Varicose vein
DISSERTATION
SUBMITTED TOTHE DEPARTMENT OFSURGERY
FOR THE WINNING AWARD OF
THE DEGREE OF
BACHELOR OF HOMOEOPATHIC MEDICINE AND SURGERY
Submitted by
UNIVERSITY OF KERALA
2015
CERTIFICATE
This is to certify that the dissertation entitled "VARICOSE VEIN and ITS
HOMOEOPATHIC MANAGEMENT has been carried out by. Dr.SHARY
Date:30.4.2015
Place: Trivandrum
Countersigned by:
Dr.ANILA KUMARI. C. T
.
(1755-1843)
AFFECTIONATELY DEDICATED TO
ALMIGHTY GOD,
MY MOTHER, MY FATHER, MY SISTER, MY
TEACHERS AND MY DEAR FRIENDS
ACKNOWLEDGEMENT
First & foremost I would like to thank God, who has given me the
power to believe in myself & pursue my dreams.
PREFACE
Dr.SHARY KRISHNA.B.S.
INDEX
CONTENTS
Page no:
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Introduction
Definition
History
Surgical anatomy
Venous physiology
Surgical pathology
Epidemiology
Predisposing factors
Classification
Etiology
Clinical features
Clinical examination
Investigation
Complication
Varicose ulcer
Treatment
Self-care at home
Prognosis
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HOMOEOPATHIC MANAGEMENT
Case taking
Plan of treatment in homoeopathic system of medicine
Miasmatic diagnosis of different stages of varicose vein and their
treatment
Therapeutics
Medicines and their differentiating features
Selection of potency
Selection of dose
Diet and regimen
Maintaining cause
Observation and follow up
Case discussion
Conclusion
Bibliography
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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 interdependently,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.
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.
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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 constantOne 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).
Tributaries1. 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
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PREDISPOSING FACTORS
(a)
Prolonged standing-
(b) Obesity Excessive fatty tissue in the subcutaneous tissue offer poor
support to the veins. This leads to the formation of varicosity.
(c)
Pregnancy-
(d)
Old age- This causes atrophy and weakness the vein wall. At the same
(e)
Athletes:
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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.
2.
3.
i.
ii.
iii.
iv.
v.
vi.
vii.
4.
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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 asi.
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 middleaged 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 askedi.
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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
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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
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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 saphenofemoral 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. PERCUSSION1. 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.
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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.
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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.
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COMPLICATION
Complications of Varicose Vein1. HEMORRHAGEIt 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.
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
37
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
Thrombophlebitis,
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
42
Complications of Surgery
a.
b.
c.
d.
Bruising
Sensory Nerve Injury
Deep vein thrombosis (rare)
Most common is Recurrence
43
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
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
<Hanging- Think of Pulsatilla or Vipera
>Warm application-Arsalb,Calcfluor
<Warmth-Pulsatilla
48
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
51
52
THERAPEUTICS
KENTS REPERTORY
EXTREMITIES
EXTREMITIES - VARICES , - Lower Limbs
Ambr.arg-n.ARN.Ars.CALC.calc-f.calc-p.Carbn-s.CARB-V.cardm.Caust.clem.Crot-h.Ferr.ferr-ar.FL-AC.Graph.HAM.Hep.Kaliar.Kreos.lac-c.Lach.LYC.LYCPS-V.Natm.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.Nuxv.PULS.Zinc.
EXTREMITIES c.Puls.sep.Zinc.
VARICES
Thigh
--
Calc.ferr.HAM.lac-
--
brom.Caust.Ham.Lyc.Mill.PULS.Zinc.
EXTREMITIES - VARICES , - Leg painless -- calc.
EXTREMITIES - VARICES , - Leg
FERR.Ham.Lyc.Lycps-v.Mill.PULS.Zinc.
painful
pregnancy,during
--
53
EXTREMITIES - VARICES
ac.graph.Ham.lach.puls.
Leg
sensitive
--
Fl-
inflamed
arn.Ars.Calc.Ham.kreos.lyc.Lycps-v.Puls.sil.spig.sulph.zinc.
veins
painful
pregnancy,during
54
Borger Boenninghausens
characteristics and repertory
CIRCULATION - Blood-vessels varicose - aesc.AMBR.Antt.ARN.ARS.bell-p.bufoCALC.Calc-f.carb-an.CARBV.CAUST.coloc.FERR.Ferr-p.FL-AC.formac.GRAPH.HAM.Kreos.LACH.LYC.Mag-c.mill.NAT-M.nuxv.phos.plb.PULS.Sep.Sil.SPIG.sul-ac.SULPH.THUJ.vip.ZINC.
CIRCULATION - Blood-vessels - varicose - and inflamed ARN.ARS.Calc.HAM.Kreos.LYC.nuxv.PULS.SIL.SPIG.SULPH.thuj.Zinc.
