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GOVERNMENT HOMOEOPATHIC MEDICAL COLLEGE

THIRUVANANTHAPURAM

Varicose vein

DISSERTATION

SUBMITTED TOTHE DEPARTMENT OFSURGERY

FOR THE WINNING AWARD OF

THE DEGREE OF

BACHELOR OF HOMOEOPATHIC MEDICINE AND SURGERY

Submitted by

Dr. SHARY KRISHNA.B.S.

HOUSE SURGEON

2008BATCH

UNIVERSITY OF KERALA

2015

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GOVT HOMOEOPATHIC MEDICAL COLLEGE

THIRUVANANTHAPURAM

CERTIFICATE

This is to certify that the dissertation entitled "VARICOSE VEIN and ITS

HOMOEOPATHIC MANAGEMENT has been carried out by. Dr.SHARY

KRISHNA B.Sunder my guidance and supervision in Govt. Homoeopathic

Medical College, Thiruvananthapuram. She has taken keen interest in the

work and has made a remarkable compilation on the subject.

Date:30.4.2015

Place: Trivandrum

Dr.Tessy Mole Mathew

Professor and Head of Department

Department of Surgery

Govt .Homoeopathic medical college

Thiruvananthapuram

Countersigned by:

Dr.ANILA KUMARI. C. T

. Principal And Controlling Officer

Govt.Homoeopathic Medical College

Thiruvananthapuram

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OUR GREAT MASTER

Dr.CHRISTIAN FRIEDRICH SAMUEL HAHNEMANN

(1755-1843)

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AFFECTIONATELY DEDICATED TO

ALMIGHTY GOD,

MY MOTHER, MY FATHER, MY SISTER, MY

TEACHERS AND MY DEAR FRIENDS

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ACKNOWLEDGEMENT

First & foremost I would like to thank God, who has given me the

power to believe in myself & pursue my dreams.

I express my sincere gratitude to all teachers who taught me , as

well as my friends in the Govt. Homoeopathic Medical college , Trivandrum ,

whose presence guided & inspired me all through the days of my career.

I would like to thank Dr.AnilaKumari.C.T , Principal , Govt.

Homoeopathic Medical College, Trivandrum , for providing me an

opportunity for doing this work. I would also like to thank Dr.Jose M

Kuzhimthottyil , Superintendent , and Dr.Tessy Mole Mathew, Professor

,Department of Surgery for providing the necessary inspiration & guidance

for carrying out this work.

Words of appreciation are also to the staff at the college library for

all the help during my studies. There are so many others whom I may have

inadvertently left out and I sincerely thank all of them for their help.

Dr. SHARY KRISHNA B.S

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PREFACE

Within a score of decades of its advent, Homoeopathy

has gained widespread acceptance around the world. The intuition

and intellect of our master with the untiring work of our pioneers

remains as the bedrock of all these developments.

This dissertation is presented to the readers in the hope

that enables them to provide better understanding about varicose

vein and its homoeopathic management. I hope this will help the

readers to understand the disease, its medicines and also the

indications of important medicines.

Bowing at the footstep of Hahnemann, I am

submitting this humble work.

Dr.SHARY KRISHNA.B.S.

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INDEX

CONTENTS Page no:

1 Introduction 8

2 Definition 9

3 History 9

4 Surgical anatomy 10

5 Venous physiology 15

6 Surgical pathology 16

7 Epidemiology 18

8 Predisposing factors 19

9 Classification 20

10 Etiology 21

11 Clinical features 23

12 Clinical examination 24

13 Investigation 30

14 Complication 33

15 Varicose ulcer 35

16 Treatment 39

17 Self-care at home 43

18 Prognosis 45

19 HOMOEOPATHIC MANAGEMENT 46

20 Case taking 47

21 Plan of treatment in homoeopathic system of medicine 48

22 Miasmatic diagnosis of different stages of varicose vein and their

treatment

50

23 Therapeutics 52

24 Medicines and their differentiating features 57

25 Selection of potency 68

26 Selection of dose 69

27 Diet and regimen 70

28 Maintaining cause 71

29 Observation and follow up 72

30 Case discussion 76

31 Conclusion 97

32 Bibliography 98

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INTRODUCTION

As far as a country like India is concerned, where people like manual

laborers live in co-ordination and intermingled with people of high dignity, a

place where large number of people of extreme socio-economic status live inter-

dependently,there are limitations in covering medicial service to the whole

population. In a situation of high demand for manual laborer and cities with

mixed culture, we come through the age old disease prevailing even today,

one among which is Varicose vein, a disease which was first described by the

Father of Medicine Hippocrates . It went through the lives of ancient farmers

underwent transformation and manifest even today in the working people of

modern India. In this scientifically advanced world, the new investigation

procedures and treatment methods have shown way to study and analyze the

disease in its full extent. When viewing in the angle of homoeopathic

perspective, the evolution of the disease gives an image or concept entirely

different from that of modern medicinal aspect.

Varicose vein is significant clinical problem and not just a cosmetic

issue because of their unsightly nature. Problem arises from fact that varicose

vein actually represent underlying chronic venous insufficiency with ensuing

venous hypertension. Venous hypertension leads to aspectrum of clinical

manifestations, ranging from symptoms to cutaneous findings like varicose

veins, reticular veins, telangiectasia, swelling, skin discoloration, and

ulcerations.

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DEFINITION

Varicose veins are veins that have become distended over time. Long,

tortuous and dilated veins of the superficial varicose system due to the pooling

of blood in the lower extremities.

PHYSIOLOGICAL DEFINITION - A varicose vein is one which permits

reverse flow through its faulty valves.

Varicose veins are manifestation of an underlying disease process not itself a

disease.

Varicose veins represent enlarged collaterals of saphenous venous system

affected by disease called superficial venous insufficiency of lower extremities.

History

"In the case of an ulcer; it is not expedient to stand; more especially if the

ulcer be situated in the leg"

Hippocrates (460-377 BC)

Description of varicose vein as clinical entity can be traced back as early as 5th

century BC.Forefathers of medicine including Hippocrates and Galen described

the disease and treatment modalities, which are still used.

Royle J et al Varicose vein ANZ J Surg. D2007;77(12):1120-7

As in many other medical events, Hippocrates gets first credit for varicose vein

treatment. He recommended multiple punctures and cautioned against cutting

directly into the varicosity and engorged tissues. He also suggested elevation

and compression bandages as appropriatetreatment. During the Roman time

treatment of bandaging with linen was advised by Celsus(25BC-50AC) and

applying wine to the ulcer was recommended by Galen (130-200AC)3

Throughout centuries, surgical treatments have evolved from large, open

surgeries to minimally invasive approaches.

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SURGICAL ANATOMY

Venous drainage of the lower limb can be conveniently described under 3

heads.

(I) Deep veins,

(II) Superficial veins.

(III) Perforating or Communicating veins which connect the superficial

with the deep veins.

(I). Deep Veins

The deep veins of the lower limb accompany the arteries and their branches.

These veins possess numerous valves. The main veins are- The Posterior tibial

vein and their tributaries, the peroneal vein, the anterior tibial, the popliteal vein

and the femoral vein

The characteristic features of the deep veins are

1. There are numerous valves in these veins. These values direct the flow of the

blood upwards and prevent regurgitation of flow downwards.

2. Within the soleus muscle,which is the most powerful muscle of the calf there

and venous plexus or sinuses. These are devoid of valves. These veins empty in

segments in to the posterior tibial and the peroneal veins. These posterior tibial

veins and the peroneal veins also receive perforating or communicating veins

from the superficial veins and both these perforating veins and the soleus

venous plexuses or sinuses may enter the same sites of these veins.

II Superficial veins

These veins lie in the subcutaneous fat between the skin and the deep fascia.

These superficial veins of the lower limb are the long and short saphenous veins

and their tributaries.

Long (Great) Saphenous Vein.

It is the longest vein in the body. It begins in the medial marginal vein of

the foot and ends in the femoral vein about 3 cm below the inguinal ligament. It

ascends in front of the tibial malleolus, runs upwards crossing the lower part of

medial surface of the tibia obliquely to gain its medial border then it ascends a

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fingers breadth, behind the medial border of the tibia up to the knee. Here it

runs upwards on the posterior parts of the medial condyles of the tibia and

femur and alone themedial side of the thigh to the saphenous opening.

Saphenous opening lies about 3.5 cm below and lateral to the pubic tubercle. It

passes through the cribriform fascia of the saphenous opening and ends in the

femoral vein.

There are about 10 to 20 valves in this long saphenous vein which are more

numerous in the leg than in the thigh. Of these, two valves are almost constant-

One lies just before the vein pierces the cribriform fascia and another at its

junction with the femoral vein (this valve is concerned with saphenofemoral

sufficiency).

Tributaries-

1. At the ankle:

It receives veins from the sole of the foot through the medial marginal

veins.

2. In the leg.

(i) It communicates freely with the small saphenous vein.

(ii) Just below the knee it receives three large tributaries: (a) One

from the front of the leg (b) One from the region of the tibial

malleolus (which communicates with the perforating veins) and

(c) one from the calf which communicates with the small or

short saphenous vein.

(3)Inthethigh:

(i) A large accessory saphenous vein-which communicates below with the

small saphenous vein. This receives numerous tributaries from the medial and

posterior parts of the thigh.

(ii) A fairly constant large vein,sometimes called the anterior femoral

cutaneous vein Commences from a network of veins on the lower part of the

front of the thigh and crosses the apex of the femoral triangle to enter the long

saphenous vein in the upper part of the thigh.

