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Clinical comparison of sclerosing solutions in injection treatment of varicose veins delayed slough; recurrence of varices
CLINICAL COMPARISON OF SCLEROSINGSOLUTIONS IN INJECTION TREATMENT OF VARICOSE VEINS DELAYED SLOUGH; RECURRENCE
OF VARICES
ADOLPH A. SCHMIER, M.D. NEW
A
LTHOUGH the eficacy of the injection treatment of varicose veins has been definiteIy established, I have been repeatedIy questioned by physicians regarding the proper sites to begin injecting, the type of soIution to use, the possibIe dangers invoived, and the resuIts that can be expected. It was the impression of many that the injection of veins in the upper thigh is contraindicated. The Iiterature aIso Ieads one to beIieve that certain scIerosing soIutions are non-toxic systematicaIIy and never produce sIoughs IocaIIy, thereby making these soIutions the most ideaI. The written reports aIso Iead one to expect a high percentage of recurrences. Since my observations over a number of years do not confirm these impressions, I fee1 that a r&urn6 of my findings is warranted. In addition, I shouId Like to describe what I caI1 a “delayed or postobIiterative sIough,” a finding which I beheve has not been reported. The cases suppIying the data for this paper were treated both in the Varicose Vein CIinic at the BrookIyn Jewish HospitaI, a branch of Dr. B. Wolfort’s Orthopedic CIinic, and in my private practice. GENERALFACTORS
INFLUENCING
INJECTION
TREATMENT It is a known fact that many patients and even some physicians stiI1 regard the injection treatment of varicose veins with suspicion and advise against the procedure. This is due to the immediate or deIayed IocaI pain, the systemic reaction due to drug idiosyncrasy, the occurrence of sloughs, and the supposedIy high
YORK
incidence of recurrences. The genera1 and IocaI factors that determine the success or faiIure of this form of treatment have been repeatedIy reported, and need onIy to be enumerated. UntiI recentIy the two main contraindications to the injection treatment have been an ineffIcient circuIation through the deep venous system, and an acute superficial phIebitis. Postobliterative Infectious Pblebitis. In the past few years I have noted that active foci of infection, even distantIy removed, have produced extensive painful obIiteration in the veins injected. It is therefore important to postpone injections in patients suffering from upper respiratory infections or other active foci. It is aIso important for patients who have aIready had their veins obIiterated to guard against a11 types of respiratory infections. I have had severa cases in which a typica infectious phIebitis has been superimposed upon a chemicaIIy obIiterated vein an invariabIe Iength of time foIIowing its injection. In 2 of these cases, the patients deveIoped a sore throat and rhinitis just prior to the onset of the phIebitis. In a third case an inAuenza1 bronchitis was present. The veins had been chemicaIIy scIerosed from two to six weeks before. It is evident that the recent phIebitis couId not have been chemica1 in origin, but must have been infectious in type, metastatic in origin. This I have termed infectious p h Ie b i t i s.” “postobIiterative This is different from the severe, painful phIebitis which occurs within a few days after the injection of a vein in which a Iatent subcIinica1 phIebitis existed. Tests to determine Iatent phIebitis have been described in the Iiterature. When these
3%
American
390
Journal
of Surgery
Schmier-Varicose
are positive, injections shouId be given cautiousIy and in smaI1 amounts. In the cases of postobIiterative phIebitis, there
FIG. I. Type of thin-walled vein IikeIy to produce a delayed sIough.
were no evidences phIebitis.
Drug
of a pre-existing
Idiosyncrasy,
Morrhuism.
Veins
APRIL,
,937
had practicaIIy subsided, she was given a second injection of onIy 2 C.C. of morrhuate. The generaIized rash again appeared,
FIG. 2. Same vein three weeks Iater; note glossy, tense appearance. DeIayed slough subsequently formed.
Iatent
Another genera1 factor detrimenta to the injkction treatment is the individua1 idiosyncrasy to various drugs empIoyed. The accompanying tabIe indicates that of the more common soIutions empIoyed, untoward generaIized reactions are common with sodium morrhuate, quinine hydrochIoride and urethane, and sodium saIicyIate. I have never yet seen any genera1 reaction foIIowing the use of sodium chloride. After the use of sodium morrhuate, severa patients deveIoped gastrointestina1 upsets with nausea and vomiting. One patient received 3 C.C. of sodium morrhuate and the foIIowing day a pruritic rash covered her entire body and scaIp. ExfoIiation occurred Iater which Iasted more than three weeks. About one month after this injection, when the desquamation
aIthough less marked than previously. The remaining veins were treated with sodium chIoride with no untoward effects. Cinchonism. Cinchonism foIIowing the use of quinine hydrochIoride and urethane has been described in a previous publication. AIthough ampouIes of 2 C.C. are put on the market, I advise against the use of more than I C.C. of the drug at one sitting. Dizziness, ringing in the ears, paIpitation and gastrointestina1 upset have occurred in some of my cases. I have heard of cases of syncope and 2 cases of exitus foIIowing its use. I once empIoyed quinine in the treatment of an interne who had innumerabIe fine thin waIIed veins. On many occasions from 0.5 to I C.C. of the drug was injected with no systemic reaction. Upon the insistence of the interne that Iarger doses be given in order to hasten the resuIts, I empIoyed 1.5 C.C.