CIRCULATION - Blood-vessels
brom.caust.HAM.lyc.mill.Puls.sang.
varicose
painful
55
MURPHYS REPERTORY
Legs - VARICOSE, veins, legs
Ambr.arg-n.ARN.Ars.CALC.calc-f.calc-p.CARB-V.Carbn-s.cardm.Caust.clem.Crot-h.Ferr.ferr-ar.FL-AC.Graph.HAM.Hep.Kaliar.Kreos.lac-c.Lach.LYC.LYCPS-V.Natm.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.
56
57
signs
and
symptoms
of
the
remedy
arechiefly
considered here.
Pulsatillanigricans
Particular symptom
Physical generals
Concomitant
symptoms
Relation
ship
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
<Warmth and keeping legs
hanging.
>cold application and open
air.
Comply
Kali m
Lyc
Sil
Sul ac
Kali m
58
Lachesismutus
Particular
Physical generals
symptom
Blue colour in area Hot patient
mainly on left side. Hotperspiration
Hot flushes
blue-red swelling
Climacteric ailments
of the varicose
Sensitive to touch
vein
Intolerance to
tightness
Veins tend to bleed Physical mental
rather easily.
exhaustion
Hemorrhagic
diathesis
Wants fanning from
a distance
Left side affinity
Mental generals
Long lasting grief
Sorrow
Fright
Jealousy
Great loquacity
Concomitant
symptoms
Allsymptoms <after
sleep
Head ache <sleep
Tonsillitis begin in
left <hot fluids
Constipation
sensation of
constriction of
sphincter
Menses at regular
time
Allpains>by flow
LYCOPODIUMclavatum
Particular
symptom
Drawing or tearing
pains are felt in the
legs, numb
sensation< when
the person is
keeping still, legs
may cramp at night
in bed.
affectingthe right
leg; varicose of
genital organs of
labia during
pregnancy, often of
hepatic origin;
Physical generals
Hot
patientpreferring
warm drinks
Right side affinity
Easy satiety a few
mouthfuls fill up the
throat
Mental generals
Concomitant
symptoms
Ailments from anger Tonsillitis<cold
vexation
drinks
Irritable
Excessive
<contradiction
accumulation of
Verysensitive ,cries flatulence
even when thanked Fullness not>by
Fear of being alone belching
Red sand in urine
Fullness esply in
lower abdomen
Digestive problems,
sluggish liver
function, and poor
circulation.
59
Zincummetallicum
Particular symptom
Physical
generals
All complaints
better when
menses begin
to flow, but
return after flow
ceases
Modality
Concomitant
symptoms
> appearance
oferuptions,
> during
menses
> discharge
generally
Vipera
Particular symptom
Physical generals
Concomitant
symptoms
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
HOT PATIENT
Feels as if
burning vapors
were emitted
from pores.
Offensive
perspiration
Degenerative
process
Syphilitic miasm
Burning pain
Crave cold water
and is continually
hungry
<warmth,
<morning
>cold
>walking
Concomitant
symptoms
All gone sensation
in the stomach
Morning diarrhea
Caries and
necrosis of long
bone
Relationship
Complementary
Coca ,Sil.
Inimical:
Merc sol
Calc. Fluorata
Particular symptom
Varicose veins and their
ulceration;enlarged, prominent veins
Veins hard and knotty. It helps to
restore the elasticity of the veins.
Hard elevated edge of ulcer
Secreacting thick yellow pus
Physical generals
Sensitive to cold
Swelling or indurations of
stony hardness
Induration threatening
suppuration
Modality
< rest
<change of
weather
>warm
applications
61
Calcareacarbonica
Particular
symptom
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
Physical generals
Modality
Concomitant symptoms
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
<from exertion
<ascending
<cold in every
form
<water
washing
<standing
>dry climate
>lying on
painful side
Antidote ;camph
Nitric acid,Nux
Complymentary
Bell , Rhus , Lyco,Sil
Incompactable
Bry ,Sulphur should not
be given after calcarea
Carbovegetabilis
Particular symptom
Poor circulation with icy
coldness of the extremities,
and mottled skin with
distended veins and a bruised
or marbled look,
Legs feel weak and heavy
often itch and burn.
Veins are distended and itch
especially in the evening and
in bed<night
Ulcers of varicose veins.
Bluish discolouration
Physical generals
Old people with venous
congestions
Desire to be constantly
fanned
Craving for fresh or moving
air for older people, or
those who are slow to
recover from an illness.
Poor circulation.
Putrid septic condition
Burning sensation
Cold sweat
Modality
Itching<in
evening
<warm in
bed
<warm
damp
weather.
