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MAY, 1898 
VARICOSE VEINS AND THEIR TREATMENT BY 
TRENDELENBURG’S OPERATION. 
CHARLES GREENE CUMSTON, M.D., 
OF BOSTON, 
Assistant Professor of Surgical Pathology, Tufts College Medical School. VARICOSE VEINS AND THEIR TREATMENT BY 
TRENDELENBURG’S OPERATION. 
CHARLES GREENE CUMSTON, M.D., 
OF BOSTON, 
ASSISTANT PROFESSOR OF SURGICAL PATHOLOGY, TUFTS COLLEGE 
MEDICAL SCHOOL. 
Varices, or ectases of the veins, were for a long period 
considered as simple dilatations of the vessel without any 
change in its tissues, but to-day we know that this under- 
standing is erroneous. Varices are met with in various re- 
gions of the body, but only infrequently are they found in the 
head, mouth, vagina, or bladder. Sometimes the upper limbs 
may be the seat of the affection. The hsemorrhoidal veins and 
those of the spermatic cord are often the seat of venous 
ectasis, but by far the most common site for this pathological 
condition is the lower limb, and more especially in the domain 
of the saphenous vein. 
According to their shape we have simple, cylindrical, 
cirsoid, and serpentine ectasis; in the latter case there is also 
an elongation of the vessel. We often meet with cases pre- 
senting true nodes of varicose veins which form a tumor. 
Now, as varicose veins are, so to speak, a special affection of 
the saphenous vein, and as Trendelenburg’s operation is per- 
formed for the relief of these cases, a few words regarding the 
situation of this vessel may not be perhaps out of place here, 
and which we will quote from Ouain’s “ Anatomy,” ninth 
edition. 
“ The external or short saphenous vein, smaller than the 
internal, proceeds from the outer end of the arch on the dor- 
sum of the foot. It passes behind the outer ankle and ascends^ CHARLES GREENE CUMSTON. 
in the leg along the outer border of the tenclo Achillis, in 
company with the external saphenous nerve, and then over 
the internal, between the heads of the gastrocnemius, to 
the lower part of the popliteal space, where it perforates the 
deep fascia to end in the popliteal vein. Opposite the ankle 
and along the leg it communicates with the deep veins; and 
it receives superficial branches from the outer part of the foot 
and heel, and the back of the leg, as well as one which de- 
scends on the posterior surface of the thigh. A communi- 
cating branch passes from this vessel near its termination 
upward and forward to the internal saphenous vein, and 
sometimes the trunk itself follows this course, having no 
connection, or only a very small one, with the popliteal vein.” 
The deep veins may also be the seat of ectasis, as has 
been demonstrated by Verneuil, but these are far from having 
the clinical importance of the saphenous vein. The deep ves- 
sels are surrounded on all sides by hard and firm tissues which 
uphold and protect their walls, and, what is more, the mus- 
cular contractions greatly aid the circulation in the deeply 
situated veins. 
In 1877, Bardeleben demonstrated that the veins of the 
lower extremities were very richly supplied with unstriped' 
muscle and valves, for, of all the veins in the economy, these 
are most assuredly the ones that have the greatest amount 
of pressure to support, and, consequently, when the muscles 
and valves become insufficient, they will be more easily dis- 
tended than others. The valves are of the greatest impor- 
tance, because they divide the blood column into several seg- 
ments, so that in the normal state this column does not brine 
all its weight to bear on the veins of the lower limb. 
When the valves become insufficient, from no matter 
what cause, the entire weight of the blood column must be 
supported by the walls of the veins. Other factors may pro- 
duce an increase in the pressure, such as an elastic circular 
garter, which is so frequently a cause, or a hernia truss having 
too much pressure over the crural canal. A stricture of the 
orifice in the fascia lata has also been mentioned as a cause of TREA TMENI OF VARICOSE VEINS. 
3 
varix of the saphenous vein. Pregnancy is particularly favor- 
able for the development of ectasis, either by increasing the 
abdominal pressure or by direct pressure on the iliac vein and 
vena cava. A varix so produced does not always disappear 
after labor, even when the circulation is again in a normal 
condition, and, according to Lesguillon, 5 per cent, of women 
who have borne children are subjects to this affection, a 
statement that the writer believes to be correct. Cysts of the 
ovary and uterine fibroids have the same effect as a pregnant 
uterus. 
