

 varix, unless we confound under the same 

 denomination a condition of the vessel natural 

 and healthy except in regard to its size, neither 

 originating nor terminating in a morbid condi- 

 tion, with every variety and degree of disease 

 accompanied with enlarged capacity of the vein. 

 \Ve have seen the veins of the abdomen en- 

 larged so as to fulfil the office of the vena cava 

 inferior, which was obliterated. But there was 

 not the slightest mark of disease in these super- 

 ficial vessels. The uterine veins, also, in preg- 

 nancy become enlarged in a similar manner, 

 thus answering to the call for the increased 

 circulation of blood in the uterus. This state 

 of the vessels has been aptly termed hyper- 

 trophy, and the term varix has been restricted 

 to permanently dilated states of the veins, at- 

 tended with the accumulation of dark blood, 

 which more or less generally becomes coagu- 

 lated and adherent to the parietes of the vessels. 

 Of this latter species Andral enumerates six 

 varieties : 1st, simple dilatation without any 

 other change, such dilatation affecting either 

 their whole length, or occurring at intervals ; 

 2d, dilatation, either uniform or at intervals, 

 with a thinned stale of the veins at the dilated 

 points ; 3d, uniform dilatation with thickening 

 of the venous coats ; 4th, dilatation at inter- 

 vals with thickening of the dilated points ; 5th, 

 dilatation, with the addition of septa within the 

 vein, whereby the cavity is divided into little 

 cells in which the blood lodges and coagulates ; 



O O 7 



6th, a similar disposition combined with per- 

 forations in the parietes of the veins, which 

 communicate with the surrounding cellular 

 tissue in a more or less diseased state by nume- 

 rous small apertures. From repeated observa- 

 tion of its practical importance we should be 

 inclined to add to this list one other variety, 

 viz. when the varicose state had extended into, 

 or existed distinctly in, the capillaries of the 

 skin. We believe that in those troublesome 

 ulcers known as varicose we shall frequently, 

 if not generally, find this state of the minuter 

 veins and capillaries, and we are more inclined 

 to attribute the pain and the obstinate character 

 of these ulcers to the pathological condition now 



VOL. III. 



mentioned than to the mere vicinity of an en- 

 larged vein as it passes through the superficial 

 fascia. The causes of the diseased state in 

 question have been variously stated, nor do 

 opinions yet agree upon it, some attributing it 

 to mechanical influence, and others supposing 

 a morbid tendency. Both these causes pro- 

 bably act in different instances, or even co- 

 operate in the same case ; we shall now only 

 mention in illustration of the effect produce- 

 able by the mechanical influence of too much 

 standing, that it is not necessary to suppose 

 that the valves are either destroyed or even 

 materially injured in structure to nullify their 

 agency in supporting the column of blood 

 above them, since ever so small a communi- 

 cation between the two columns, the upper 

 and the under, is sufficient to destroy all the 

 beneficial agency of the valves as supporters of 

 the gravitating fluid in the veins. Therefore 

 a dilatation of the vein merely enough to draw 

 the opposed edges of the valve ever so little 

 apart, or even a thickening of the valves pre- 

 venting the accurate coaptation of their edges, 

 will be sufficient to prevent their power of 

 support to the superincumbent column, and 

 as far through the vein as this defective state 

 of the valves may exist, so far will the gravi- 

 tating column of blood be virtually unbroken 

 and entire, and in the same proportion will the 

 tendency to the varicose state be increased. 

 This reasoning will explain many, probably 

 the majority of cases where the morbid dila- 

 tation having once begun goes on to increase 

 rapidly by the continued operation of this ex- 

 citing cause. That there are other causes 

 capable of producing this state of the veins 

 cannot be disputed ; indeed the occurrence of 

 it in parts not likely to be affected by the up- 

 right position, and even in several different 

 parts of the body of the same subject, shews 

 that there is occasionally a morbid tendency in 

 the venous system to this particular state, 

 which acts independently of any mechanical 

 cause; but we believe that this predisposing 

 cause is not necessary to the production of the 

 disease, and that the morbid tendency, when it 

 is met with, should be regarded rather as the 

 exception than as the rule. 



In considering the causes of the disease in 

 question, we should not lose sight of the rela- 

 tive proportion of the deep and superficial 

 venous circulations of the lower extremities, a 

 proportion varying in almost every individual. 

 In one, the superficial veins are large and nu- 

 merous, and lie immediately under the skin ; 

 in another, they are few and small. It is ob- 

 vious, that in the first case the blood retained 

 by this route bears a large proportion to that 

 passing through the deep set, much larger than 

 it would in the latter case. In the first in- 

 stance, therefore, these vessels will have a 

 greater proportional weight of blood to sustain 

 and transmit, than in the second ; while, in 

 those individuals who have the superficial cir- 

 culation small, the blood is chiefly returned by 

 the deep set, which, from circumstances before 

 mentioned, are more equal to the task, and in 

 such persons the diseased stnte in question 



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