(4)Nearthesaphenousopening:

JustbeforethelongSaphenousveinpiercesthesaphenousopeningitisjoinedbyfourvei

ns-

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(i)Thesuperficialepigastric,(ii)Superficialcircumflexiliac,(iii)Superficialexternal

pudendaland(iv)thedeepexternalpudendalvein,whichjointsthegreetsaphenousvei

natthesaphenousopening.

Surgicalimportance

A. As there is Communication between the long and short saphenous veins

varicosities may spread from one system to the other

B. In case of varicosity of the long saphenous vein, the smell veins from the

sole of the foot and the ankle which drains in to this venous system

through the medial marginal vein become dilated and this gives rise to

swelling of ankle, which is known as ankle flare.

Short(small)saphenousvein:-

Thisveinbeginsbehindthelateralmalleolusasacontinuationofthelateralmargi

nalveinofthefoot. It first ascends along the lateral border of the tendo Achilles

and then along the mid line of the back of the leg. It perforates the deep fascia

and passes between the two heads of the Gastrocnemius in the lower part of the

popliteal fossa and ends in the popliteal vein 3 to 7.5 cm above the level of the

knee joint.

In the leg it is in close relation with sural nerve.

This vein possesses 7 to 13 valves, one of which is always found near its

termination in the popliteal vein.

Tributaries:

It sends several tributaries upwards and medially to join the long saphenous

vein. The most important communicating branch arises from the small

saphenous veins before it pierces the deep fascia ad passes upwards and

medially to join the accessory saphenous vein. This Communication may

occasionally form the main continuation of the short saphenous vein.

III. Perforating or communicating veins

These veins communicate between the superficial and deep veins. These

always pierce the deep fascia. There are values within these veins which under

normal conditions allow blood to flow from the superficial to the deep veins.

Only when these valves become incompetent blood may flow in the opposite

direction and thus leads to varicosity of the superficial veins.

When the calf muscles contract the blood is pumped upwards in the deep

veins and blood flow into the superficial veins is prevented by the valves in the

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perforating veins. During relaxation of the calf muscles blood is aspirated from

the superficial into deep veins. If the valves in the perforating vein become

incompetent these veins become high pressure leaks during muscular

contraction and this transmission of high pressure in the deep veins to the

superficial veins results in dilatation of the superficial veins producing varicose

veins. Perforating veins are of two types:

(a). Indirect perforators:

There are numerous small vessels which start from the superficial venous

system, pierce the deep fascia and communicate with a vessel in an

underlying muscle. The latter vessel in turn is connected with the deep vein.

These in direct perforators are mostly seen in the upper part of the leg.

(b). Direct Perforators.

These veins directly connect the saphenous veins or their tributaries to the

deep veins. A few of these direct veins are constant in number and site.

These are:

(i). In the thigh-Between the long saphenous and the femoral vein in the

adductor canal.

(ii) In the leg:- The perforators in the leg are divided into three groups:-

(a) Medial perforating veins: There are three constant medial leg perforators

situated in line with the posterior border of the tibia 2 inches, 4 inches

and 6 inches above the medial malleolus. The upper two enter the

posterior tibial vein where an unvalvedsoleal venous sinus also enters it.

The importance of this is that the soleal venous sinuses are devoid of

values. Moreover the clot arising in the soleal veins may extend in to the

posterior tibial vein and then into the perforating veins thus destroying

the valves of the perforators. The lowest perforator has a short course

connecting long saphenous with the posterior tibial vein.

(b) Central Perforating veins: - One or two veins connect the short saphenous

system to the veins in the gastrocnemius and soleus muscles. Where one

enters the muscle on the medial side close to its junction with the tendo

Achilles, the other is situated further up in the calf.

(c) Lateral perforating veins: - These are inconstant perforators at the

posterior border of the fibula. These are connected with the Peroneal

veins.

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VENOUS PHYSIOLOGY

The veins perform many functions that are necessary for a normal blood

circulation. They are capable of constricting and enlarging, of storing large

quantities of blood and making this blood available when it is required by the

remainder of the circulation, of actually propelling blood forward by means of

so called "venous-pump" and even of helping to regulate cardiac outputand

body temperature. Their main function is to transport blood from the capillaries

to the heart, and this venous return can be passive or active .The pressure in the

right atrium is frequently called the central venous pressure. The pressure in the

peripheral veins depends to a great extent on the level of this pressure, but with

superposition of hydrostatic pressure components. Factors that increase the

tendency of venous return are

1. increased blood volume,

2. increased large vessel tone throughout the body with resultant increased

peripheral venous pressure and

3. Dilatation of the arterioles, which decreases the peripheral resistance and

allows rapid flow of blood from the arteries to the veins.

VENOUS MUSCLE PUMP

The muscle pump mechanism facilitates the return of blood to the heart

during exercise. It has been calculated that 30% of the energy required to

circulate blood during strenuous exercise is supplied by this mechanism. In

addition, the muscle pump, by reducing peripheral pressures, decreases oedema

in the dependent tissues and prevents the accumulation of excessive quantitiesof

blood in the leg veins. The skeletal muscles act as the power source, and the

sinusoids, deep veins and superficial veins in the order of decreasing

importance, act as the bellows. As in any unidirectional pump, valves are vitally

important to ensure efficient performance. In a motionless upright subject, veins

simply collect blood from the capillaries and transport it passively to the heart,

the energy being supplied totally through the cardiac effect. During exercise,

contraction of the calf muscles compresses the venous sinusoids directly and the

other veins indirectly, forcing blood cephalad. Closure of the valves in the

perforating veins and in the deep veins below the calf precludes reflux of blood

into the superficial tissues or down the leg. When the muscles relax, a potential

space develops in the deep veins. Blood is "sucked" from the superficial veins

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through the perforators into the deep veins and the accumulated blood in the

peripheral veins moves cephalad into the more proximal veins. Reflux down the

leg is prevented by closure of the proximal valves. Closure of these valves

interrupts the hydrostatic blood column so that it no longer continues unbroken

from the periphery to the heart but extends for only a few centimetres above

each valve to prevent over distension of the thin-walledveins. Consequently,

hydrostatic pressure is markedly reduced. This reduction in venous pressure

increases the pressure gradient across the capillaries, thereby augmenting blood

flow. With cessation of exercise, capillary inflow gradually replenishes the

blood in the deep veins, extends the hydrostatic column and returns venous

pressure to its pre-exercise level. The calf muscle pump function is complex; it

is reflecting venous reflux, venous patency and muscular power.

SURGICALPATHOLOGY

Undernormalconditionsthebloodfromthesuperficialvenoussystemispassedt

othedeepveinsthrough the competent perforators and from the deep veins the

blood is pumped up to the heart by muscle pump, competent valves and

negative in intrathoracic pressure. But if this mechanism breaks down, either

due to destruction of the values of the deep veins (following deep vein

thrombosis), or of the perforators or of the superficial venous system, the blood

becomes stagnated in the superficial veins which become the pray of 'high

pressure leaks 'and thus becomes distended and tortuous to become varicose

veins. If an individual stands motionless for a long period of time, venous

pressure at the ankle 'may rise to 80 to 100 mmHg and gradually swelling

appears. Even with modest activity of the calf muscles and with competent

venous valves, this pressure is reduced to 20 or 30 mmHg.

VENOUSHYPERTENSION

Venous hypertension is present, when the patient is unable to sufficiently

reduce venous pressure by muscle pump activation. Calf muscle contraction

may force blood to flow cephalad in the deep veins; but during muscle

relaxation (pump diastole), regurgitation may occur through the perforators in

cases of superficial vein incompetence. A portion of blood in the leg is,

therefore, consigned to an inefficient circular pathway. If the valves below a

pump segment are incompetent, muscle pump activation forces blood in both

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directions increasing the pressure in the more distal veins. Incompetent valves

above the pump segment cause fast retrograde refilling of the veins, which,

contributes to the persistent venous hypertension.

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EPIDEMIOLOGY

Annual incidence of varicose veins is about 2%.Life-time prevalence of

varicose veins approaches 40%.

Varicosities are more common in women (about 2-3 times as prevalent in

women than in men)

10-20% actually are symptomatic enough to complain about their lower leg

varicose veins and seek treatment.

25 Million people suffer from venous reflux disease, the underlying cause for

most varicose veins.

Venous reflux disease is 2x more prevalent than coronary heart disease (CHD)

and 5x more prevalent than peripheral arterial disease (PAD)

Of the estimated 25 million people with symptomatic superficial venous reflux

Only 1.7 million seek treatment annually Over 23 million go untreated

Incidence and prevalence in 1973, United States Tecumseh community health

study estimated about 40 million persons (26 million females) in US were

affected

Coon WW et al Circulation. Oct 1973;48(4):839-46

In 1994, a review byCallam found half of adult population have minor stigmata

of venous disease (women 50-55%; men 40-50%) and fewer than half have

visible varicose veins (women 20-25%; men 10-15%)

Callam MJ. Br J Surg. Feb1994;81(2):167-73

In 2004, these finding also seen in a French cross- sectional study that found

odds ratio per year for varicose veins 1.04 for women and 1.05 for men

Age and gender have been the only consistently identified risk factors for

varicose veins

For men working mostly in a standing position, the risk ratio for varicose veins

was 1.85 [95% confidence interval (95% CI) 1.33-2.361 in a comparison with

all other men. The corresponding risk ratio for women was 2.63 (95% CI 2.25-

3.02). The results were adjusted for age, social group, and smoking.

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PREDISPOSING FACTORS

(a) Prolonged standing- During prolonged standing long column of blood along with gravity puts pressure on the weakened valves of the

veins. This causes failure of the valves quickly giving rise tovaricosity of

the long or short saphenous vein.During prolonged standing the

calfmuscles also dont work quite often so the calf pump mechanism also cannot push the venous blood upwards.