NEW
SERIES
VOL. XXXVI.
FIG. 3. Another
Schmier-Varicose
No. I
thin wakd vein which later formed a deIayed sIough.
Veins
FIG. 4. DeIayed
slough occurring almost five months after injection.
I3
A
FIG. 5. Case 1. Before treatment;
A,
note large pendulous sac f&d
with veins; B, lateral view.
392
Schmier-Varicose
American Journalof Surgery
of the solution. He immediateIy deveIoped dizziness and genera1 weakness and was confined to bed for the rest of the day.
Veins
drug has not as yet been found. The three drugs mentioned above cannot be considered idea1 because of the possibility
B
A
FIG. 6. Case 1. After treatment;
A,
sac only partiaIIy contracted;
Quinine is contraindicated during the menses since it may produce menorrhagia. I have had 2 cases where quinine initiated the menstrua1 ffow prematureIy. Salicylism. SaIicyIism has occurred in severa of my cases foIIowing the injection of 20 to 40 per cent sodium saIicyIate. In addition to a gastrointestina1 upset, a generahzed rash has been noted on a few occasions. The disadvantages of the remaining solutions are recorded in the chart. From the genera1 viewpoint, therefore, it is my beIief that sodium chloride is the best and Ieast harmfuI drug at our disposa1. It is important to note, however, that the idea1
B, appearance
folIowing skin plastyic.
of individua1 idiosyncrasy to them. The remaining soIutions in&ding sodium chloride are ruIed out as being idea1 because of the IocaI disadvantages to be enumerated. LOCAL
FACTORS
INFLUENCING
INJECTION
TREATMENT
It shouId be understood primariIy that any drug which is caustic enough to destroy the intima of a vein to produce occIusion, is strong enough to destroy perivenous tissue and produce a sIough when injected outside the vein. The reported cIaims that quinine and morrhuate do not produce sIoughs is unwar-
NEW SERIES VOL. XXXVI,
No. I
Schmier-Varicose
ranted. I have intentiona1Iy injected smaI1 amounts of every soIution subcutaneousIy and have in each instance produced a slough. Any soIution which wiII not produce a slough when injected perivenously wiII generaIIy not be strong enough to obliterate a vein. It is foIIy therefore to Iook for the idea1 soIution which never produces a sIough. The physician must realize that early sIoughs can onIy be avoided by proper, meticuIous technique. An idea1 soIution must be one that produces no pain or cramp, is generaIIy non-toxic, and one which causes effective obliteration. According to this definition, none of the drugs in common use is ideal. If the cramp folIowing the injection of sodium chIoride couId be eliminated, I shouId consider it an idea1 soIution. AIthough sodium morrhuate, quinine hydrochIoride and urethane, and sodium saIicyIate are eIiminated as idea1 because of the possibiIity of idiosyncrasy to them, they aIso faI1 short because of possible untoward IocaI reactions. Sodium salicylate genera1Iy produces a cramp which is more painfu1 than that of any other drug. AIthough sodium morrhuate generaIIy does not produce an immediate cramp, it does often cause a severe burning, stinging or Iancinating pain which begins severa minutes after the injection. This pain may Iast from an hour to severa days and often confines the patient to bed. In a busy cIinic it is easy for the physician to lose sight of this delayed reaction. Th e patlent . has usuaIIy Ieft the cIinic, and the pain may come on whiIe she is on her way home. At the foIIowing visit no inquiry is made regarding any interva1 discomfort since there was no immediate pain folIowing the Iast injection. Quinine seldom produces any cramp, aIthough 0ccasionaIIy a patient may compIain of miId pain. It does, however, often produce a bronzed discoIoration of the skin at the site of injection. This discoIoration may last for over two years. In addition, quinine may produce what I have termed a “delayed or postobIiterative sIough.”
Veins
American Journal ot Surgery
393
Postobliterative or Delayed postobIiterative from one to
Slough. A sIough is one which occurs severa months after the
FIG. 6. c, lateral view.
injection of a thin walled vein. This vein may be Iarge or smaI1, but it is usuaIIy thin waIIed. OccasionaIIy it may occur in a thick waIIed vein into which too much solution was injected. It occurs even though the technique of injection is perfect. The solution not onIy destroys the intima but aIso the atrophied media and adventitia of the vein waI1. FoIIowing the injection the vein becomes obIiterated and tender. The skin over it may become red, warm and gIossy. The destruction graduaIIy advances unti1 after several weeks a sIough occurs. With experience, these thin waIIed, superficia1 veins that are IikeIy to produce deIayed sIoughs can be predetermined. Figure I presents such a vein on the posterior upper aspect
394
AmericanJournal
of
Surgery
Schmier-Varicose
Veins
APRIL.