Evening,
Cold
>fanning
Relationship
Comply:
Kali carb
Antidot:
Ars ,Camph
62
Arsalb
Particular
symptom
Varicose vein:
itching ,burning,
swelling , edema,
<cold ,scratching
Cramps in calves
Trembling,spasm,
weakness
Varicose ulcers
with offensive
discharge
Burning
pain<midnight,
>from heat
Physical
generals
Chilly
Great thirst for
cold water drinks
often but little at a
time
Prostration
<aftermidnight,
1-2am
From cold drinks
or food
<lying on affected
side
>heat in general
Mental generals
Concomitant
symptoms
Anxious,Anguish,Irritab Complaints return
le
annually
Sensitive
Diarrhea after eating
Restless
and
Fear of death
drinking,offensive,foll
Mentally restless but
owed by prostration
physically too weak to Breathing
move ,cannot rest in
difficulty<after12pm,
one place ,changing
midnight>sit or bent
places
forward
continually,wants to be
moved from one bed to
another
Anxiety<aftermidnight
Hamamelisvirginica
Particular symptom
Physical
generals
Modality
Associated
symptoms
Passive
hemorrhages
: profuse
dark
Weakness
from loss of
blood
Bruised
soreness of
affected part
Intense
soreness
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
<evening ,left
side
After sweat
>pressure,
Hot application,
Drawing limbs
up
Ferrummetallicum
Particular
symptom
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
Physical generals
Modality
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.
<Night, at rest,
while sitting
still.sweating
Pain and
suffering come
on during rest
Rapid motion
aggravates the
complaints.
Concomitant
symptoms
Anemic and weak
Extreme paleness
of face which
become red and
flushed on least
emotion
Every quick motion
aggravates
headache
Rheumatism of left
shoulder
Relationship
Antidote: Ars,Hep
Comply :Chin,Alum,
hamamel
64
Mercurius sol
Particular
symptom
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
Physical
generals
Profuse sweat
without relief
Moist tongue
with intense
thirst
Offensive
breath
Sensitive to
heat and cold
Syphilitic
miasm
Modality
Concomitant
symptoms
<night,
Profuse
<perspiration offensive
<by warmth
salivation
< lying on right Tongue large
side
,flabby with
imprint of
teeth;mapped
tongue
Relationship
Follows well:
after Bell,
Hep, Lach,
Aur,
Sulph but
should not be
given before
or after
Silicea.
Belladonna
Particular
symptom
Phlebitis
Acute
inflammation
Red, hot, swollen,
and tender
varicose veins.
Dry,hot burning
Imparts a hot
burning sensation
to examining
hand
Physical generals
Modality
Relationship
Complementary:
Calcarea
Antidotes :Camph;
Coff; Opium;Acon
Incompatible :Acet
ac
Millifolium
Particular symptom
Painful varicose veins
occurring in pregnancy
when PAINFUL
Varicose ulcer:ooze a
bright red blood
Relationship
Follow well:after
Acon, and Arnica in
hemorrhages.
65
Arnica montana
Particular
symptom
Physical
generals
Mental generals
varicose veins
with sore and
bruised feeling
Bruising and
swelling associated
with trauma,
surgery or
overexertion.Feelin
g as if one has
been beaten.
bluish or blackish
discoloration of the
veins. Any exertion
aggravates the
trouble.
Everything on
which he lies
seems too hard;
complains
constantly of it
and keeps
moving from
place to place in
search of a soft
spot
Whole body over
sensitive
<rest lying down
>motion
Says there is
nothing matter
with him
Nervous Great
fear of being
touched or stuck
by persons
coming near him
Concomitant Relationsh
symptoms
ip
Heat of upper
part of body
coldness of
lower
Comply
Acon
Hyper
Rhustox
Causticum
Particular
symptom
Varicose
ulcer:Burning
,rawness ,and
sourness
Pain in limb>warmth
esply heat of bed
Restless at night
Itching in dorsum of
feet
Network of vein in
skin
Physical generals
Mental generals
Rawness and
soreness
Chilly patient
Preferring cold
drinks
<clear fine weather
>damp,wet weather
Intense sympathy
for the suffer of
other
Long lasting
grief,sudden
emotion
Melancholy mood
Concomitant
symptoms
Drooping of upper
eye lids
Constipation >stool
passes better when
standing
Involuntary urination
<coughing
Menses only on day
>on lying down
Cough >drinking
cold water
>expiration
66
Graphites
Particular symptom
Varicose veins with
itching.
Cramping pains in the
legs.
