If the patient is placed on a couch and the limb elevated, the veins are emptied, and if pressure is then made over the region of the saphenous opening and the patient allowed to stand up, so long as the great saphena system alone is involved, the veins fill again very slowly from below.  If the small saphena system also is involved, and if communicating branches are dilated, the veins fill up from below more rapidly.  When the pressure over the saphenous opening is removed, the blood rapidly rushes into the varicose vessels from above; this is known as Trendelenburg’s test.

The most marked dilatation usually occurs on the medial side of the limb, between the middle of the thigh and the middle of the calf, the arrangement of the veins showing great variety (Fig. 67).

There are usually one or more bunches of enlarged and tortuous veins in the region of the knee.  Frequently a large branch establishes a communication between the systems of the great and small saphenous veins in the region of the popliteal space, or across the front of the upper part of the tibia.  The superficial position of this last branch and its proximity to the bone render it liable to injury.

[Illustration:  FIG. 67.—­Extensive Varix of Internal Saphena System on Left Leg, of many years’ standing.]

The small veins of the skin of the ankle and foot often show as fine blue streaks arranged in a stellate or arborescent manner, especially in women who have borne children.

Complications.—­When the varix is of long standing, the skin in the lower part of the leg sometimes assumes a mahogany-brown or bluish hue, as a result of the deposit of blood pigment in the tissues, and this is frequently a precursor of ulceration.

Chronic dermatitis (varicose eczema) is often met with in the lower part of the leg, and is due to interference with the nutrition of the skin.  The incompetence of the valves allows the pressure in the varicose veins to equal that in the arterioles, so that the capillary circulation is impeded.  From the same cause the blood in the deep veins is enabled to enter the superficial veins, where the backward pressure is so great that the blood flows down again, and so a vicious circle is established.  The blood therefore loses more and more of its oxygen, and so fails to nourish the tissues.

The ulcer of the leg associated with varicose veins has already been described.

Haemorrhage may take place from a varicose vein as a result of a wound or of ulceration of its wall.  Increased intra-venous pressure produced by severe muscular strain may determine rupture of a vein exposed in the floor of an ulcer.  If the limb is dependent, the incompetency of the valves permits of rapid and copious bleeding, which may prove fatal, particularly if the patient is intoxicated when the rupture takes place and no means are taken to arrest the haemorrhage.  The bleeding may be arrested at once by elevating the limb, or by applying pressure directly over the bleeding point.