193~
of the right caIf. Figure 2 shows the same vein three weeks after obIiteration. The vein is shiny and tense. This site Iater
appeared, not even did any blister form. Counter-injection tiIIed water or 0.5 per cent
superficial with disnovocaine
broke down. Figure 3 iIIustrates another such vein on the anterior upper aspect of the Ieft Ieg. This case aIso deveIoped a deIayed sIough. Figure 4 is an exampIe of a deIayed sIough. A thin waIIed vein was injected with I C.C. quinine hydrochIoride and urethane on March 31, 1930, and the sIough appeared. On August 25, 1930. It is important to note that these deIayed sloughs are not due to injection of the soIution perivenousIy. When extravasation occurs at the time of injection, the sIough forms much earIier. The Iatter is immediateIy evidenced by a bluish white discoIoration surrounded by a red areoIa, a sign described in a previous pubIication. In the deIayed sIough cases no such sign
soIution will prevent the earIy sIoughs but wiII have no effect upon the delayed sIough cases. In my experience quinme has been the chief offender in producing these deIayed sIoughs. Morrhuate is second aIthough far behind. Any soIution presumably can produce these deIayed sIoughs, aIthough I have onIy seen them foIIowing the use of quinine and morrhuate. In order to avoid these sIoughs, miIder soIutions shoufd be empIoyed when injecting fine veins. I have never seen this compIication when 15 per cent sodium chIoride soIution was used in smaI1 doses. Considering the above factors, therefore, it is my beIief that sodium chIoride is the best soIution even from the IocaI stand-
NFH. Smrm
VOL. XXXVI,
No.
1
Schmier-Varicose
Veins
American
Journal
III Surg<.ry
395
point. If the cramp accompanying its injection couId be eliminated, it would be quite ideaI. NevertheIess, the cramp
in time and become prominent does not justify the diagnosis of recurrence. These cases were never treated thoroughIy in
is never as severe as that foIIowing the injection of sodium saIicyIate. In addition, patients who have received both the chIoride and the morrhuate injections have expressIy preferred the momentary cramp of the chIoride to the Iong, drawnout pain of the morrhuate. Recurrence of Varices. The opinion that varicose veins recur in the majority of cases is unfounded. I have seen many cases who have received from four to eight injections and who were discharged as cured. The Iarger and more conspicuous veins were injected, but many smaIIer visibIe veins were Ieft untreated. In addition, many untreated invisibIe veins couId be paIpated beneath the skin. The fact that these smaIIer veins enIarge
the first place. ShouId treatment cease at this point, not onIy wiI1 the smaIIer veins enIarge but they wiI1 also tend to recanaIize the few obhterated veins. On the other hand, we must admit that even those cases which are thoroughly treated may deveIop new varicosities in time. The infra-red photographs have demonstrated that many veins are present subcutaneousIy which are neither visibIe nor paIpabIe. The same etioIogica1 factors that originaIIy produced the varicosis may aIso cause these veins to become enIarged. We know that certain individuaIs possess a varicose vein diathesis. Otherwise, under simiIar conditions, why should some peopIe develop varicose veins and
396 others
American Journal of Surgery
not?
Why
Schmier-Varicose
shouId varicose
veins
appear so reguIarIy in certain famihes and not in others? Since a good proportion
B
A
rapidIy if the origina treatment is done more thoroughly. It is important to obliterate the main trunk of the internal saphenous in the thigh if earIy and extensive recurrences are to be avoided. Often this vein is not visibIe, but it is usuaIIy paIpabIe and can easiIy be injected. After treatment is compIeted, I advise my patients to return for inspection every six months, during which time onIy a few, if any, new veins may be present. CASE
REPORTS
The impression that the injection of varicosities in the upper thigh is dangerous is disproved by the report of the foILowing cases.