Varicoseulcer: oozes a
watery ,transparent, sticky
fluid.
burning pain with
numbness
Old ulcer with proud flesh
and burning ,itching and
stinging, ulcer with
indurated base and
margins
Physical generals
Chilly patient
Sensitive to draft of air
Suffering part
emaciate
Fidgety while sitting at
work
Offensive sweat and
breath
Craving for air
Weakness
The patient is usually
obese, constipated
and may have skin
problems
Modality
< At
night;<before
midnight
< during and
after menses
Motion
increases all
symptoms
except the
numbness
Relationship
Complementary:
Caust , Hep,Lyc
Graphites follows
well: After
Lyco,Puls;
after Calc in
obesity of young
women with
large amount of
unhealthy
adipose
tissue;followsSul
pher in skin
affections
Apismellifica
Particular symptom
Leg swollen shiny
Sensitive, sore, stinging pain
Feet swollen stiff
Edematous swelling ,Red rosy
hue
Extreme sensitive to touch
and general soreness.
Modality
<heat, touch,
pressure, late
in afternoon,
>Open air,
cold bathing
Physical generals
Thirstlessness
Right side affinity
Extreme sensitive to
touch
Pain :Burning
Stinging, Sore;
suddenly migrating
from one part to
another
Relationship
Complemetery
Nat mur
Inimical
Rhustox
Sulphur
Particular symptom
Bluish spots, swollen
varicose vein. Painful fatigue
Restless leg and feet,cramps
Burning pain in soles at night
Itching, burning,
Pruritus especially from
warmth. phlebitis
Modality
Physical
generals
<Scratching and Washing Burning
<When standing, Warmth Pain, Itching
in bed, 11 am, night > dry Standing is
warm Weather, lying on
the worst
Right Side.
position
Relationsh
ip
Compliment
ary
Psorin,
Acon
67
ThujaOccidentalisAnanti-sycoticMedicine,toremovethemiasmatictendency
in
cases
wheretheblowoutshaveappeared. There may be muscular twitching, weakness.
Pain in heels. Increased perspiration, Sensitive to touch, Coldness of one side,
Chilly Patient, < night, 3am, and 3 pm, Cold
Silicea terra
In painless varicose ulcer. Cramps in calves and soles. icy cold and sweaty
feet. Offensive sweat on feet, varicose ulcer - with Offensive pus. Long lasting
suppuration. Itch only in day time and evening. <Lying on left side, Cold >
Warmth.
Ferrumphos:Varicose and haemorrhoids in young people; stool hard& difficult followed by
backache throbbing pain.
Bellisperennis
Varicose veins that are bruised and sore, walking is difficult
Aconite napellus:
This remedy may be beneficial in cases that are usually brought on by long
periods of standing, painful, uncomfortable, restless legs as well as a feeling of
fatigue.
68
SELECTION OF POTENCY
Psoric stage.
In the psoric stage where the objective symptoms are absent, and the
patient complaints of only the subjective sensations like aching pain, burning
sensation, muscle cramps; then it indicates only functional disturbance and no
well-marked pathology is established. In this condition start the treatment with
higher potency like 200.
Sycotic and Syphilitic stage.
In the sycotic or syphilitic stages, where the valvular incompetency and
varicose ulcer are present, the pathology is well evident. Start the treatment with
30th potency and follow up to higher and higher potency as and when indicated.
The susceptibility of the patient
The more similar theremedy, the more clearly and positively the
symptoms of the patient take on the peculiar and characteristic form of the
remedy, the greater the susceptibility to that remedy and the higher the potency
required; that is when the symptoms of a case clearly indicate one remedy,
whose characteristic symptoms correspond closely to the characteristic
symptoms of the case, we give the high potencies- 200th , 1M or higher.
The nature and intensity disease.
In case of varicose ulcers with intense pain, we have to first aid and ameliorate
the pain as soon as possible, in such case go for low potency (30 th ). Another
advantage of 30th potency is that its action starts and stops rapidly and so if the
selected remedy was wrong, it will be soon evident and we can go to the next
indicated remedy based on present totality. At the same time if the case is not
yet progressed much, and the symptoms are of only mild character associated
with the symptoms in other systems then go for totality of symptoms ,and
prescribe in high potency.
The stage and duration of the disease.
In long standing case of varicose vein and venous ulcers, with well-marked
venous incompetency, thinkof low potency. On the other hand recently occurred
aching pain due to prolonged standing is considered as functional disorder and
gives higher potency.
69
SELECTION OF DOSE
For this purpose it is most convenient to employ fine sugar globules of
the size of poppy seeds, one of which imbibed with the medicine and put into the
dispensing vehicle constitutes a medicinal dose, which contains about the three
hundredth part of a drop, for three hundred such small globules will be
adequately moistened by one drop of alcohol. The dose is vastly diminished by
laying one such globule alone upon the tongue and giving nothing to drink.
