panied by
actual pain, from which relief is at once obtained by raising the limb.
Cramp-like pains in the muscles are often associated with varix of the
deep veins.

The dilated and tortuous vein can be readily seen and felt when the
patient is examined in the upright posture. In advanced cases, bead-like
swellings are sometimes to be detected over the position of the valves,
and, on running the fingers along the course of the vessel, a firm
ridge, due to periphlebitis, may be detected on each side of the vein.
When the limb is oedematous, the outline of the veins is obscured, but
they can be identified on palpation as gutter-like tracks. When large
veins are implicated, a distinct impulse on coughing may be seen to pass
down as far as the knee; and if the vessel is sharply percussed a fluid
wave may be detected passing both up and down the vein.

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 bl