(b) Obesity Excessive fatty tissue in the subcutaneous tissue offer poor support to the veins. This leads to the formation of varicosity.

(c) Pregnancy- Pregnancy is said to predispose the formation of varicose vein. Varicose veins are often noticed in multiparous women.

Pregnancy acts in various ways-

(1) Progesterone causes dilatation and relaxation of the veins of the lower limb. This may make the values incompetent. This

hormonal effect is maximum in the first trimester of pregnancy.

(2) Pregnant uterus causes pressure on the inferior venacava, thus causing obstruction to the venous flow. This effect is mostly

been in the last trimester of pregnancy. After each pregnancy

both hormonal and mechanical effects are removed and there is

improvement of varicosity. During the subsequent pregnancy

these factors again cause the varicosities to develop in a bigger

way. That is why varicose veins are commonly seen in

multiparous women.

(d) Old age- This causes atrophy and weakness the vein wall. At the same time with ageing the values in the veins becomes gradually incompetent.

(e) Athletes: Sometimes varicose veins are noticed among athletes. Forcible contraction of the calf muscles may force blood through the

perforating vein in reverse direction. This will cause destruction of the

valves of the perforating veins and ultimately lead to formation of

varicose vein. Similarly Ricksawpullers often suffer from varicose veins.

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CLASSIFICATION

(CEAP) Classification from the American Venous Form, last revised

Clinical

C0 - No visible or palpable signs of venous disease

C1Telangiectases or reticular veins

C2 Varicose Veins

C3 Edema

C4a Pigmentation or eczema

C4b- Lipodermatosclerosis or atrophic blanche

C5- Healed venous ulcer

C6 Active venous ulcer

Etiologic

EC Congenital

Ep- Primary

Es- Secondary (Post thrombotic)

En No venous cause identified

Anatomic

As- Superficial veins.

Ap- Perforator veins.

Ad Deep veins

An- No venous location identified

Pathophysiologic

Pr- Reflux

Po obstruction

Pr,oReflex and obstruction

Pn No venous Pathophysiology identifiable

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AETIOLOGY

1. Morphological factor - Varicose veins of the lower limbs are the penalty the man has to pay for its erect posture. The veins have to drain

against gravity. The superficial veins have loose fatty tissue to support

them and thus suffer from varicosity.

2. Primary Varicose Veins- These are more common. This condition is mainly due to defect in the values. The defect may be

congenital or acquired (either due to thrombosis or due to inflammation is

the veins).

i. Defect in the saphenofemoral valve leads to varicosity of the

long saphenous veins.

ii. Defect in the sapheno-popliteal value leads to varicosity of the

short saphenous vein.

iii. Defect in the valves of the perforators lead to varicosity of

either long saphenous or short saphenous system.

3. Secondary varicose veinsoccur due to venous obstruction i. Mechanical factors eg: pregnancy or tumors in the pelvis (eg:

uterine fibroids, ovarian cyst, cancers of the cervix, uterus,

ovary or rectum).

ii. Deep vein thrombosis leading to damage of the valves.

iii. Hormonal causes: progesterone may cause varicosity in

multiparous females.

iv. Acquired arteriovenous fistula (due to trauma or deliberate

shunting for dialysis).

v. Extensive cavernous (venous) haemangioma.

vi. Retroperitoneal lymphadenopathy or retroperitoneal fibrosis.

vii. Iliac vein thrombosis.

4. Congenital varicose veins Occasionally varicose veins may develop below 20 years of age. These cases are mostly due to either

congenital arteriovenous fistula or cavernous (venous) haemangioma.

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CLINICAL FEATURES

(a) The commonest symptom is tired and aching sensation in the affected

lower limb, particularly in the calf at the end of the day. The severity of

symptoms depends mostly on the extent of high back pressure.

(b) Sharp pains may be complained of in grossly dilated veins.

(c) Some patients may suffer from cramp in the calf shortly after retiring to

bed. Such cramp is usually due to sudden change in the caliber of

communicating veins which stimulates the muscles through which they

pass.

(d) Pain may be bursting or severe in nature and may be particularly

localized to the site of the incompetent perforating veins. Such bursting

pain while walking indicates deep vein deficiency.

(e) Patients may presents with no other symptoms except dilated and tortuous

veins of leg.

(f) There may be other complaints or complications of the dilated and

tortuous veins. Such as-

i. Ankle Swelling towards evening

ii. The skin over the varicosities may itch. It may be pigmented

iii. Eczema of the affected skin.

iv. Venous ulceration

(g) In the personal history one may find that the patient is involved in a job

of prolonged standing eg: bus or tram conductors.

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CLINICAL EXAMINATION

EXAMINATION OF VARICOSE VEIN

HISTORY

AGE Though varicose vein can affect individuals of all agegroup, yet middle-

aged individuals are the usual sufferers.

SEX Women are affected much more commonly in the ratio of10:1 .

OCCUPATION -- Certain jobs demand prolonged standing e.g. tram drivers,

policemen etc. and the persons involved in these jobs often suffer from varicose

veins. Varicose vein may also occur in individuals involved in excessive

muscular contractions e.g. Ricksaw-pullers and athletes.

SYMPTOMS

PAIN--The commonest symptom is the pain which is aching sensation felt in

the whole of the leg or in the lower part of the leg according to the position of

the varicose vein particularly towards the end of the day. The pain gets worse

when the patient stands for a long time and is relieved when he lies down.

Patient may complain of bursting pain while walking , which indicates deep

vein thrombosis . Night cramps may also be present. The ankle may swell

towards the end of the day and the skin of the leg may be itching. Varicose ulcer

may be seen on the medial malleolus

A few questions should be asked-

i. Whether the patient is feeling difficulty in standing or walking, which

indicates presence of deep vein thrombosis

ii. The patient should be asked if he has any other complaint than varicose

vein itself. If the patient is suffering from constipation or a swelling in the

abdomen, it may be a case of secondary varicose vein.

7. Morrissey's cough Impulse Test veins

The limb is elevated to empty the varicose vein. The limb is then put to

bed and the patient is asked to cough forcibly. An expansive impulse is felt in

the long saphenous vein particularly at the saphenous opening if the saphenous-

femoral valve is incompetent. Similarly bruit may be heard on auscultation.

PAST HISTOY

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Enquiry must be made if the patient had any injection treatment or

operation for varicose veins. Any serious illness or previous complicated

operation may cause deep vein thrombosis which is the case of varicose vein

now.

PERSONAL HISTORY

Women should be asked about obstetric history, like details of previous

pregnancies. Whether the patient suffered from white leg during the previous

pregnancies. If the patient had contraceptive pills for quite a long time, as this

may cause deep vein thrombosis.

FAMILY HISTORY

It is not uncommon to find varicose veins to run in families. Often patients

mother and sisters might have suffered from this disease.

PHYSICAL EXAMINATION

A. INSPECTION

1. VARICOS VEINS Note, which vein has been varicose long saphenous

or short saphenous or both. In case of the former a large venous trunk is

seen on the medial side of the leg starting from in front of the medial

malleolus to the medial side of the knee and along the medial side of the

thigh upwards to the saphenous opening. This venous trunk receives

tributaries in its course. In case of short saphenous vein varicosity the

dilated venous trunk is seen in the leg from behind the lateral malleolus

upwards in the posterior aspect of the leg and ends in the popliteal fossa.

2. Swelling.

a. Localized --varicose vein affecting a segment of superficial vein or the whole

trunk of a venous segment-either long or short saphenous Vein.

b. Generalized swelling of the leg is mostly due to deep vein thrombosis

3. Skin of the limb.

(i) Colour- local redness is usually due to superficial thrombophlebitis.

Generalized change of color may be white [phlegmasiaalbadolens] also known

as white leg. This is due to swollen limb from excessive edema or lymphatic

obstruction. When the skin of the limb becomes congested and blue then it is

26

due to deep vein thrombosis and this condition is called

phlegmasiaceruleadolens. In such severe venous obstruction the arterial pulses

may gradually disappear and venous gangrene may ensue.

(ii) TEXTURE.

(a) Skin is stretched and shiny due to edema following deep vein thrombosis

(b) Eczema or pigmentation of the skin affecting mostly the medial aspect of

the lower part of the leg

(c). Ulceration on the medial aspect of the lower part of the leg, known as

venous ulcer

(d) Scar may be seen on the lower part of the leg which may be healed venous

ulcer or previous operation of varicose vein

(e). Inspect the toes to note if there is loss of hair or brittleness of the nails due

to chronic varicosity which indicate impending venous gangrene.

4. The patient should be asked to cough and it is noted whether there is any

impulse on coughing at the saphenous opening (Saphena-varix.) This test is

known as Morrissey's test

B. PALPATION

Aim is to locate the incompetent values communicating the superficial and deep

1. BrodieTrendelenburg test

This test is performed to determine the incompetency of the sapheno-

femoral valve and other communicating systems.This test can be performed

in two ways.In both the methods, the patient is first placed in the recumbent

position and his legs are raised to empty the veins.This may be hastened by

milking the Veins proximally. The Sapheno-femoral junction is now

compressed with the thumb of the clinician ora tourniquet is applied just

below the sapheno-femoral junction and the patient is asked to stand up

quickly.(I) In first method, the pressure is released .If the varies fill very

quickly by a column of blood from above, it indicates incompetencyof the

sapheno-femoral valve. This is called a positive Trendelenburg test (2). To

test the Communicating system, the pressure is not releasedbut maintained

for about 1 minute.Gradual filling of the veins during the period indicates in

competency of the communicating veins mostlysituated on the medial side of

27

the lower half of the leg allowing the blood to flow from deep to the

superficial veins. This isconsidered as positive Trendelenburg test.