Aphorism 285 foot note,Organon of Medicine
Dispensing one doseTo prepare the pellets to give to patients, one or a couple of such little
pellets are put into the open end of a paper capsule containing two or three
grains of powdered sugar of milk; this is then stroked with a spatula or the nail
of the thumb with some degree of pressure until it felt that the pellet or pellets
are crushed and broken then the pellets will easily dissolve if put into water.
70
Coffee; fine Chinese and other herb teas; beer prepared with medicinal
vegetable substances unsuitable for the patients state; so-called fine liquors
made with medicinal spices; all kinds of punch; spiced chocolate; odorous
waters and perfumes of many kinds; strong-scented flowers in the apartment;
tooth powders and essences and perfumed sachets compounded of drugs; highly
spiced dishes and sauces; spiced cakes and ices; crude medicinal vegetables for
soups; dishes of herbs, roots and stalks of plants possessing medicinal qualities;
old cheese, and meats that are in a state of decomposition, or that passes
medicinal properties (as the flesh and fat of pork, ducks and geese, or veal that
is too young and sour viands), ought just as certainly to be kept from patients as
they should avoid all excesses in food, and in the use of sugar and salt, as also
spirituous drinks, heated rooms, woolen clothing next the skin, a sedentary life
in close apartments, or the frequent indulgence in mere passive exercise (such
as riding, driving or swinging), prolonged suckling, taking a long siesta in a
recumbent posture in bed, sitting up long at night, uncleanliness, unnatural
debauchery, enervation by reading obscene books, subjects of anger, grief or
vexation, a passion for play, over-exertion of the mind or body, especially after
meals, dwelling in marshy districts, damp rooms, penurious living, etc. All these
things must be as far as possible avoided or removed, in order that the cure may
not be obstructed or rendered impossible. Some of my disciples seem needlessly
to increase the difficulties of the patients dietary by forbidding the use of many
more, tolerably indifferent things, which is not to be commended.
260 Fifth Edition footnote, Organon of Medicine
71
MAINTAINING CAUSE
The factor which leads to occurrence, continuation and progress of the
disease should be first eliminated. Prolonged standing and lack of physical
exercises are the maintain cause for the persistence of varicose vein. In cases
where the maintaining factor has progressed the disease beyond a limit, then
even after the removal of the maintaining cause, the effect still persists as
pathological alternation, this cannot be reversed back to normal without the
administration of medicinal agent.
Hence the careful investigation into such obstacles to cure is so much
the more necessary in the case of patients affected by chronic diseases, as their
diseases are usually aggravated by such noxious influences and other diseasecausing errors in the diet and regimen, which often pass unnoticed.
260 Fifth Edition
72
73
Amongthesignsthat,inalldiseases,especiallyinsuchasareofanacutenature,i
nformusofaslightcommencementofameliorationoraggravationthatisnotperceptibl
etoeveryone,thestateofmindandthewholedemeanourofthepatientarethemostcertai
nandinstructive.Inthecaseofeversoslightanimprovementweobserveagreaterdegre
eofcomfort, increasedcalmnessandfreedomofthemind,higherspiritsakindofreturnofthenaturalstate.Inthecaseofeversosmallacommencementofaggra
vationwehave,onthecontrary,theexactoppositeofthis:aconstrained,helpless,pitiab
lestateofthedisposition,ofthemind,ofthewholedemeanour,andofallgestures,postur
esandactions,whichmay be
easilyperceivedoncloseobservation,butcannotbedescribedinwords.
Aphorism 253,Organon of Medicine by Samuel Hahnemann
Butevenwithsuchindividualswemayconvinceourselvesonthispointbygoing
withthemthroughallthesymptomsenumeratedinournotesofthediseaseonebyone,an
dfindingthattheycomplainofnonewunusualsymptomsinadditiontothese,andthatno
neoftheoldsymptomsareworse.Ifthisbethecase,andifanimprovementinthedispositi
onandmindhavealreadybeenobserved,themedicinemusthaveeffectedpositivedimi
nutionofthedisease,or,ifsufficienttimehavenotyetelapsedforthis,itwillsooneffectit.
Now,supposingtheremedyisperfectlyappropriate,iftheimprovementdelaytoolongi
nmakingitsappearance,thisdependseitheronsomeerrorofconductonthepartofthep
atient,oronthehomoeopathicaggravationproducedbymedicinelastingtoolong(aph
orism157),consequentlyonthedosenotbeingsmallenough.
Aphorism 255,Organon of Medicine by Samuel Hahnemann
Ontheotherhand,ifthepatientmentiontheoccurrenceofsomefreshaccidentsa
ndsymptomsofimportancesignsthatthemedicinechosenhasnotbeenstrictlyhomoeopathiceventhoughheshouldgoodnaturedlyassureusthathefeelsbetter,[asisnotinfrequentlythecaseinphthisicalpati
entswithlungabscessintheSixthEdition] we
mustnotbelievethisassurance,butregardhisstateasaggravatedasitwillsoonbeperfe
ctlyapparentitis.