APRIL, 193,
CASE I. A forty year old woman had enIarged veins distributed over the right thigh and Ieg and a Iarge pendulous sac fiIIed with
FIG. 9. Case III. A, before treatment;
of patients with varicose veins dispIay this tendency, we must expect recurrences in them. But these wiI1 not appear so
Veins
B, after treatment.
veins at the IeveI of the saphenofemora1 junction. After twenty-four injections the veins were entirely obliterated. Following the disappearance of the veins the penduIous sac near the groin onIy partiaIIy contracted. A skin pIastic was therefore performed under IocaI anesthesia. CASE II. A fifty-four year old woman presented large saccufar veins over the right thigh and both Iegs and an uIcer over the inner aspect of the Ieft ankIe. On the middIe third of the Ieft caIf wil1 be noted a prominent, shiny, thin waIIed vein, the type in which a deIayed or postobliterative sIough may occur. This patient required ninety-six injections to obliterate a11her veins. The uIcer was treated with metuvit ointment and eIastopIast bandage, as described previousIy. A deIayed sIough deveIoped several months after the thin waIled vein was sclerosed. CASE III. A middIe-aged man with large saccuIar veins over the right thigh and leg.
NEW SEIUES VOL.XXXVI,
No.
Schmier-Varicose
1
The dark area on the inner mid aspect of the Ieg is due to an old injury and has no relation to the varicosities. Twenty-four injections were required to occlude these veins.
CONCLUSIONS
Although the idea1 solution has not been found as yet, sodium chloride stiII ranks as the best choice. Any soIution that CLINICAL
COMPARISON
OF
Veins
397
American Journal of Surgery
is capabIe of sclerosing a vein can also produce a sIough. EarIy sloughs can be avoided by proper technique. DeIayed or postobIiterative sIoughs occur in thin waIIed veins even though the technique of injection is perfect, but they can be avoided by using weaker soIutions and smaIIer EarIy and extensive recurrences doses. of varicosities can be avoided by more thorough treatment. SCLEROSING
SOLUTIONS
-iSolution
Amount
Advantages
I _ I s-30 per cent sodium chloride.
Non-toxic,
2. 3 per cent sodium morrhuate.
Seldom good tion, action
3. Quinine hydrochloride and urethane.
Seldom cramps, good obliteration, prompt action Good obliteration, prompt action, relieves arthritic pain Slight cramp
4. x-40 per cent sodium salicylate. 5. so-7fi per cent invert sugar. 6. 50 per cent dextrose..
7. Varicosmon..
. .....
good
obliteration,
prompt
action
cramps, obliteraprompt
Slight cramp Seldom cramps
Length of Vein Obliterated
Indications for Use
Disadvantages
Cramp. danger of necrosis
In alI types of
local Necrosis, burning generalized rash, g.i. upset
In a11 types of
Necrosis, cincho&m. starts menses, discolors skin Marked cramp, necrosis. salicyfism
SmalI veins; test for susceptibiIitJ
Necrosis in diabetes, too visCO”S Necrosis in diabetes, action weak Necrosis; too viscous
I v’aries
with individual venous sensitiveness i 4ffected by late” phlebitis
veins veins; test for susceptibility
Occlusion
Time
Varies with individual VCIIOUS sensitiveness Different veins in same individual obliterate may quickly or SlOWly
14verage
length of occlusion is 1-3 inches
..............
Resistant veins used combined with chloride
Average time to occlude all veins to weeks Average number of iniections20
Large veins nondiabetic jmaller veins corn. bined with 30 per cent NaCL Large veins -
REFERENCES I. CARTER,
7. LEWIS, K. M. The injection
2.
8.
3.
4.
5.
R. M. The injection treatment of varicose veins. Am. Jour. Surg., 8: 551, 1930. COLT, G. H., RAMSAY, I. S. W. and MORRISON, N. Injection treatment of varicose veins: Iate results; question of recurrence. &it. Med. Jour., 2: 49. 1935. DETAKATS, G. Injection treatment of varicose veins: causes of failure. J. A. A4. A., 96: I I I II I 14 (April 4) 1931. HOWARD, N. J., JACKSON, C. R. and MAHON, E. J. Recurrence of varicose veins foIlowing injection. Arch. Surg., 22: 353, 1931. JACQUES, L. Varico-phIebitis and the injection treatment. Ann. Surg., 95: 746-753 (May) ‘932.
6. JENSEN, D. R. Varicose veins and their treatment. Ann. Surg., 95: 738, 1932.
g. IO. I I. 12.
13.
treatment of varicose veins. Ann. Surg., 95: 727, 1932. MCPHEETERS, H. O., MERKERT, C. E. and LUNDBLAD, R. A. The injection treatment of varicose veins: causes of failure. J. A. M. A., 96: I I r41117 (ApriI 4) 1931. PAYNE, R. T. Infra-red photography of superficia1 venous system. Lance& I: 235, 1934. SCHMIER, A. A. ScIerotizing injections in varices of the Iower extremities. J. A. M. A., 94: 1222, 1930. SCHMIER, A. A. Treatment of varicose ulcers. Am. Jour. Surg., 23: 195, 1934. TUNICK, I. S. and NACH, R. Sodium morrhuate as a sclerosing agent. Ann. Surg., 95: 734, 1932. TUNICK, I. S., DUBIN, S. and SCHMIER, A. A. The injection treatment of varices and ukers of the Iower extremities. Am. Jour. Surg., 6: 479, Igzg.