Occupations obliging the subject to remain on his feet 
for hours at a time, such as postmen, shop-girls, waiters, 
soldiers, porters, etc., predispose to venous ectasis of the 
lower limbs, and it may be for this reason that men appear 
to be more often affected by this trouble than are women. 
Certain affections of the legs may produce varices, for ex- 
ample, a large callus or a cicatrix of the skin which directly 
compresses the subcutaneous veins. And, lastly, pulmonary 
emphysema or an organic disease of the heart may be set 
down as factors on account of the obstacles to the general 
circulation produced by them. 
Venous ectases produced by these various causes de- 
velop slowly and progressively in most cases, but infre- 
quently we meet with subjects whose veins became varicosed 
after a violent exertion or a contusion. But it must be said 
that an increase in the blood-pressure is not generally suffi- 
cient in itself to produce a varix, and it coincides with a 
pathological change in the walls of the veins. Billroth, Orth, 
Bardeleben, Ziegler, and Lesser have demonstrated this fact. 
The researches made by Cruveilhier and Cornil have demon- 
strated that the walls of the veins in a state of ectasis are 
thickened at certain parts and thinned at others. The middle 
tunic presents the most marked changes, and occasionally it 
is so very thin that some parts of the vessel will be entirely 
lacking in it, while at other points a true hypertrophy of the 
middle tunic will be present. 
The condition of the vessel walls naturally varies with' 4 
CHARLES GREENE C VMS TON, 
the degree the morbid changes present, because it often hap- 
pens that the middle tunic is in the first place hypertrophied 
and later on undergoes atrophy. Epstein demonstrated that 
dilatation of the veins produced a change in the walls of the 
vessels, and he clearly showed that hypertrophy of the middle 
tunic, followed by atrophy, is the process that takes place. 
This tunic, as well as the external, is more vascularized and 
presents a round-celled infiltration. The writer has always 
found the intima the seat of a formative endophlebitis, which 
decreases the size of the lumen of the vessel, and has also 
noted a dilatation of the vasa vasorum, with hypertrophy of 
their walls. 
Dilatation of the veins always produces a slow circula- 
tion in the distant venous branches. This is what also occurs 
in the case of dilated arteries, and in both instances there is 
a neoformation in the tissues of the intima, with this dif- 
ference that the neoformative process commences with a 
slight amount of change in the dilated arteries, while in the 
veins this change occurs later on. 
According to their stage of development we can divide 
varicose veins into three degrees. 
First Degree.—The veins are only dilated, without any 
pathological change in their walls. These dilatations may 
disappear after the cause has been removed, as, for example, 
after labor or the removal of an abdominal tumor. 
Second Degree.—Here we have dilatation and deformity 
of the veins with hypertrophy of the middle tunic. If such 
a vein be cut across it will remain gaping and give rise to 
severe haemorrhage. 
Third Degree.—ln this stage we have marked morbid 
changes in the vessel walls. Hypertrophy is everywhere, and 
often the middle tunic is so thin that it readily bursts, and at 
the points of rupture partial sacculated dilatations arise. On 
account of this dilatation the valves are prevented from 
coming in contact with each other, and insufficiency results. 
It must be remembered that the valves are simply a re- 
duplication of the intima, and consequently undergo the same TREATMENT OF VARICOSE VEINS. 
5 
pathological changes as the walls of the vessel. After their 
function is lost they undergo fibrous contraction and may 
even disappear. 
At a very advanced stage the vessel walls will have lost 
their elasticity; they are soft and imbibed with blood. 
The blood in the first and second degrees of ectasis re- 
mains normal, only circulation is slower in the dilated vessels. 
In the third degree circulation is still slower, and coagulation 
takes place at certain points, and the clot thus formed ob- 
literates more or less completely the lumen of the vein. This 
coagulation is not the result of the slow circulation, but is 
due to the morbid changes in the walls of the vessel. 
The parts surrounding the diseased veins are altered. 
The cellular tissue is infiltrated with an inflammatory exuda- 
tion, and sometimes its vascularization is increased. The 
skin is thickened and adherent, while the subcutaneous veins 
are dilated; or, on the other hand, it may be thin, shiny, and 
ulcerated. The pigmentation is the result of capillary ex- 
travasation and transudation of the red corpuscles. 