Aphorism 256,Organon of Medicine by Samuel Hahnemann
74
75
A patient who has recovered from an acute disease by the use of these
non-antipsoric medicines, should never be regarded as cured; on the contrary,
no time should be lost in attempting to free him completely, by means of a
prolonged antipsoric treatment, from the chronic miasm of the psora, which, it
is true, has now become once more latent but is quite ready to break out anew;
if this be done, there is no fear of another similar attack, if he attend faithfully to
the diet and regimen prescribed for him.
Concept extracted fromAphorism 222
76
CASE DISCUSSION
CASE 1
NAME OF THE PATIENT
AGE/SEX
OCCCUPATION
ADRESS
I.P. NO:
DATE
Alphonsa
38 years/female
House hold job
Kottiyam
624
9-12-2014
PRESENTING COMPLAINTS
1. Ulcer in the inner aspect of left leg above the ankle( 2 months)
With burning pain and edema around the ulcer.
Associated with itching
< night , movement
>rest
HISTORY OF PRESENTING COMPLAINTS
1. The complaint started 5 months before; took homoeopathic treatment,
got relief. But the ulcer reopens 2 months back. Took allopathic
treatment got no relief. Now the ulcer becomes large and painful. Now
under homoeopathic treatment.
HISTORY OF PAST ILLNESS
1.
2.
3.
4.
5.
FAMILY HISTORY
NP
PERSONAL HISTORY
PLACE OF BIRTH
Kottiyam
EDUCATION
OCCUPATION
MARITALSTATUS
HABITS AND
HOBBIES
5th standard
Housemaid
Un married
Nonvegetarian
SOCIAL STATUS
RELIGION
ECONOMIC STATUS
NUTRITIONALSTATUS
Middle
class
Christian
BPL
Moderate
77
PHYSICAL GENERALS
APPETITE
Good (desire warm
food)
THIRST
Good
SLEEP
Decreased due to pain
in leg
REACTION
TO
CONSTIT
UTION
PSYCHIC
FEATURES
Desire fanning
Lean thin emaciated
URINE
NP
BOWELS
SWEAT
Regular
Generalized
THERMAL
REACTION
SIDE
AFFINITY
Hot patient
Left side
MENSTRUAL HISTORY
Menarche 13 years
Hysterectomy done 7 years before
due to hysterectomy
OBSTETRIC HISTORY
Nil
REGIONALS
Head ache < reading books
Heart burn < after eating banana, peas
PHYSICAL EXAMINATION
Built : well
Temperature :Afebrile
built
Respiratory rate :14/mit
Gait :steady
Pulse rate: 72/mit
No pallor
B.P- 130/82mmHg
Not cyanotic
Not icteric
No clubbing
78
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
FINAL DIAGNOSIS
TOTALITY OF SYMPTOMS
Fastidious
Desire fanning
Hot patient
Left side affinity
79
FOLLOW UP
Date
20-12-14
Analyse
relief
28-12-14
Slight pain
Remedy
Rx
Sac lac
Rx
Arsalb 200/1 dose
80
CASE 2
NAME OF THE PATIENT
AGE/SEX
OCCCUPATION
ADDRESS
I.P. NO:
DATE
Jagadeshwaran
42 years / Male
Stationary shop owner
Thirunalveli
815/40154
11-3-2015
PRESENTING COMPLAINTS
1.Pain and swelling of right leg (1 week)
Associated with tiny vesicles
Stitching type of pain
< walking , standing , hanging the legs
>rest , keeping leg straight in the bed
FAMILY HISTORY
Father: DM
Mother: RA
81
PERSONAL HISTORY
PLACE OF BIRTH
Chennai
EDUCATION
+2
OCCUPATION
Stationary
shop owner
MARITAL
Married,
STATUS
have 2
children
PHYSICAL GENERALS
APPETITE
Good (prefer
warm food)
THIRST
Decreased
[ Prefer warm
drinks]
SLEEP
Decreased
REACTION TO
THERMAL REACTION
CONSTITUTIONAL
PSYCHIC FEATURES
SOCIAL STATUS
RELIGION
ECONOMIC
STATUS
NUTRITIONAL
STATUS
Middle class
Hindu
APL
Moderate, Non
vegetarian.
URINE
NP
BOWELS
Regular
SWEAT
Increased all
over the body.
Desire Sweets.
Desire non-vegetarian food
Body feels hot.
Desire Cold climate
< hot climate
Hot Patient
Memory week
Desire Company
Easily angered.