OF VARICES
ADOLPH A. SCHMIER, M.D. NEW
A
LTHOUGH the eficacy of the injection treatment of varicose veins has been definiteIy established, I have been repeatedIy questioned by physicians regarding the proper sites to begin injecting, the type of soIution to use, the possibIe dangers invoived, and the resuIts that can be expected. It was the impression of many that the injection of veins in the upper thigh is contraindicated. The Iiterature aIso Ieads one to beIieve that certain scIerosing soIutions are non-toxic systematicaIIy and never produce sIoughs IocaIIy, thereby making these soIutions the most ideaI. The written reports aIso Iead one to expect a high percentage of recurrences. Since my observations over a number of years do not confirm these impressions, I fee1 that a r&urn6 of my findings is warranted. In addition, I shouId Like to describe what I caI1 a “delayed or postobIiterative sIough,” a finding which I beheve has not been reported. The cases suppIying the data for this paper were treated both in the Varicose Vein CIinic at the BrookIyn Jewish HospitaI, a branch of Dr. B. Wolfort’s Orthopedic CIinic, and in my private practice. GENERALFACTORS
INFLUENCING
INJECTION
TREATMENT It is a known fact that many patients and even some physicians stiI1 regard the injection treatment of varicose veins with suspicion and advise against the procedure. This is due to the immediate or deIayed IocaI pain, the systemic reaction due to drug idiosyncrasy, the occurrence of sloughs, and the supposedIy high
YORK
incidence of recurrences. The genera1 and IocaI factors that determine the success or faiIure of this form of treatment have been repeatedIy reported, and need onIy to be enumerated. UntiI recentIy the two main contraindications to the injection treatment have been an ineffIcient circuIation through the deep venous system, and an acute superficial phIebitis. Postobliterative Infectious Pblebitis. In the past few years I have noted that active foci of infection, even distantIy removed, have produced extensive painful obIiteration in the veins injected. It is therefore important to postpone injections in patients suffering from upper respiratory infections or other active foci. It is aIso important for patients who have aIready had their veins obIiterated to guard against a11 types of respiratory infections. I have had severa cases in which a typica infectious phIebitis has been superimposed upon a chemicaIIy obIiterated vein an invariabIe Iength of time foIIowing its injection. In 2 of these cases, the patients deveIoped a sore throat and rhinitis just prior to the onset of the phIebitis. In a third case an inAuenza1 bronchitis was present. The veins had been chemicaIIy scIerosed from two to six weeks before. It is evident that the recent phIebitis couId not have been chemica1 in origin, but must have been infectious in type, metastatic in origin. This I have termed infectious p h Ie b i t i s.” “postobIiterative This is different from the severe, painful phIebitis which occurs within a few days after the injection of a vein in which a Iatent subcIinica1 phIebitis existed. Tests to determine Iatent phIebitis have been described in the Iiterature. When these
3%
American
390
Journal
of Surgery
Schmier-Varicose
are positive, injections shouId be given cautiousIy and in smaI1 amounts. In the cases of postobIiterative phIebitis, there
FIG. I. Type of thin-walled vein IikeIy to produce a delayed sIough.
were no evidences phIebitis.
Drug
of a pre-existing
Idiosyncrasy,
Morrhuism.
Veins
APRIL,
,937
had practicaIIy subsided, she was given a second injection of onIy 2 C.C. of morrhuate. The generaIized rash again appeared,
FIG. 2. Same vein three weeks Iater; note glossy, tense appearance. DeIayed slough subsequently formed.
Iatent
Another genera1 factor detrimenta to the injkction treatment is the individua1 idiosyncrasy to various drugs empIoyed. The accompanying tabIe indicates that of the more common soIutions empIoyed, untoward generaIized reactions are common with sodium morrhuate, quinine hydrochIoride and urethane, and sodium saIicyIate. I have never yet seen any genera1 reaction foIIowing the use of sodium chloride. After the use of sodium morrhuate, severa patients deveIoped gastrointestina1 upsets with nausea and vomiting. One patient received 3 C.C. of sodium morrhuate and the foIIowing day a pruritic rash covered her entire body and scaIp. ExfoIiation occurred Iater which Iasted more than three weeks. About one month after this injection, when the desquamation
aIthough less marked than previously. The remaining veins were treated with sodium chIoride with no untoward effects. Cinchonism. Cinchonism foIIowing the use of quinine hydrochIoride and urethane has been described in a previous publication. AIthough ampouIes of 2 C.C. are put on the market, I advise against the use of more than I C.C. of the drug at one sitting. Dizziness, ringing in the ears, paIpitation and gastrointestina1 upset have occurred in some of my cases. I have heard of cases of syncope and 2 cases of exitus foIIowing its use. I once empIoyed quinine in the treatment of an interne who had innumerabIe fine thin waIIed veins. On many occasions from 0.5 to I C.C. of the drug was injected with no systemic reaction. Upon the insistence of the interne that Iarger doses be given in order to hasten the resuIts, I empIoyed 1.5 C.C.