The diagnosis of varicose veins is generally a simple 
matter. The process often commences by a dilatation of the 
cutaneous veins, which are first seen as bluish spots or pig- 
mented points. When the patient stands the veins become 
turgescent, but if the leg be raised while the subject is in the 
recumbent position the ectasis becomes rapidly emptied, but 
will fill again as soon as the limb is in a declining position. 
Varicose veins are more often larger in summer than in 
winter; they dilate when the patient takes a warm bath and 
contract by contact with a cold application. Slightly de- 
veloped ectasis gives rise to hardly any svmptoms, the skin 
is normal or nearly so and moves easily over the underlying 
tissues, the only thing complained of by the patient being a 
sensation of weight or a vague pain in the leg after walking. 
In a more advanced degree the varix affects the shape 
of sacciform dilatations, which may be as large as a walnut 
or even larger. These varices are soft, fluctuating, and the 
skin covering them is thin. These large varices are more 6 
CHARLES GREENE CUMSTON. 
frequently found on the trunk of the saphenous vein near the 
crural ring or below the internal condyle of the femur. A 
chronic oedema is often present in their neighborhood, which 
renders their dissection difficult. 
A large varix seated near the crural ring has been mis- 
taken for a hernia on account of the reduction of the tumor 
obtained by digital pressure, but this error is avoided if the 
leg be raised or if the femoral vein be compressed above the 
tumor. 
A very large varix may pulsate, and give rise to bruit 
isochronous to the heart-beat, but this bruit and the pulsa- 
tions do not belong to the varix, but are propagated from the 
underlying arteries. 
The diagnosis of deep-seated venous ectasis is far more 
difficult. Here we find the patient complaining of a tired 
feeling in the limb after a short walk. Cramps and neuralgic 
pains are frequent and are more especially felt in the calves 
of the legs. Perhaps we can explain these painful phenomena 
by the pressure produced by the dilated vessels on the neigh- 
boring nerves. 
A gentleman of forty consulted the writer not long since for 
a very disagreeable tingling sensation in both legs, particularly 
in the calves. His family and personal history excluded gout, 
rheumatism, malaria, venereal disease, or nervous trouble. The 
patient was engaged in a large grain business which kept him 
constantly on his feet. 
When he retired his legs would immediately feel better, and 
in the morning, unless he had taken an unusual amount of exer- 
cise on the previous day, they would give him no trouble until 
he had been about for a couple of hours. 
When the patient was first seen this state of affairs had ex- 
isted for over seven years. He had seen many physicians, most 
of whom had pronounced his case to be muscular rheumatism, 
while one or two told him that he was commencing a tabes dor- 
salis. A diagnosis of deep venous ectasis was made, and he was 
ordered elastic stockings to extend above the knee, and when 
last seen by the writer was quite comfortable, although not en- TREATMENT OF VARICOSE VEINS. 
7 
tirely cured. It may be said that there was absolutely nothing 
to be noted as to the appearance of either legs; the skin was 
normal excepting a very slight dilatation of the subcutaneous 
veins at certain points, and their development symmetrical. 
The progress and prognosis of venous ectasis are very 
different according to the case, and really greatly depend on 
the occupation and social condition of the patient. Conse- 
quently the worst cases are more frequently met with among 
the working class. 
As has already been said, their development is slow, but 
after a time changes occur in the varix and surrounding tis- 
sues. As a slow circulation is most favorable for the forma- 
tion of a thrombus, these often arise in varicose dilatations, 
especially in the pockets formed by the valves. Their changes 
are numerous. 
In the more favorable cases the thrombus becomes or- 
ganized, transforming little by little into hard connective 
tissue, and by thus completely obstructing the lumen of the 
vessel brings about a spontaneous cure of the affection. But 
the thrombus formation is not without danger, because if it 
should disintegrate it will give rise to emboli. A thrombus 
may become infected and give rise to abscess or pyaemia. 