2. Tourniquet test

It can be called a varient of trendelenburg test. In this test the tourniquet

is tied around the tight or the leg at different levels after the superficial veins

have been made empty by raising the leg in recumbent position. The paint is

now asked to standup. If the veins above the tourniquet fill up and those

below it remain collapsed, it indicates presence of incompetent

communicating vein above the tourniquet. Similarly if the veins below the

tourniquet fill rapidly whereas veins above the tourniquet remains empty, the

incompetent communicating vein may be below the tourniquet. Thus by

moving the tourniquet down the leg in steps one can determine the position of

the incompetent communicating veins.

In case of In case of short saphenous incompetence application of the

venous tourniquet to the upper thigh has the paradoxical effect of increasing the

strength the reflux, as shown by faster filling time. This sign is pathognomonic

of varies of the short saphenous system. The mechanism is: application of the

upper thigh tourniquet block off the normal internal saphenous system which is

carrying most of the superficial venous return and thus thrown into greater

prominence the retrograde leak for the saphenous popliteal junction.

Final definite proof of short saphenous incompetence is obtained through

following examination:- the sapheno-popliteal junction is marked with a pen

with the patient standing. The short saphenous vein is emptied by elevation of

the leg; Firm thump pressure is applied to the ink mark. The patient is made to

stand. The pressure is released and the vein will be filled immediately. It should

be remembered that there is no other incompetent perforating vein in the short

saphenous system.

3. Perthes test- The affected lower extremity is wrapped with elastic bandage.

With the elastic bandage on; the patient is instructed to move around and

exercise. Severe crampy pain is complained if there is deep vein thrombosis.

Arterial occlusive disease should be excluded.

4. Perthes test (Modified) This test is primarily intended to know whether

the deep vein is normal or not. A tourniquet is tied round the upper part of

the thigh enough to prevent any reflex down the vein. The patient is asked to

walk quickly with the tourniquet in place. If the communicating and the deep

28

veins are normal the varicose vein will shrink whereas if they are blocked

the varicose veins will be more distended.

5. Pratts test-This test is performed to know the positions of leg perforators.

An elastic bandage is applied from toes to the groin. A tourniquet is then

applied at the groin. This causes emptying of the varicose veins. The

tourniquet is kept in position and elastic bandage is taken off. The same

elastic bandage is now applied from groin downwards. At the positions of

the perforators blow outs or visible varies can be seen. These are marked

with a skin pencil.

6. Morrissey's cough Impulse Test

The limb is elevated to empty the varicose vein. The limb is then put to bed

and the patient is asked to cough forcibly. An expansive impulse is felt in the

long saphenous vein particularly at the saphenous opening if the sapheno-

femoral valve is incompetent. Similarly bruit may be heard on auscultation.

7. Fagans method to indicate the sites of perforators:

In standing posture the places of excessive bulges within the varicosity are

marked. The patient now lies down. The affected limb is elevated to

empty the varicosed veins. The examiner palpates along the line of the

marked varicosities carefully and finds out gaps or pits in the deep fascia

which transmit the incompetent perforators.

8. One should look for pitting edema or thickening, redness or tenderness at the

lower part of the leg. These changes are due to chronic venoushypertension

following deep vein thrombosis. Sometimes a progressive sclerosis of skin

andsubcutaneous tissue may occur due to fibrin deposition, tissue death and

scarring this is known as lipoderamatosclerosis. And is also due to chronic

venous hypertension. This may follow formation of venous ulcer.

C. PERCUSSION-

1. Schwartz test. - In a long standing case if a tap is made on the long

saphenous varicose vein in the lower part of the leg an impulse can be

felt at the saphenous opening with the other hand. Sometimes the

percussion wave can be transmittedfrom above downwards and this

will imply absent or incompetent values between the tapping finger

and the palpating finger.

29

D. AUSCULTATION- The importance of auscultation is limited to the

arteriovenous fistula where a continuous machinery murmur may be

heard.

E. Regional lymph nodes [inguinal]. Are only enlarged if there be venous

ulcer and this is infected.

F. Other limb-should be examined for presence of varicose vein and

different tests to exclude deep vein thrombosis, incompetent perforators

and venous ulcer to plan treatment.

GENERAL EXAMINATION

Examination of the abdomen.-

Sometimes a pregnant uterus or intra-pelvic tumor [fibroid, ovarian cyst,

cancer of cervix or rectum] or abdominal lymphadenopathy may cause pressure

on the external iliac vein and becomes responsible for secondary varicosities.

30

INVESTIGATIONS

1) THOROUGH HISTORY

2) CLINICAL EXAMINATION

a) Localize the anatomical location of the disease ,

b) Nature of the lesion, Rule out DVT

c) BRODIE TRENDELENBERG TEST

d) TOURNIQUET TEST

e) ASSESS SKIN CHANGES

f) PERIPHERAL PULSES

g) ABDOMINAL EXAMINATION

3) DOPPLER ULTRASOUND

4) DUPLEX ULTRASOUND

5) VENOGRAPHY

MAXIMUM VENOUS OUTFLOW (MVO)

Functional test; detect obstruction to venous outflow.It can help detect

more proximal occlusion of iliac veins and IVC, as well as extrinsic causes of

obstruction in addition to DVTs.MVO uses plethysmography (technique to

measure volume changes of leg) to measure speed at with which blood can flow

out of a maximally congested lower leg when an occluding thigh tourniquet is

suddenly removed.

MAGNETIC RESONANCE VENOGRAPHY (MRV)

Most sensitive and most specific test to find causes of anatomic obstruction.

MRV is particularly useful because unsuspected nonvascular causes for leg pain

and edema may often be seen on scan image when clinical presentation

erroneously suggests venous insufficiency or venous obstruction. This is

expensive test used only as adjuvant when doubt still exists.

31

TESTS USED TO DEMONSTRATE REFLUX

DUPLEX US WITH COLOR-FLOW IMAGING (SOMETIMES CALLED

TRIPLEX ULTRASOUND)

Special type of 2-dimensional ultrasound that uses Doppler-flow information to

add colour for blood flow in the image.Vessels in blood are coloured red for

flow in one direction and blue for flow in other, with a graduated colour scale to

reflect the speed of flow.

Venous valvular reflux is defined as regurgitant flow with valsalva that lasts

great than 2 seconds

Duplex ultrasound -Most useful tool for workup, replaced many of physical

examination maneuvers and physiological tests. Tests used to rule out deep vein

thrombosis obstruction as a cause of varicose veins. Noninvasive imaging with

good sensitivity and selectivity

DOPPLER AUSCULTATION

Doppler transducer is positioned along axis of vein with probe at angle of

45 to skin.When distal vein is compressed audible forward flow exists.If valves

are competent no audible backward flow is heard with release of compression.If

valves are incompetent an audible backflow exists.These compression-

decompression maneuvers are repeated while gradually ascending limb to level

at which reflux can no longer be appreciated.

VENOUS REFILLING TIME (VRT)

This is a physiologic test,using plethysmography. VRT is time necessary

for lower leg to become infused with blood after calf-muscle pump has emptied

lower leg. In healthy subjects VRT is greater than 120 seconds.In patients with

significant venous insufficiency VRT is abnormally fast at 20-40 seconds.VRT

of less than 20 seconds is markedly abnormal and is nearly always

symptomatic.If VRT is less than 10 seconds venous ulcerations are likely.

Muscle pump ejection fraction (MPEF)

Detect failure of calf muscle pump to expel blood from lower leg.Results are

highly repeatable but require skilled operator.Patient performs ankle

dorsiflexion 10-20 times, and plethysmography is used to record change in calf

blood volume. In healthy patients, venous systems will drain, but in patients

32

with muscle pump failure, severe proximal obstruction, or severe deep vein

insufficiency, amount of blood remaining within the calf has little or no change.

Tests used to define anatomy

Duplex US

Two-dimensional ultrasound forms an anatomic picture. Normal vessel appears

as a dark-filled, white-walled structure. Doppler-shift: measurement of flow

direction and velocity. Structural details that can be observed include most

delicate venous valves, small perforating veins, reticular veins as small as 1 mm

in diameter and (using special 13-MHz probes) even tiny lymphatic channels

DIRECT CONTRAST VENOGRAM

Intravenous catheter placed in dorsal vein of foot, and radiographic contrast

material is infused into the vein. X-rays used to obtain image of superficial

venous anatomy. If deep vein imaging is desired, superficial tourniquet is

placed around leg to occlude superficial veins and contrast is forced into deep

veins. Assessment of reflux can be difficult because it requires passing a

catheter from ankle to groin, with selective introduction of contrast material into

each vein segment.Labor-intensive and invasive venous imaging technique with

a 15% chance of developing new venous thrombosis from the procedure itself.

Rarely used, and has been replaced by duplex ultrasound. Reserved for difficult

or confusing cases.

33

COMPLICATION

Complications of Varicose Vein-

1. HEMORRHAGE-

It may occur from minor trauma to the dilated vein. The bleeding

may be profuse due to high pressure within the incompetent vein. Simple

elevation of the leg does a lot to stop such a bleeding.

2. PHLEBITIS:

This may occur spontaneously or secondary to minor trauma. Mild

phlebitis may be produced by the sclerosis fluid used in the injection

treatment. In this condition varicose vein becomes extremely tender and

firm. The overlying skin becomes red and edematous. Pyrexia and

malaise may be associated with.