NEW
SERIES
VOL. XXXVI.
FIG. 3. Another
Schmier-Varicose
No. I
thin wakd vein which later formed a deIayed sIough.
Veins
FIG. 4. DeIayed
slough occurring almost five months after injection.
I3
A
FIG. 5. Case 1. Before treatment;
A,
note large pendulous sac f&d
with veins; B, lateral view.
392
Schmier-Varicose
American Journalof Surgery
of the solution. He immediateIy deveIoped dizziness and genera1 weakness and was confined to bed for the rest of the day.
Veins
drug has not as yet been found. The three drugs mentioned above cannot be considered idea1 because of the possibility
B
A
FIG. 6. Case 1. After treatment;
A,
sac only partiaIIy contracted;
Quinine is contraindicated during the menses since it may produce menorrhagia. I have had 2 cases where quinine initiated the menstrua1 ffow prematureIy. Salicylism. SaIicyIism has occurred in severa of my cases foIIowing the injection of 20 to 40 per cent sodium saIicyIate. In addition to a gastrointestina1 upset, a generahzed rash has been noted on a few occasions. The disadvantages of the remaining solutions are recorded in the chart. From the genera1 viewpoint, therefore, it is my beIief that sodium chloride is the best and Ieast harmfuI drug at our disposa1. It is important to note, however, that the idea1
B, appearance
folIowing skin plastyic.
of individua1 idiosyncrasy to them. The remaining soIutions in&ding sodium chloride are ruIed out as being idea1 because of the IocaI disadvantages to be enumerated. LOCAL
FACTORS
INFLUENCING
INJECTION
TREATMENT
It shouId be understood primariIy that any drug which is caustic enough to destroy the intima of a vein to produce occIusion, is strong enough to destroy perivenous tissue and produce a sIough when injected outside the vein. The reported cIaims that quinine and morrhuate do not produce sIoughs is unwar-
NEW SERIES VOL. XXXVI,
No. I
Schmier-Varicose
ranted. I have intentiona1Iy injected smaI1 amounts of every soIution subcutaneousIy and have in each instance produced a slough. Any soIution which wiII not produce a slough when injected perivenously wiII generaIIy not be strong enough to obliterate a vein. It is foIIy therefore to Iook for the idea1 soIution which never produces a sIough. The physician must realize that early sIoughs can onIy be avoided by proper, meticuIous technique. An idea1 soIution must be one that produces no pain or cramp, is generaIIy non-toxic, and one which causes effective obliteration. According to this definition, none of the drugs in common use is ideal. If the cramp folIowing the injection of sodium chIoride couId be eliminated, I shouId consider it an idea1 soIution. AIthough sodium morrhuate, quinine hydrochIoride and urethane, and sodium saIicyIate are eIiminated as idea1 because of the possibiIity of idiosyncrasy to them, they aIso faI1 short because of possible untoward IocaI reactions. Sodium salicylate genera1Iy produces a cramp which is more painfu1 than that of any other drug. AIthough sodium morrhuate generaIIy does not produce an immediate cramp, it does often cause a severe burning, stinging or Iancinating pain which begins severa minutes after the injection. This pain may Iast from an hour to severa days and often confines the patient to bed. In a busy cIinic it is easy for the physician to lose sight of this delayed reaction. Th e patlent . has usuaIIy Ieft the cIinic, and the pain may come on whiIe she is on her way home. At the foIIowing visit no inquiry is made regarding any interva1 discomfort since there was no immediate pain folIowing the Iast injection. Quinine seldom produces any cramp, aIthough 0ccasionaIIy a patient may compIain of miId pain. It does, however, often produce a bronzed discoIoration of the skin at the site of injection. This discoIoration may last for over two years. In addition, quinine may produce what I have termed a “delayed or postobIiterative sIough.”
Veins
American Journal ot Surgery
393
Postobliterative or Delayed postobIiterative from one to
Slough. A sIough is one which occurs severa months after the
FIG. 6. c, lateral view.
injection of a thin walled vein. This vein may be Iarge or smaI1, but it is usuaIIy thin waIIed. OccasionaIIy it may occur in a thick waIIed vein into which too much solution was injected. It occurs even though the technique of injection is perfect. The solution not onIy destroys the intima but aIso the atrophied media and adventitia of the vein waI1. FoIIowing the injection the vein becomes obIiterated and tender. The skin over it may become red, warm and gIossy. The destruction graduaIIy advances unti1 after several weeks a sIough occurs. With experience, these thin waIIed, superficia1 veins that are IikeIy to produce deIayed sIoughs can be predetermined. Figure I presents such a vein on the posterior upper aspect
394
AmericanJournal
of
Surgery
Schmier-Varicose
Veins
APRIL.