Another complication of great danger is venous haemor- 
rhage. It may take place from a slight wound from scratch- 
ing or by spontaneous rupture from exertion. The skin 
being so thin, it gives way at the same time that the vessel 
wall ruptures. As these ruptures are without pain, the pa- 
tient may not be aware of the large amount of blood that is 
escaping from the wound, and fatal cases have been re- 
ported.1 
It may also happen that the skin does not rupture at 
the time the vein opened, so that the blood becomes pent 
up in the subcutaneous cellular tissue, in which case the pa- 
tient is seized with pain and a considerable tumefaction of 
the parts.2 
The last and at the same time most frequent and impor- 8 
CHARLES GREENE CUMSTON. 
tant complication of varices is varicose ulcer. The lower limb 
offers a particularly good position for the development of 
ulcers on account of difficulty of circulation. If to this cir- 
cumstance we add a circulation which is hindered by the 
ectasis, an incomplete nutrition of the parts, we can readily 
understand why a slight, superficial erosion, contusion, or 
eczema are sufficient to provoke the formation of a varicose 
ulcer. For that matter these ulcers also arise spontaneously. 
They extend in surface little by little as well as in depth, 
and an irregular wound with cleanly cut borders, with a bot- 
tom covered with sluggish granulations or none at all, se- 
creting a fetid and bloody liquid, results. This wound may 
become infected and suppurate, and in some cases give rise to 
a general infection or to erysipelas. Haemorrhages also 
occur. The ulceration may take on such dimensions that in 
some cases amputation has had to be performed. 
It is only when these ulcers are of considerable size that 
the patient will come for treatment, for varicose veins do not 
generally give rise to much trouble, and many are the thera- 
peutical measures that have been extolled for their cure. 
Without going further into the consideration of the treat- 
ments of varicose veins and ulcers, as none of them are really 
of any value, for the very simple reason that they only treat 
the ulcer without suppressing its cause, we will simply de- 
scribe Trendelenburg’s operation, which, as we shall endeavor 
to demonstrate, is the ideal method of treating these most 
unfortunate patients. 
Trendelenburg’s operation is certainly the greatest prog- 
ress that has ever been made in the treatment of ectasis of 
the saphenous vein, and although every case operated on has 
not resulted in a complete and radical cure, we at least almost 
always have a very marked improvement, with rapid cicatri- 
zation of the ulcers. 
While studying the conditions of blood-pressure in the 
veins, Trendelenburg based his theory on the fact that the 
greater number of varicose veins of the lower limb are in rela- 
tion with a general dilatation of the saphenous vein, and that TREATMENT OF VARICOSE VEINS. 
9 
on account of this dilatation insufficiency of the valves results. 
As the inferior vena cava and iliac veins are devoid of valves, 
it naturally results that the blood column which extends from 
the saphenous vein to the right heart is not divided into seg- 
ments, and consequently presses with air its weight on the 
walls of the saphenous and its ramifications. This hypothesis 
might explain the oedema, vague pains, and ulceration so fre- 
quent in varicose veins. 
Fig. i. 
In order to give weight to his hypothesis, Trendelenburg 
performed the following experiment: He emptied the vari- 
cose veins of the leg by elevation of the limb and then 
lowered the leg again, but exercising strong pressure over 
the trunk of the saphenous vein. He then remarked that the 
veins were refilled slowly by the return blood coming from 
the arteries, while at the instant compression of the vein was CHARLES GREENE CUMSTON. 
stopped a blood wave came from above downward, instantly 
filling all the venous trunks, thus proving that there is a great 
central pressure acting on the walls of the veins, and from 
this reasoning Trendelenburg advised ligature of the saphe- 
nous vein at two points followed by section of the vessel be- 
tween the ligatures. 
The operation of ligaturing the external saphenous vein 
is very simple and requires no special instruments. The re- 
Fig. 2. 
gion of the incision should be shaven and properly disinfected, 
and a rigorous asepsis must be maintained throughout, for 
infection of the vein, resulting in a suppurative phlebitis, with 
all its consequences, might otherwise occur, and it is for the 
same reason that union of the incision by first intention 
should be secured. We do not recommend the use of Es- 
march’s band, although some surgeons advise its use. 
To find the line of incision, the internal aspect of the TREATMENT OF VARICOSE VEINS. 
11 
thigh should be carefully explored, and a bluish line will be 
seen, which indicates the course of the internal saphenous 
vein. The vessel will be very easily found if it presents an 
ectasis in this region. 