3. ULCERATION: -

This is more due to deep venous thrombosis rather than varicose

vein alone. The patients often give previous history of venous thrombosis

suggested by painful swelling of the leg. After thrombosis has been

recanalized the values of the deep veins are irreparably damaged. The

deoxygenated blood gets stagnated in the lower part of the leg

particularly on the medial side where there are plenty of perforating

veins. The superficial tissue loses its vitality to certain extent and a

gravitational ulcer follows either spontaneously or following minor

trauma. The majority of patients with venous ulcers have incompetent

communicating veins. The arteries and veins should be examined to

exclude other causes of ulceration. These ulcers are commonly found at

the lower third of the leg, usually on the medial side end even on the foot,

but never above the junction of the middle and lower thirds of the leg.

Venous ulcer are shallow and flat. The edge of the ulcer is sloping and

pale purple-blue in color. The floor is usually covered with pink

granulation tissue. In chronic ulcers white fibrous tissue are more seen

than pink granulation tissue. This discharge is seropurulent with trace of

blood. The surrounding tissue show signs of chronic venous hypertension

i.e. induration, tenderness and pigmentation; these ulcers have ragged

edges.

If the ulcer is healing, a faint blue rim of advancing epitheliummay

be seen at the margin. Rarely malignancy can develop at the edge of a

long standing venous ulcer (Marjolin'ulcer). A patient when presents

34

with long history of venous ulceration with edge raised and elevated

inguinal lymph nodes are enlarged-it is suspicious of a Marjolin's ulcer or

different from the typical features of ulcer described above and when the

inguinal lymph node are enlarged it is suspicious of a Marjolins ulcer

(Malignant change in a chronic ulcer.

4. PIGMENTATION: This is particularly seen in lower part of the leg.

Brownish to black pigmentation is noticed. This is due to hemosiderin

deposits from breakdown of RBC which have come out of the thin walled

veins

5. ECZEMA [CHRONIC DEMATITIS]:Due to extravasation and breaking

down of R.B.Cs in the lower part of the leg, the skin may itch. The

patient scratches which may lead to eczema formation. Alternatively such

eczema may occur following minor trauma or as an allergic manifestation

resulting from various ointment applications.

6. LIPODERMATOSCLEROSIS: This means the skin becomes thickened,

fibrosed and pigmented. This is due to high venous pressure which causes

fibrin accumulation around the capillary and it also activates white cells.

7. CALCIFICATION OF VEIN:

8. PERIOSTITIS: In case of long standing ulcer over the tibia.

9. EQUINUS DEFORMITY: This only result from long standing ulcer.

When the patient finds that walking on toes relieves pain, so he continues

to do so and ultimately the Achilles tendon becomes shorter to cause this

defect.

35

VARICOSE ULCER

According to the Stockbridge study in Scotland17, chronic leg ulcer is

defined as "an open sore below the knee anywhere on the leg orfoot which

takes more than six weeks to heal".

Varicose ulcers/Venous ulcers result from loss of epithelial cells causing

exposure of the underlying tissue due to improper functioning of valves in the

veins usually of the legs.

They are found more commonly in females compared to males.

Common age group is 50-70 years.

Site-Lower 2/3rd of the lower leg (slightly higher on anterior and medial

aspect) and on parts of foot not supported by shoe.

Size-Variable. 18 to 20 cm square on the lower leg is quite common.

Occasionally may become very large and encircle the leg.

PREDISPOSING FACTORS-

Venous and lymphatic congestion associated with varicose vein

Prolonged standing during work.

Poor personal hygiene and malnutrition.

In patients with varicose veins, those with skin changes of chronic venous

insufficiency and deep vein incompetence are at greatly increased risk of

ulceration. Popliteal vein incompetence was an independent risk factor for

venous ulceration.

The poor calf muscle itself may be responsible for calf muscle pump

failure in some patients with chronic venous insufficiency and leg ulceration.

In patients with established venous disease, obesity was a significant risk factor

for ulceration

Cigarette smoking was associated with an increased risk of

ulceration.Subjects who had ever smoked cigarettes were almost twice as likely

to develop an ulcer compared with subjects who had never smoked.

PATHOLOGY:Due to failure of venous pump and lack of pumping action by

calf muscles, there is venous congestion. Venous hypertension alters the

hemodynamic at the capillary level and causes a shift towards the outflowof

capillary fluid and development of oedema. Excessive fluid in the interstitial

36

spaces inhibits the exchange of nutrients and removal of metabolic degradation

products. This problem is enhanced by the loss of protein into the interstitial

spaces. Maintenance of these conditions for a prolonged period will result in

stasis dermatitis, hemosiderin deposition and skin ulceration at the ankle

region.Nutrition of the tissue is decreased and the skin is devitalized.

Cellsnecrosis and skin breaks down. There is insufficient oxygen and nutrition

to promote healing and the area remains open.Bacteria may invade the area or

the dead cells may irritate the normal tissues, causing inflammation and the

ulcer spreads.

CLINICAL FEATURES

1-Floor of the ulcer may be-

a) PALE and ANAEMIC with watery discharge - indolent ulcer -static and non-healing ulcer.

b)GREEN or YELLOW DISCHARGE-infected ulcer.

c) PINK, BUBBLY WITH RED SPOTS-granulating ulcer.

2-Edge of the ulcer(boundary between floor and the surrounding skin)may be-

a) Well defined, straight, red and shiny-spreading ulcer. b) Hard, edematous and over hanging floor-chronic ulcer.

c)Shallow, slopping out from the floor-healing ulcer.

3-Base of the ulcer may show-

A) Gross induration (hardening), the extent of which varies according to

the severity and duration of the ulcer.

b)Pigmentation due to breakdown of RBC's .

c)Poor circulation.

d)Course skin texture with heavy scaling or papery thin and eczematous

tissue.

4-Edema of the base of the ulcer and the foot and ankle to shoe line.

5-Pain in infected ulcers. Increases with walking.

6-Decreased range of motion of the ankle and foot.

7-Muscle weakness and atrophy mainly of the calf muscles and loss of

pumping action. Prolonged inactivity and bed rest can lead to muscle atrophy,

contracture, and degenerative jointdisease. Muscles particularly affected by

resting the leg are the gastrocnemius soleus and the anterior tibialis, which acts

37

as a dorsiflexor. Those with an active ulcer had a lower range of movement at

12.5

8-Push off missing in the gait.

VARICOSE ULCERS MORDERN MEDICAL TREATMENT

a)conservative

b)surgical

since physical therapist's role is limited to conservative treatment of skin

ulcer

Aims of Conservative/Physiotherapy Management of venous ulcer-

1-To relieve pain.

2-To relieve congestion and edema.

3-To improve general circulation of lower limb.The potential benefit of

exercise is that using the calf muscle pump reduces the ambulatory

venous pressure.

4-Soften induration of lower leg especially around the ankle area.

5-Mobilize joints of lower limb and improve strength.

6-To improve the condition of the skin of the lower limb.

Specific local aims-

Increase circulation to the ulcer to promote healing.

Clear any infection.

Reduce edema and induration around the ulcer. Free adherent ulcer from underlying tissue.

METHODS OF TREATMENT OF VARICOSE ULCER

1-Soft tissue techniques-

-Remove the bandage and dressings, clean wound and cover with gauge swabs.

-Elevate leg to an angle of 45 degree at hip to aid venous drainage.

-Soft tissue techniques to the whole limb to decrease edema.

Effleurage, slow deep kneading, Picking up, wringing the thigh. Special

attention to dorsum of foot, region of tendocalcaneus and behind the malleoli

(as in this area vascular supply is less). Thumb kneading over the tibialis

anterior muscle.

38

The region of the ulcer is next treated with finger and thumb kneading to soften

the induration, working inward from the periphery to the edge of the ulcer.

2-UVR- a)FOR INFECTED ULCERS-to destroy the micro-organism and

increase the circulation to the area. Most commonly used is kromayer lamp and mercury vapour lamp.

b)FOR HEALING ULCER-As ulcer heals, it grows inwards from the

edge or outwards from the middle.UVR is given to promote granulation

tissue formation.

c) FOR INDOLENT ULCERS-UV rays are given to stimulate the

circulation. Absorption of rays produces hyperemia in the congested area

and produces an increased exudate.

3-ULTRASOUND THERAPY

a) It promotes healing of the ulcer.

b) Soften the induration

c) Increase vascularity in the surrounding tissue.

Ultrasound is contraindicated in infected ulcers or in DVT.

4-LASER THERAPY-It increases vasodilation and increase the number of

fibroblasts.

39

TREATMENT OF VERICOSE VEIN

Conservative management

For elderly unfit patients or with mild symptoms

Elastic support, weight reduction, regular exercise, avoidance of

constricting garments and prolonged standing

Elastic crepe bandage stockings -30-40mm Hg

Elevation of limbs -Above the level of heart

Graded compression stockings

Compression Stockings

Wearing of graduated compression stockings with pressure of 30

40 mmHg has been shown to correct swelling, nutritional exchange & improve

microcirculation in affected legs.Caution should be exercised in patients with

concurrent arterial disease.They are offered in different levels of

compression.They are constructed using elastic fibers or rubber which help

compress limb, aiding in circulation.

MORDERN MEDICAL TREATMENT

1.InjectionSclerotherapy

Inject directly to the superficial vein the 3 % sodium tetradecylesulphate. And

compression are applied

It destroys the lipid membrane of endothelial cells causing them to shed, leading

to thrombosis, fibrosis and obliteration (sclerosis).

It is not suitable for major saphenous incompetence.