193~
of the right caIf. Figure 2 shows the same vein three weeks after obIiteration. The vein is shiny and tense. This site Iater
appeared, not even did any blister form. Counter-injection tiIIed water or 0.5 per cent
superficial with disnovocaine
broke down. Figure 3 iIIustrates another such vein on the anterior upper aspect of the Ieft Ieg. This case aIso deveIoped a deIayed sIough. Figure 4 is an exampIe of a deIayed sIough. A thin waIIed vein was injected with I C.C. quinine hydrochIoride and urethane on March 31, 1930, and the sIough appeared. On August 25, 1930. It is important to note that these deIayed sloughs are not due to injection of the soIution perivenousIy. When extravasation occurs at the time of injection, the sIough forms much earIier. The Iatter is immediateIy evidenced by a bluish white discoIoration surrounded by a red areoIa, a sign described in a previous pubIication. In the deIayed sIough cases no such sign
soIution will prevent the earIy sIoughs but wiII have no effect upon the delayed sIough cases. In my experience quinme has been the chief offender in producing these deIayed sIoughs. Morrhuate is second aIthough far behind. Any soIution presumably can produce these deIayed sIoughs, aIthough I have onIy seen them foIIowing the use of quinine and morrhuate. In order to avoid these sIoughs, miIder soIutions shoufd be empIoyed when injecting fine veins. I have never seen this compIication when 15 per cent sodium chIoride soIution was used in smaI1 doses. Considering the above factors, therefore, it is my beIief that sodium chIoride is the best soIution even from the IocaI stand-
NFH. Smrm
VOL. XXXVI,
No.
1
Schmier-Varicose
Veins
American
Journal
III Surg<.ry
395
point. If the cramp accompanying its injection couId be eliminated, it would be quite ideaI. NevertheIess, the cramp
in time and become prominent does not justify the diagnosis of recurrence. These cases were never treated thoroughIy in
is never as severe as that foIIowing the injection of sodium saIicyIate. In addition, patients who have received both the chIoride and the morrhuate injections have expressIy preferred the momentary cramp of the chIoride to the Iong, drawnout pain of the morrhuate. Recurrence of Varices. The opinion that varicose veins recur in the majority of cases is unfounded. I have seen many cases who have received from four to eight injections and who were discharged as cured. The Iarger and more conspicuous veins were injected, but many smaIIer visibIe veins were Ieft untreated. In addition, many untreated invisibIe veins couId be paIpated beneath the skin. The fact that these smaIIer veins enIarge
the first place. ShouId treatment cease at this point, not onIy wiI1 the smaIIer veins enIarge but they wiI1 also tend to recanaIize the few obhterated veins. On the other hand, we must admit that even those cases which are thoroughly treated may deveIop new varicosities in time. The infra-red photographs have demonstrated that many veins are present subcutaneousIy which are neither visibIe nor paIpabIe. The same etioIogica1 factors that originaIIy produced the varicosis may aIso cause these veins to become enIarged. We know that certain individuaIs possess a varicose vein diathesis. Otherwise, under simiIar conditions, why should some peopIe develop varicose veins and
396 others
American Journal of Surgery
not?
Why
Schmier-Varicose
shouId varicose
veins
appear so reguIarIy in certain famihes and not in others? Since a good proportion
B
A
rapidIy if the origina treatment is done more thoroughly. It is important to obliterate the main trunk of the internal saphenous in the thigh if earIy and extensive recurrences are to be avoided. Often this vein is not visibIe, but it is usuaIIy paIpabIe and can easiIy be injected. After treatment is compIeted, I advise my patients to return for inspection every six months, during which time onIy a few, if any, new veins may be present. CASE
REPORTS
The impression that the injection of varicosities in the upper thigh is dangerous is disproved by the report of the foILowing cases.
APRIL, 193,
CASE I. A forty year old woman had enIarged veins distributed over the right thigh and Ieg and a Iarge pendulous sac fiIIed with
FIG. 9. Case III. A, before treatment;
of patients with varicose veins dispIay this tendency, we must expect recurrences in them. But these wiI1 not appear so
Veins
B, after treatment.
veins at the IeveI of the saphenofemora1 junction. After twenty-four injections the veins were entirely obliterated. Following the disappearance of the veins the penduIous sac near the groin onIy partiaIIy contracted. A skin pIastic was therefore performed under IocaI anesthesia. CASE II. A fifty-four year old woman presented large saccufar veins over the right thigh and both Iegs and an uIcer over the inner aspect of the Ieft ankIe. On the middIe third of the Ieft caIf wil1 be noted a prominent, shiny, thin waIIed vein, the type in which a deIayed or postobliterative sIough may occur. This patient required ninety-six injections to obliterate a11her veins. The uIcer was treated with metuvit ointment and eIastopIast bandage, as described previousIy. A deIayed sIough deveIoped several months after the thin waIled vein was sclerosed. CASE III. A middIe-aged man with large saccuIar veins over the right thigh and leg.