REGIONALS
Breathing difficulty occur recurrently on exposure to cold season leading to
wheezing
Tongue-moist
82
PHYSICAL EXAMINATION
Built-well built
Temperature: Afebrile
Gait- Steady
Pulse rate: 70/ min
No pallor
B.P- 130/80mmHg
Not cyanotic
Not icteric
No clubbing
Edema present in Right lower leg.
No lymphadenopathy
SYSTEMIC /LOCAL EXAMINATION
EXAMINATION OF VARICOSE VEIN
INSPECTION
Varicose vein: slight dilatation on the medial side of the leg starting from in
front of the medial malleolus to the medial side of the right thigh
Swelling :present in right leg
Skin of the limb: evidence of inflammation present
Reddish discoloration,
Edema present
Two Small circular vesiclesruptures and oozing pus
PALPATION
Tenderness present in calf
Brodie-Trendelenburg testPositive
Morriseys Cough Impulse Test-Positive
ASCULTATION: murmur absent
REGIONAL LYMPH NODES: lymphadenopathy present
EXAMINATION OF ABDOMEN
No palpable mass
no abdominal lymphadenopathy
INVESTIGATIONS
14- 3 -2015
ESR: 30 mm/ hr
Urine sugar: NIL
RBC: 5.52106 /l
Platelet: 440103 /l
FBS: 75 mg %
S.cholestesol- 167 mg %
Triglyceride :163mg%
HDL :28mg %
LDL: 106 mg %
VLDL :33mg %
83
Varicose vein
TAO
Phebitis
FINAL DIAGNOSIS
TOTALITY OF SYMPTOMS
Hot patient,
Desire sweets.
Pain and Oedema of Right leg.
< hanging legs.
> Keep leg in elevated position
MIASMATIC EXPRESSION-Trimiasmatic
MANAGEMENT AND TREATMENT
ACCESSORY MANAGEMENT
Avoid standing still for long periods of time.
Avoid applying any external application on the ulcer. Keep the area of ulcer
clean and hygiene
Lie down with ankles raised above chest level for at least half an hour
Take moderate exercise
Avoid being over weight
BASIS OF PRESCRIPTION
Oedema in right leg
Thirsty during complaint
84
REMEDY
Rx
Apis 30/1dose
FOLLOW UP
Date
Analyse
26-3-2015
30-3 2015
6-4-2015
Slight pain
29-4-2015
Relief
Itching in skin
Anti-miasmatic remedy
Remedy
Rx
Pulsatilla 200/1 Dose.
Rx
SacLac/1 dose
Rx
Pulsatilla1M/1 dose
Rx
Sulphur 1M/1Dose
85
CASE 3
NAME OF THE PATIENT
AGE/SEX
OCCCUPATION
ADRESS
O.P.NO.
DATE
Thambi
68 years/male
Engineer
Neyyattinkara
1560
18-4-2015
PRESENTING COMPLAINTS
1. Diatated vein on both leg (since 7-8 years)
More in the left leg
2. Pain in soles of both feet (since ) .
< raising from sitting position ,
>walking
HISTORY OF PRESENTING COMPLAINTS
Diatated vein in leg started since 7 -8 years, he took no treatment and used to
apply ayurvedic oil and got slight relief.
Known DM, since 35 years and used to take Allopathic medicine.
HISTORY OF PAST ILLNESS
1. Measles childhood homoeopathic treatment
2. Mumps - childhood homoeopathic treatment
3. Recurrent stye 16 years homoeopathic treatment cured
4. Bleeding piles 65 years ayurvedic treatment
5. Cataract in both eye 2005 and 2008 --surgery
FAMILY HISTORY
DM father ,mother and brother
RA father , mother
CAD -- brother
PERSONAL HISTORY
PLACE OF
Neyyattinkara
SOCIAL
Middle class
BIRTH
STATUS
EDUCATION
Graduate
RELIGION
Hindu
OCCUPATION Engineer
ECONOMIC
Above poverty line
STATUS
MARITAL
Married (have 2
NUTRITIONA Moderate
STATUS
daughters )
L STATUS
Non vegetarian
HABITS AND
Farming ,
ADDICTIONS Smoking since 30
HOBBIES
gardening
years ;5 cigar/day
Tea ,5 times /day
86
PHYSICAL GENERALS
APPETITE Good
THIRST
Increased (desire cold
drink, large quanties at
2-3 hour intervel)
SLEEP
Good
REACTION TO
THERMAL REACTION
CONSTITUTIONAL
PSYCHIC FEATURES
URINE
BOWELS
Frequent urination
Regular
SWEAT
Generalized
DREAMS
Conflicts, anxious
dreams
Desire fanning ,
Intolerance cold climate
Complaints < cold climate
Desire sore and pungent food.