Disadvantages - Anaphylaxis/shock, Abscess, Thrombophlebitis,

Intravenoushematoma, Temporary ocular disturbances

2. US guided foam sclerotherapy

In U/S guided sclerotherapy,USare used to visualize underlying vein so surgeon

can deliver and monitor injection.Air mixed with sclerosant and injected into

veins by US image

Complications: Extravasation: Skin ulceration, Escape into deep veins, DVT

Entering brain: Stroke, Headache

40

3. Surgery

a. Trendelenburg operation: It is a juxta femoral flush ligation of long

saphenous vein (i.e. flush with femoral vein), after ligating named

(superficial circumflex, superficial external pudendal, superficial

epigastric vein) and unnamed tributaries. All tributaries should be ligated,

otherwise recurrence will occur.

b. Stripping of vein:Using Myers stripper vein is stripped off. Stripping

from below upwards is technically easier. Immediate application of crepe

bandage reduces the chance of bleeding and hematoma formation.

Complication is injury to saphenous nerve causing saphenous neuralgia.

Trendelenburgs Operation

Stripping is not usually done for the veins in the lower part of the leg. Stripping

of the vein are more effective.

Inverting or invagination stripping using rigid Oesch pin stripper is

better as postoperative pain and haematoma is less common and also there is

tissue damage. Vein should be very firmly fixed to the end of the stripper and

pulled out to cause the inverting of the vein.

Stripping of short saphenous vein is more beneficial than just ligation at

sapheno popliteal junction. It is done from above downwards using a rigid

stripper to avoid injury to sural nerve.

GSV Saphenectomy

Surgical removal of GSV have evolved from large open incisions to less

invasive stripping.Stripping consists of removal of all or part of saphenous vein

main trunk.Perforation-invagination (PIN) stripper is mainly used now a days.

SSV Saphenectomy

Removal of SSV is complicated by variable local anatomy and risk of injury to

popliteal vein &peroneal nerve

Stab or Ambulatory Phlebectomy

41

It is extremely useful for treatment of residual vein clusters after

saphenectomy& for removal of nontruncal tributaries when saphenous vein is

competent.

Subfascial Ligation of Cockett and Dodd

Perforators are marked out by Fegans method. Perforators are ligated deep to

the deep fascia through incisions in antero medial side of the leg.

SEPS

Video techniques that allow direct visualization through small-diameter scopes

have made endoscopic subfascial exploration and perforator vein interruption

possible.The connective tissue between the fascia cruris and the underlying

flexor muscles is so loose that this potential space can be opened up easily and

dissected with the endoscope.This operation, done with a vertical proximal

incision, accomplishes the objective of perforator vein interruption on an

outpatient basis

NEW TECHNIQUES:

Radiofrequency ablation

Thermal energy is delivered directly to the vessel wall and destroys the

endothelial lining.

Endovenous radio frequency ablation (Closure procedure) is a minimally

invasive.In-office treatment alternative to surgical stripping of the great

saphenous vein. The skin on the inside of the knee is anesthetized and a

radiofrequency catheter is inserted into the damaged vein through a needle stick

in the skin. The catheter delivers Radiofrequency energy to the vein wall

causing it to heat. As the vein warms, it collapses and seals shut.

Endovenous laser ablation

A laser fiber produces endoluminal heat that destroys the vascular endothelium

and cause collapse.Seldinger technique is used to advance long catheter along

entire length of truncal varicosity to be ablated.Under U/S guidance tumescent

solution with local anesthetic is inj: around entire length of vessel.Firm pressure

is applied to collapse vein around laser fiber & laser is fired generating heat

leading to intraluminal steam bubbles,irreversible endothelial damage &

thrombosis.This process is repeated along entire course of vessel.

42

Complications of Surgery

a. Bruising

b. Sensory Nerve Injury

c. Deep vein thrombosis (rare)

d. Most common is Recurrence

43

SELF CARE AT HOME

1. Avoid standing still for long periods of time.

2. If your job entails standing keep compressing your calf muscles (i.e., by

moving your feet up and down for 5 minutes every hour).

3. Lie down with your ankles raised above chest level for at least half-an-hour

to aid circulation.

4. Take plenty of exercise and avoid being overweight, avoid tight

undergarments or garters. Constipation and straining to defecate are bad for

the blood flow in your legs, switch to a high fiber diet and try to avoid

being overweight. Varicose veins patients suffer from varicose veins which

show up as knots of colour in the legs.

5. A good whole food diet, plenty of exercise and hot and cold baths to aid

blood circulation will be suggested; some extra vitamin-E and vitamin-C

may be recommended.

6. The most helpful advise will be the provision of support stockings which

help prevent the veins from distending and blood from pooling, blood then

circulates in other veins, which however unfortunately may then become

distended themselves in years to come.

7. Straining during bowel movements puts intense pressure on the veins of the

lower body; over time, it can cause veins to weaken and enlarge.Regular

elimination is an important part of the treatment.

8. A high-fiber diet is your best weapon against varicose veins. Reduce your

risk of constipation by eating plenty of fresh vegetables and fruits, whole

grains, and nuts and seeds.

9. Saturated fats, along with hydrogenated or partially hydrogenated oils, slow

down your circulation and worsen the inflammation of the blood vessels.

Avoid them.

10. Sugar and other refined carbohydrates can lead to weight gain and

constipation. Dramatically reduce your intake of sweets and refined foods.

11. Caffeine and alcohol are dehydrating, and they worsen varicose veins or

varicosities.

12. There are avoidance techniques you may practice as well. Avoid prolonged

periods of time standing or sitting. Also, you should avoid high heels which

put undue pressure on your legs. Tight clothing or hosiery, which restricts

blood flow and disrupts circulation, should also be avoided to help prevent

44

varicose veins. You should also avoid excess heat on your legs. Heat

contributes to the swelling in varicose veins, so avoid hot tubs and baths

that are too hot.

45

PROGNOSIS

Progression is related to aging

Progression is worse in C2 patients with incompetent GSV or SSV

Circumstantial evidence shows that:C2 patients with incompetent GSV or

SSV should be treated to prevent progression to venous ulceration.

Recurrent and residual venous incompetence after vein surgery

Varicose vein recurrence is still a problem despite skilled surgical

experience and reasons for recurrences after adequate varicose vein could be

new reflux in an early post-surgery phase or neovascularisation at a later stage.

Neovascularisation starts very often with a number of smaller vessels in parallel

and is today a well-established factor for recurrent venous insufficiency.

Incorrect or incomplete surgery might be a more important reason for

residual venous insufficiency, and "missed"tributaries in the groin are very

likely to be seen when no meticulous dissection of the sapheno-femoraljunction

has been performed.

All legs with residual venous incompetence might have a risk for ulcer

recurrence,but those with signs of better ambulatory muscle pump (APF% >40)

seem to be more protected. When excluding the patients with incomplete

surgery, 13% (14/104) suffered of ulcer recurrence.20% of the patients have a

calculated five year probability of recurrence of more than 25%, whereas quite

40% have a probability less than 4%.

46

HOMOEOPATHIC

MANAGEMENT

47

CASE TAKING

Questions to be asked in a case of varicose vein in order to

make a successful prescription

(1) Inspect whether the surrounding area is blue, black or red.

If it is blue with well-marked dilated veins, then think of Carbo Veg or

Hamamelis.

If it is red and inflamed then think of Belladonna and if purplish

blue,Lachesis. If black think of Ars alb.

(2) Enquire the side affinity of the varicose vein. If it is present in both leg

the enquire in which leg it first started.

If started in right leg and shifted to left leg think of Lycopodium. If it

started in left leg and go to right leg then think of Lachesis.If the pain

constantly shift from one part to another then think of Pulsatilla.

Enquire whether these is varicose ulcer as a complication.

(3) Enquire whether the varicose ulcer is painful or painless.

If it is painfulthink of HeparSulph. If it is painless then think of Silicea.

Also ask about the discharge from ulcer,in the case of bleeding tendency

think of Lachesis,Hamamelis etc.

(4) Enquire about the subjective sensation.

Burning sensations-think of Sulphur, or Arsalb

If it is sore, bruised pain then think of Arnica Montana or Hamamelis.

If it is stinging pain then ApisMelifica or Pulsatilla.

(5) Enquire about the well-marked modality

Warm application-Arsalb,Calcfluor

48

PLAN OF TREATMENT IN HOMOEOPATHIC

SYSTEM OF MEDICINE

Abstract: Considering the totality of symptoms ofVaricose

vein, we have to first look for the predominant presenting complaint

or enquire about the primary symptom (symptom which appeared

first) and consider the acute totality and prescribe based on that and

after subsiding the acute condition, follow up the case with anti-

miasmatic remedy (based on the stage of the disease) which again

should be completely corrected by constitutional remedy to eradicate

the tendency.

Eachcaseofthevaricoseveinshouldbeindividualizedbytheuncommonpeculi

archaracteristicsymptomandbythewell-

markedmodality.Wemustgivepriorimportancetothepeculiarsymptomsinthefirstvi

sit.Analyzeanddifferentiatebetweenthesymptomsofthepatientandcommonsympto

msofthedisease.Consideringthesymptomsofthepatient give more weightage to

the side affinity, (in which leg the varicose vein first appeared), the well-marked

modality and subjective sensation of the patient.

Differentiation of Acute and Chronic presentation

Consideration of acute presentation

Varicoseveinmaypresentaspectrumofclinicalsymptomsalonewiththesympt

omsofitscomplications.Butthepatientsittingbeforeyoumaypresent

oneortwoprominentsymptom.Inthefirstvisitweshouldfirstanalyzewhetherthepres

entingcomplaintisacuteandsevere.Ifitissevereespeciallywithpainandcomplication

slikeulcerationthenwehavetoaidandsupposetoamelioratetheacutesymptom.Insuc

hconditions,thechoice of remedy willbe

thosehavingpredominantactiononvaricoseveinortheulcerasthecasedepend.