NEW SEIUES VOL.XXXVI,
No.
Schmier-Varicose
1
The dark area on the inner mid aspect of the Ieg is due to an old injury and has no relation to the varicosities. Twenty-four injections were required to occlude these veins.
CONCLUSIONS
Although the idea1 solution has not been found as yet, sodium chloride stiII ranks as the best choice. Any soIution that CLINICAL
COMPARISON
OF
Veins
397
American Journal of Surgery
is capabIe of sclerosing a vein can also produce a sIough. EarIy sloughs can be avoided by proper technique. DeIayed or postobIiterative sIoughs occur in thin waIIed veins even though the technique of injection is perfect, but they can be avoided by using weaker soIutions and smaIIer EarIy and extensive recurrences doses. of varicosities can be avoided by more thorough treatment. SCLEROSING
SOLUTIONS
-iSolution
Amount
Advantages
I _ I s-30 per cent sodium chloride.
Non-toxic,
2. 3 per cent sodium morrhuate.
Seldom good tion, action
3. Quinine hydrochloride and urethane.
Seldom cramps, good obliteration, prompt action Good obliteration, prompt action, relieves arthritic pain Slight cramp
4. x-40 per cent sodium salicylate. 5. so-7fi per cent invert sugar. 6. 50 per cent dextrose..
7. Varicosmon..
. .....
good
obliteration,
prompt
action
cramps, obliteraprompt
Slight cramp Seldom cramps
Length of Vein Obliterated
Indications for Use
Disadvantages
Cramp. danger of necrosis
In alI types of
local Necrosis, burning generalized rash, g.i. upset
In a11 types of
Necrosis, cincho&m. starts menses, discolors skin Marked cramp, necrosis. salicyfism
SmalI veins; test for susceptibiIitJ
Necrosis in diabetes, too visCO”S Necrosis in diabetes, action weak Necrosis; too viscous
I v’aries
with individual venous sensitiveness i 4ffected by late” phlebitis
veins veins; test for susceptibility
Occlusion
Time
Varies with individual VCIIOUS sensitiveness Different veins in same individual obliterate may quickly or SlOWly
14verage
length of occlusion is 1-3 inches
..............
Resistant veins used combined with chloride
Average time to occlude all veins to weeks Average number of iniections20
Large veins nondiabetic jmaller veins corn. bined with 30 per cent NaCL Large veins -
REFERENCES I. CARTER,
7. LEWIS, K. M. The injection
2.
8.
3.
4.
5.
R. M. The injection treatment of varicose veins. Am. Jour. Surg., 8: 551, 1930. COLT, G. H., RAMSAY, I. S. W. and MORRISON, N. Injection treatment of varicose veins: Iate results; question of recurrence. &it. Med. Jour., 2: 49. 1935. DETAKATS, G. Injection treatment of varicose veins: causes of failure. J. A. A4. A., 96: I I I II I 14 (April 4) 1931. HOWARD, N. J., JACKSON, C. R. and MAHON, E. J. Recurrence of varicose veins foIlowing injection. Arch. Surg., 22: 353, 1931. JACQUES, L. Varico-phIebitis and the injection treatment. Ann. Surg., 95: 746-753 (May) ‘932.
6. JENSEN, D. R. Varicose veins and their treatment. Ann. Surg., 95: 738, 1932.
g. IO. I I. 12.
13.
treatment of varicose veins. Ann. Surg., 95: 727, 1932. MCPHEETERS, H. O., MERKERT, C. E. and LUNDBLAD, R. A. The injection treatment of varicose veins: causes of failure. J. A. M. A., 96: I I r41117 (ApriI 4) 1931. PAYNE, R. T. Infra-red photography of superficia1 venous system. Lance& I: 235, 1934. SCHMIER, A. A. ScIerotizing injections in varices of the Iower extremities. J. A. M. A., 94: 1222, 1930. SCHMIER, A. A. Treatment of varicose ulcers. Am. Jour. Surg., 23: 195, 1934. TUNICK, I. S. and NACH, R. Sodium morrhuate as a sclerosing agent. Ann. Surg., 95: 734, 1932. TUNICK, I. S., DUBIN, S. and SCHMIER, A. A. The injection treatment of varices and ukers of the Iower extremities. Am. Jour. Surg., 6: 479, Igzg.