Subjects in which the course of the vein is not readily 
seen may necessitate a slight constriction at the upper part 
of the thigh, so that the superficial veins will distend as the 
blood continues to be pushed through by the arteries. 
An incision measuring from seven to ten centimetres 
should then be made, beginning slightly above the union of 
the lower with the middle third of the thigh. The vein is 
usually found without difficulty, although in stout persons it 
may take a little time to find it. The vein is then carefully 
freed by a blunt dissection so as not to injure the vessel. All 
branches going off from the saphenous vein are now ligated, 
and when this has been done a ligature is placed on the vein 
at the upper and one at the lower angle of the skin incision. 
That portion of the vein situated between the two ligatures 
is then exsected with the scissors. 
The cutaneous incision is then sutured and a large piece 
of xeroform or dermatol gauze placed over it, then over this 
a thick layer of cotton, this dressing being kept in place by a 
roller bandage. The use of a general anaesthetic is not neces- 
sary, although the writer prefers it, and cocaine may be em- 
ployed. 
After the operation the ectasis rapidly decreases, and if 
there be ulcerations they will soon cicatrize. It is quite evi- 
dent that rest in bed is also a help for the cure, but it is certain 
that they heal more rapidly after this operation than by any 
other treatment combined with rest in bed. It is well to have 
an elastic stocking worn, for a few months at least, after the 
operation. 
Tenacious varicose ulcers, which, as we all know too 
well, resist all treatment, certainly heal in a most astonishing 
manner after ligature of the vein. 
The results reported by Trendelenburg, Tobold, Chate- 
lain, Faisst, Perthes, Cordebart, Schaffer, and others are cer- 12 
CHARLES GREENE CUMSTON. 
tainly good in the majority of cases, and a permanent cure 
has resulted. 
The writer has done this operation seven times, and here 
reports briefly his cases. 
Case I.—Mrs. J. H., aged thirty-seven years. Four chil- 
dren; the last being three years of age. Since birth of last child 
has suffered from a well-developed ectasis of left leg. No ulcers. 
Much pain and sensation of tension in leg. Heart and lungs 
normal. Urinalysis negative. 
Operation March 12, 1896. Vein easily found. Union per 
primam. Result: Complete disappearance of ectasis within ten 
weeks after operation. Examined in October, 1897, and no re- 
lapse found. 
Case ll.—Miss S. D., aged twenty-nine years; shop-girl. 
For past six years has been considerable of a sufferer from ectasis 
of veins of left leg. Great discomfort towards afternoon, after 
patient has been standing during the morning. Otherwise in 
very fair health. 
Examination showed enlarged veins on inner aspect of leg, 
especially marked over internal condyle of tibia. 
Operation on April 17, 1896. Result: Permanent cure when 
seen in October, 1897. 
Case lII.—L. J., aged fifty-seven years, housewife; seven 
children. Well-nourished, healthy woman. Has suffered from 
ectasis of internal saphenous vein for over seven years. About 
seven months before consulting writer, an ulcer appeared about 
four centimetres above the internal malleolus, and had attained 
the size of a quarter of a dollar. 
Operation September 20, 1896. Vein quickly found. Union 
per primam. Ulcer cicatrized at the end of five weeks and ectasis 
greatly diminished. 
Seen in September, 1897. No return of ulcer ; a few vari- 
cose veins still to be seen over calf of leg, although in no manner 
to be compared with the original condition. Patient states that 
her leg gives her no inconvenience. 
Case IV.—L. F., aged sixty-four years; washwoman. 
Large varicose veins of left leg with a large circular ulcer on 
internal aspect of leg, about seven centimetres above malleolus. 
Operation November 12, 1896. Some difficulty in exposing TREATMENT OF VARICOSE VEINS. 
vein on account of abundant subcutaneous cellular tissue. When 
found, the vein was small and rather sclerous. Discharged in 
six weeks; ulcer healed; ectasis greatly diminished. 
Seen in September, 1897. Leg in excellent condition. No 
return of ectasis or ulcer. 
Case V.—G. H., aged forty-six years; housewife. Has suf- 
fered from varix of both legs for several years. Trophic dis- 
turbances began to occur in right heel, causing much pain, espe- 
cially towards evening, and obliged the patient to seek medical 
advice. 