Consideration of chronic presentation

On the other hand, if the patient present with dilated vein, but not have any

severe subjective sensation or pain and also along with it the patient have a

number of complaints of mild severity affecting other systems of body then we

have to consider the totality of symptoms by extracting the uncommon peculiar

49

characteristics of the patient. This may cover the miasmatic tendency or the

constitution of the patient and thus ameliorate the whole symptom picture along

with the symptoms of varicose vein.

Medicines in Series.

In case of acute presentation of varicose vein; first we have to select the

medicine covering the most distressing symptom of the varicose vein that is

covering the acute totality.

Medicine covering the acute totality must be selected based on

(1)The subjective Sensation

(2) The side affinity of varicose veins or on which leg it first started.

(3) The exact time modality of subjective sensation.

If there is ulceration, the objective symptoms can be extracted and prescription

can be done with certainty.

After subsiding the most distressing symptoms of the acute presentation, the

patient had gone back to a chronic stage with mild symptom presentation. In

this stage we should analyze the miasm at which the patient now reached.

Prescribe anti miasmatic remedy and go to the constitutional remedy to correct

the tendency of the disease.

Sometimes the medicine selected based on acute totality during the first visit

may also cover the miasmatic and constitutional picture of the patient. This is a

rare situation in which the first selected remedy itself will correct the whole

case; and no change of medicine will be needed. The higher potencies of the

same remedy may completely clear the case.

50

MIASMATIC DIAGNOSIS OF DIFFERENT STAGES

OF VARICOSE VEIN AND THEIR TREATMENT

Stagesof varicose vein

1. Psoric(Inflammatory) 2. Sycotic(Proliferative) 3. Syphilitic (Ulcerative)

1. Psoricmiasm [ Inflammatory stage]

Patient complaints of aching pain in the whole leg.On examination there

will not be any evidence of incompetent valves or blow out. Patient may

complain of pain aggravated by prolonged standing and cramps in legs. It is

most common in patients having transparent skin, with visible vein, but not yet

dilated. In this case we should suspect for a future occurrence of varicose vein.

If it is leaved as untreated it may progress to a fully-flourished case of varicose

vein.

In such condition, as the pathology has not yet established, consider the

presenting acute totality, [that is the subjective sensation and its predominant

modality] and prescribe acute, short acting medicine. After subsiding the

distressing acute symptom, we should prescribe the anti-psoric remedy for

correcting its miasmatic tendency. The excellent antipsoric remedy covering the

burning pain and aggravation standing position is Sulphur. Prescribe higher

potency ieSulphur 1M and observe the changes in the follow up.

2. Sycoticmiasm [Proliferative stage]

In this stage there will be visible dilated vein, the intensity of the blow outs

has no relation to the intensity of the pain. The incompetency of the vein leads

to accumulation of venous blood in the superficial veins and cause blow outs.

Prescribe based on acute totality by considering, the objective symptom [like

side affinity, discoloration] and subjective symptoms [sensations and well-

marked modality]. After subsiding the acute symptoms, prescribe anti

51

sycoticremedy in higher potency ieThuja or Medorrhinum 1M [both should be

differentiated and prescribe according to symptom similarity].

3. Syphilitic miasm [Degenerative stage] Patient may complain of varicose ulcer with pus and surrounding ischemic

change. This indicates syphilitic stage.

Here we have to first heal the ulcer, prevent infection by cleaning and

dressing the ulcer with all aseptic precaution. Prescribe based on symptoms of

ulcer [considering discoloration of surrounding area, nature of discharge,

absence or presence of pain]. Medicines that cover this acute stage are

HeparSulph, Silicea, Fluoric acid, Lachesis, Hamamelis or Merc sol.

Recurrent occurrence of ulcer and discharge of pus indicates combination of

psoric and syphilitic miasms. Medicine to avoid this recurrence of ulcer is

Tuberculinum 1M.

52

THERAPEUTICS

KENTS REPERTORY

EXTREMITIES EXTREMITIES - VARICES , - Lower Limbs Ambr.arg-n.ARN.Ars.CALC.calc-f.calc-p.Carbn-s.CARB-V.card-m.Caust.clem.Crot-h.Ferr.ferr-ar.FL-AC.Graph.HAM.Hep.Kali-ar.Kreos.lac-c.Lach.LYC.LYCPS-V.Nat-m.Plb.PULS.sabin.sars.sil.spig.Sulph.sul-ac.Thuj.vip.ZINC.

EXTREMITIES - VARICES , - Lower Limbs - painful agg.by warmth FL-AC.SULPH. EXTREMITIES - VARICES , - Lower Limbs - pregnancy,during -- acon.apisArn.Ars.CARB-V.Caust.Ferr.FL-AC.Graph.Ham.Lyc.Mill.Nux-v.PULS.Zinc.

EXTREMITIES - VARICES , - Thigh -- Calc.ferr.HAM.lac-c.Puls.sep.Zinc. EXTREMITIES - VARICES , - Leg Calc.CARBN-S.CARB-V.CAUST.coloc.ferr.Fl-ac.graph.HAM.LYC.Mill.Nat-m.PULS.sil.Sulph.ZINC. EXTREMITIES - VARICES , - Leg left -fl-ac. EXTREMITIES - VARICES , - Leg bleeding -- Ham.Puls. EXTREMITIES - VARICES , - Leg inflamed -- arn.Ars.Calc.Ham.kreos.lyc.lycps-v.Puls.sil.spig.sulph.zinc. EXTREMITIES - VARICES , - Leg itching - Graph. EXTREMITIES - VARICES , - Leg painful -- brom.Caust.Ham.Lyc.Mill.PULS.Zinc. EXTREMITIES - VARICES , - Leg painless -- calc. EXTREMITIES - VARICES , - Leg - pregnancy,during - FERR.Ham.Lyc.Lycps-v.Mill.PULS.Zinc.

53

EXTREMITIES - VARICES , - Leg sensitive -- Fl-ac.graph.Ham.lach.puls. EXTREMITIES - VARICES , - Leg stinging -- Apisgraph.Ham.PULS. EXTREMITIES - VARICES , - Leg ulceration -- ars.LACH.lyc.puls.sil. EXTREMITIES - VARICES , - Leg calf - clem.Plb. EXTREMITIES - VARICES , - Foot - ant-t.Ferr.lac-c.lach.PULS.sulph.sul-ac.Thuj.

GENERALS GENERALS - VARICOSE veins Alumn.Ambr.Ant-t.Arg-n.ARN.Ars.asaf.Bell.CALC.calc-f.calc-p.Carb-an.CARB-V.Caust.clem.coloc.Crot-h.Ferr.ferr-ar.FL-AC.Graph.HAM.Hep.Kreos.lach.Lyc.LYCPS-V.mag-c.mill.Nat-m.Nux-v.Paeon.Plb.PULS.sabin.Sep.sil.Spig.Sulph.sul-ac.thuj.Vip.Zinc. GENERALS - VARICOSE veins blue -Carb-v.Lycps-v. GENERALS - VARICOSE veins burning -ApisARS.Calc. GENERALS - VARICOSE veins - burning night -ARS. GENERALS - VARICOSE veins inflamed -arn.Ars.Calc.Ham.kreos.lyc.Lycps-v.Puls.sil.spig.sulph.zinc. GENERALS - VARICOSE veins itching - Graph. GENERALS - VARICOSE veins - net work in skin - berb.Calc.Carb-v.Caust.clem.Crot-h.Lach.lyc.nat-m.ox-ac.plat.sabad.thuj. GENERALS - VARICOSE veins painful - Brom.Caust.Ham.Lyc.Mill.PULS.sang. GENERALS - VARICOSE veins - pimples,covered with - Graph. GENERALS - VARICOSE veins - pregnancy,during - FERR.Lyc.Lycps-v.Mill.PULS.Zinc. GENERALS - VARICOSE veins soreness - graph.Ham.puls. GENERALS - VARICOSE veins stinging - Apisgraph.Ham.PULS.

54

GENERALS - VARICOSE veins stitching - kali-c.lyc . GENERALS - VARICOSE veins ulceration - ars.LACH.lyc.puls.sil. GENERALS - VARICOSE veins swollen - Apisberb.Puls.

Borger Boenninghausens

characteristics and repertory

CIRCULATION - Blood-vessels varicose - aesc.AMBR.Ant-t.ARN.ARS.bell-p.bufoCALC.Calc-f.carb-an.CARB-V.CAUST.coloc.FERR.Ferr-p.FL-AC.form-ac.GRAPH.HAM.Kreos.LACH.LYC.Mag-c.mill.NAT-M.nux-v.phos.plb.PULS.Sep.Sil.SPIG.sul-ac.SULPH.THUJ.vip.ZINC. CIRCULATION - Blood-vessels - varicose - and inflamed - ARN.ARS.Calc.HAM.Kreos.LYC.nux-v.PULS.SIL.SPIG.SULPH.thuj.Zinc.

CIRCULATION - Blood-vessels - varicose painful - brom.caust.HAM.lyc.mill.Puls.sang.

CIRCULATION - Blood-vessels - varicose ruptured - vip. CIRCULATION - Blood-vessels - varicose sore - Ham. CIRCULATION - Blood-vessels - varicose ulcerating - ant-t.ARS.kreos.LACH.LYC.mez.PULS.SIL.Sulph. CIRCULATION - Blood-vessels - varicose - veins, especially - Aesc.agar.aloealum.am-c.ambr.ApisArn.ars.asaf.aur.bov.Calc-f.carb-an.carb-v.card-m.chel.chin.cocc.Crot-h.ferr.ferr-p.gels.Ham.kali-n.Lach.Lyc.merc.mill.nat-c.Phos.Puls.pyrog.rhus-t.RutaSec.sul-i.Sulph.thuj.vip.Zinc. BOERICKES REPERTORY

CIRCULATORY SYSTEM - Veins - Varicose acet-ac.aesc.alumn.apisars.bell-p.calc.Calc-f.Calc-i.carb-v.Card-m.caust.coll.ferr-p.Fl-ac.graph.Ham.kali-ar.lach.Lyc.magn-gr.mur-ac.nat-m.paeon.plb.polyg-h.Puls.ran-s.rutascir.sep.Staph.stront-c.sul-ac.sulph.Vip.Zinc.