Examination showed a varicose condition of the veins of 
labia majora, but uterus and adnexa appeared to be normal. 
General condition good. Negative urinalysis. 
Operation on January 8, 1897. Both saphenous veins were 
ligated in one seance. Recovery uneventful. Trophic disturb- 
ances over right heel ceased almost immediately after operation. 
Discharged in six weeks. 
Seen in October, 1897. A slight ectasis on right leg; left 
leg normal. 
Cases VI and VII have been operated on within the past 
four months, and consequently it would be premature to consider 
the result, which up to the present is good, as permanent. The 
last case, an old lady of sixty, presented an anomalous condition 
of saphenous vein of right leg. After incising at the point of 
election no vein could be found, it being replaced by a number 
of small branches. A second incision over the internal aspect 
of the condyle of the femur, however, exposed the internal saphe- 
nous, which was ligated at this point. 
This anomalous condition of the internal saphenous vein is 
mentioned by Sappey, Cruveilhier, and other anatomists. 
REFERENCES. 
1 Eczema is of common occurrence in the region of a varix. It will 
appear sometimes without any material cause, while at others a trauma- 
tism will be the factor in its production. According to Broca, an eczema 
is nearly always present before the appearance of an ulcer, and is a fre- 
quent cause of the latter complication. 
Syphilitic eruptions may also arise and complicate a varix. These 
are more particularly secondary or tertiary ecthyma and gumma, which 
remain sufficiently characteristic in appearance to make a diagnosis in the 
vast majority of cases. Verneuil particularly insisted on what he termed 
“ hybridite syphilitico-variqueuse” of ulcers, and pointed out the part 14 
CHARLES GREENE CUMSTON. 
played by antisyphilitic treatment in bringing to light the true nature of 
the affection. 
2lt may be well to here append a few words regarding varicose 
phlebitis. A varix of the first degree is not so liable to become inflamed 
as those of the second and third degrees, but serpiginous ectasis and vari- 
cose tumors are more readily subject to inflammatory processes. Preg- 
nancy, constitutional conditions, and the infectious diseases are the 
predisposing causes. 
Local causes, such as a local infection entering through an ulcerated 
or ruptured vein, are important factors, while overwork and privation 
only secondary ones. The infectious agent penetrates the tissues and is 
then carried through the vessels in the circulation. 
Deep varicose veins may rupture from a sudden contraction of the 
muscles, a shock or a violent traumatism producing a fracture, and a 
phlebitis has been thus set up, which has in some cases ended in deep 
suppuration and pulmonary embolus. 
Two forms of phlebitis are met with,—viz., diffused phlebitis and 
phlebitis of varicose nodules. The first variety is usually insidious in 
its beginning; there is a rapid fatigue in walking and oedema of the leg 
at the end of the day. Finally, there are all the usual symptoms, such as 
pain and changes of the skin along the track of the vein. The phlebitis 
may remain localized to a small portion of the vein or may invade the 
entire venous system of the limb, in which case embolus is to be feared. 
A. Broca has given as special description of inflammation of the 
ampullae, which may be attacked separately, although having undergone 
little previous pathological change. The diagnosis is a simple matter 
when there are only a few inflammatory nodes, but it becomes difficult 
when they have become fused into one phlegmonous mass, which may 
be mistaken for a syphilitic gumma or an erythema nodosum. 
LITERATURE. 
Trendelenburg: Ueber die Untersuchen der Vena Saphena Magna 
bei Unterschenkelvaricen, Klinische Chirurgie, 1890. 
Bardeleben: Lehrbuch der Chirurgie und Operationslehre. 
Duplay et Reclus: Traite de Chirurgie. 
Tillaux: Traite de Pathologic externe. 
Follin: Traite de Pathologic externe. 
Bruns: Beitrage zur klinischen Chirurgie, Band xiv. 
Tobold: Ueber Varicen der unteren extremitat, etc., Dissertation, 
Bonn, 1889. 
Schaffer: Ueber der Erfolge der Unterbindung der Vena Saphena 
Magna bei Unterschenkelvaricen nach Trendelenburg, Kiel. 1896. 
Chatelain: Traitement des Varices, etc., Geneva, 1896. 
W. H. Bennett: Treatment of Varicose Veins of the Lower Limbs, 
Clinical Journal, January 19, 1898.