55

SKIN - Ulcers Varicose - calc-f.calen.Carb-v.Card-m.clem-vit.cund.eucal.Fl-ac.Ham.lach.phyt.psor.pyrog.Sec.

MURPHYS REPERTORY

Legs - VARICOSE, veins, legs Ambr.arg-n.ARN.Ars.CALC.calc-f.calc-p.CARB-V.Carbn-s.card-m.Caust.clem.Crot-h.Ferr.ferr-ar.FL-AC.Graph.HAM.Hep.Kali-ar.Kreos.lac-c.Lach.LYC.LYCPS-V.Nat-m.Plb.PULS.sabin.sars.sil.spig.sul-ac.Sulph.Thuj.vip.ZINC. Legs - VARICOSE, veins, legs calf - clem.Plb. Legs - VARICOSE, veins, legs cramping - graph. Legs - VARICOSE, veins, legs - distended, during menses - ambr.lach.puls. Legs - VARICOSE, veins, legs drawing - graph. Legs - VARICOSE, veins, legs - lower, legs -Calc.CARB-V.CARBN-S.CAUST.coloc.ferr.Fl-ac.graph.HAM.LYC.Mill.Nat-m.PULS.sil.Sulph.ZINC. Legs - VARICOSE, veins, legs - lower, legs bleeding - Ham.Puls. Legs - VARICOSE, veins, legs - lower, legs inflamed - arn.Ars.Calc.Ham.kreos.lyc.lycps-v.Puls.sil.spig.sulph.zinc. Legs - VARICOSE, veins, legs - lower, legs itching - Graph. Legs - VARICOSE, veins, legs - lower, legs left - fl-ac. Legs - VARICOSE, veins, legs - lower, legs - network in skin - berb.Calc.Carb-v.Caust.clem.Crot-h.Lach.lyc.nat-m.ox-ac.plat.sabad.thuj. Legs - VARICOSE, veins, legs - lower, legs painful - brom.Caust.coloc.Ham.Lyc.Mill.PULS.sang.Zinc. Legs - VARICOSE, veins, legs - lower, legs - painful - menses, during - graph. Legs - VARICOSE, veins, legs - lower, legs - painful - pregnancy, during - mill. Legs - VARICOSE, veins, legs - lower, legs painless - calc. Legs - VARICOSE, veins, legs - lower, legs - pimples, covered with - Graph.

56

Legs - VARICOSE, veins, legs - lower, legs - pregnancy, during - acon.apisArn.Ars.CARB-V.Caust.FERR.FL-AC.Graph.Ham.Lyc.Lycps-v.Mill.Nux-v.Phos.PULS.Sep.Zinc. Legs - VARICOSE, veins, legs - lower, legs pulsating - ham.puls.ruta Legs - VARICOSE, veins, legs - lower, legs sensitive - Fl-ac.graph.Ham.lach.puls. Legs - VARICOSE, veins, legs - lower, legs sharp - kali-c.lyc. Legs - VARICOSE, veins, legs - lower, legs soreness - arn.graph.Ham.puls. Legs - VARICOSE, veins, legs - lower, legs stinging - Apisgraph.Ham.PULS. Legs - VARICOSE, veins, legs - lower, legs swollen - Apisberb.Puls. Legs - VARICOSE, veins, legs - lower, legs tearing - sul-ac. Legs - VARICOSE, veins, legs - lower, legs tension - graph. Legs - VARICOSE, veins, legs - lower, legs ulceration - ars.LACH.lyc.puls.sil. Legs - VARICOSE, veins, legs - lower, legs ulcers - Aesc.Carb-v.card-m.Graph.Ham.hydr-ac.kali-s.Nat-m.syph. Legs - VARICOSE, veins, legs - painful, agg.by warmth - FL-AC.SULPH. Legs - VARICOSE, veins, legs - pregnancy, during - acon.apisArn.Ars.CARB-V.Caust.FERR.FL-AC.Graph.Ham.Lyc.Lycps-v.Mill.Nux-v.Phos.PULS.Sep.Zinc. Legs - VARICOSE, veins, legs thigh - Calc.ferr.HAM.lac-c.Puls.sep.Zinc.

57

MEDICINES AND THEIR

DIFFERENCIATING FEATURES

Medicine should be differentiated by its unique individualizing

symptoms and thus the logical totality of each drug differs from one

another. The most striking, singular, uncommon and peculiar

(characteristic) signs and symptoms of the remedy arechiefly

considered here.

Pulsatillanigricans

Particular symptom Physical generals Concomitant

symptoms

Relation

ship

Varicose veins that develop during pregnancy. Swollen veins in the legs, Legs feel hot and painful at night, with heaviness and weariness. Pain worse when the legs are hanging down without support. Bluish hue with soreness and stinging pain; passive haemorrhage. intense pain in the varicose

Chilly thirstlessness Dryness of mouth without thirst Pain appear suddenly leave gradually Symptoms ever changing Restless Feels better in open air. modality stinging pain that worsen in hot weather cold application and open air.

Thick ,bland ,and yellow green discharge Gastric difficulty from pork, pastry Diarrhea changeable Menses suppressed by getting feet wet Flow more during day Mental

generals

Weep easily >consolation

Comply Kali m Lyc Sil Sul ac Kali m

58

Lachesismutus

Particular

symptom

Physical generals Mental generals Concomitant symptoms

Blue colour in area mainly on left side. blue-red swelling of the varicose vein Veins tend to bleed rather easily.

Hot patient Hotperspiration Hot flushes Climacteric ailments Sensitive to touch Intolerance to tightness Physical mental exhaustion Hemorrhagic diathesis Wants fanning from a distance Left side affinity

Long lasting grief Sorrow Fright Jealousy Great loquacity

Allsymptoms

59

Zincummetallicum

Particular symptom Physical

generals

Modality Concomitant symptoms

Legs are fidgety and restless, with weakness in the muscles, must move them constantly Crawling sensations, and a tendency to twitch. Large varicose veins, with pain and soreness, appearance

oferuptions,

> during

menses

> discharge

generally

Worse from alcohol, especially wine twitching of

Single muscle all

over the body.

General trembling

Brain or nerve power

wanting Relationship

Inimical : Cham and

Nux should not be

used before or after.

Vipera

Particular symptom Physical generals Concomitant

symptoms Veins are swollen, sensitive and feel as if they will burst unless the leg is elevated Inflammation of veins with great swelling , sensitive and bursting pain Burning sensation >by elevating parts Severe cramps in legs

Hemorrhagic tendency: blood black Symptoms periodic, Return every year Persistent edema with tendency to ulcers

Paralysis of foot extending upwards Enlargement of liver.

60

Fluoric acid

Particular symptom Physical generals Modality Concomitant symptoms

Varicose veins little blue, collection of veins in small spots, Varicose of legs tend to ulceration flat naevus. Varicose veins, often with small areas of spider veins Varicose ulcer: obstinate ,long standing cases copius dischargecold ,violent pain like steaks of lightning,confined to small sports Itching especially in the orifices and in spots

61

Calcareacarbonica

Particular

symptom

Physical generals Modality Concomitant symptoms varicose veins with painlessness burning sensation in the varicose veins ; hurt while the person is standing or walking poor circulation, sole of the feet raw

Chilly patient The hands and feet remain cold and may have excessive sweating. weak or flabby muscles, cravings for sweets ,eggs,indigestible things The patient is malnourished but obese. Psoricmiasm Increased ,cold, sore ,sweat Sensitive to cold,weakness

62

Arsalb

Particular

symptom

Physical

generals

Mental generals Concomitant symptoms

Varicose vein:

itching ,burning,

swelling , edema,

63

Sepiaofficinalis

Particular

symptom

Physical generals Mental

generals Concomitant

symptoms Purple varicose veins that are congested and have lost their elasticity For women with this type of varicose veins that deal with constipation frequently.

Chilly patient Offensive urine Pain are from below upwards Easily fainting Relationship Complementary: Nat mur,Phos , Nux Inimical : Lach ,Puls

Great sadness and weeping Indifferent Indolent Modality

pressure, Hot application, Drawing limbs up

All gone feeling in epigastrium relieved by eating. Uterine prolapse >sit close,cross limbs Constipation,hard stool Sense of ball in anus not > by stool Ball sensation in inner parts

Ferrummetallicum

Particular

symptom

Physical generals Modality Concomitant symptoms

Legs look pale but redden easily on the least pain or exertion. Walking slowly relieves the weak, achy feeling. Bleeding from varicose ulcer Restless when keeping still. Rending pain in limbs>moving quietly and gently

Hemorrhagicdiathesis; blood light with dark clots, coagulates easily. Craves bread and butter Beer,tea ,Meat disagrees Oversensitive to pain Chilly patient

Always feels better by walking slowly about.

64

Mercurius sol

Particular

symptom

Physical

generals

Modality Concomitant symptoms

Relationship

Varicose ulcer with infection, pus, and foul-smelling discharge. Ulcers sting and burn and have a lardaceous base,with yellow green pus Edematous swelling of the feet

Profuse sweat without relief Moist tongue with intense thirst

Offensive breath Sensitive to heat and cold Syphilitic miasm

65

Arnica montana

Particular

sympt