Hot patient
Lean thin,robust ,firm muscular fiber
Angry disposition < contradiction
Helping ,Emotionally sensitive
Sentimental ,Punctual ,Extrovert
REGIONALS
1. Dimness of vision
2. Hypo-pigmentation in the nape of neck, axilla and chest.
3. Cracks in both soles
4. Low back ache < night , lying on abdomen
>rest , lying on back
5. Head ache on left side < mental tension, night watching.
6. Sneezing and running nose < dust
7. Tooth ache, caries of crown of the of lower left molar teeth.
8. Warts on left hip , itching < after bathing
PHYSICAL EXAMINATION
No pallor
Afebrile
Not cyanotic
B.P-120/80 mmHg
Not icteric
No clubbing
No lymphadenopathy
SYSTEMIC /LOCAL EXAMINATION
87
INVESTIGATIONS
FBS: 150 mg %
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Varicose vein
TAO
Thrombophebitis
FINAL DIAGNOSIS
TOTALITY OF SYMPTOMS
Angry disposition
< contradiction
Desire pungent food
Thirst increased
Desire cold drinks
Diatated vein on both leg
More in the left leg
Pain in soles of both feet.
< raising from sitting position ,
>walking
Hypo-pigmentation in the nape of neck, axilla and chest.
88
Analysis
relief
Remedy
Rx
Sac lac
89
CASE4
NAME OF THE PATIENT
AGE/SEX
OCCCUPATION
ADRESS
I.P. NO./O.P.NO.
DATE
Santhakumari
50 years/ female
Business
Nedumangad
16/93024
9-4-2015
PRESENTING COMPLAINTS
1. Painful ulcer on medial aspect of the left leg(since 5 days)
Discoloration of skin
< hanging the leg, walking, fanning
>rest
HISTORY OF PRESENTING COMPLAINTS
1. Complaints started 3 years back, took allopathic medicineand got
temporary relief, then took homoeopathic treatment,and complaint
relived but now aggravated since 3 days .Ulcer first in the lateral
aspect of the leg, then on the medial side.
HISTORY OF PAST ILLNESS
1. Heart complaint 4-5 years allopathic medication
2. Nephrectomy done for transplantation.
FAMILY HISTORY
NR
PERSONAL HISTORY
PLACE OF
Thiruvananthapuram SOCIAL
BIRTH
STATUS
EDUCATION
Nil
RELIGION
OCCUPATION
Business
ECONOMIC
STATUS
MARITAL
Married
NUTRITIONAL
STATUS
STATUS
HABITS AND
HOBBIES
DOMESTIC
RELATIONS
SEXUAL
RELATIONS
Middle
class
Hindu
APL
Good
Non vegetarian
Good
90
PHYSICAL GENERALS
APPETITE
Good (desire
cold food)
THIRST
Good
SLEEP
Good
REACTION TO
THERMAL REACTION
CONSTITUTION
PSYCHIC FEATURES
URINE
NP
BOWELS
SWEAT
Regular
Generalized
Aversion covering
Desire fanning
Desire cold food
Desire spicy food
Intolerance hot climate
Hot patient
Offended easily
Anxiety about others
MENSTRUAL HISTORY
Menarche 14 years
Age of menopause :45 years
OBSTETRIC HISTORY
G3P2L2A1
REGIONALS
Dilated vein in both leg
Tongue: moist
PHYSICAL EXAMINATION
Built: moderate
Gait: Steady
Complexion: Dark
No pallor
Not cyanotic
Not icteric
No clubbing
Swelling: NIL
Rashes: NIL
No lymphadenopathy
Nail: Paranoychia
Temperature: Afebrile
Pulse rate: 72/min
Respiratory Rate: 14 /min
B.P-130/90mmHg
91
INVESTIGATIONS
T3-0.8mg /ml
T4-7.92mg/dl
TSH. 3.94/ 10/ml
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
FINAL DIAGNOSIS
TOTALITY OF SYMPTOMS
Anxious about others
Offended easily
Hot patient
Prefer Warm drinks
Desire Spicy food
Ulcer on medial side of left leg <fanning
Varicose Vein on both leg.
MIASMATIC EXPRESSION-syphilitic
MANAGEMENT AND TREATMENT
ACCESSORY MANAGEMENT
Avoid standing still for long periods of time.
Avoid applying any external application on the ulcer. Keep the area of ulcer
92
FOLLOW UP
Date
14- 4 -2015
Analyse
Pain in ulcer+
18-4-2015
Pain >
Remedy
Rx
HeparSulphur 200/1Dose
Rx
Sac Lac/2Dose
93
CASE5
NAME OF THE PATIENT
AGE/SEX
OCCCUPATION
ADRESS
O.P.NO.
DATE
Nusaiba
57 years/female
House wife
Ambalathara
31688
20-4-2015
PRESENTING COMPLAINTS
1. Dilated vein in both legs (Since 3-4 years)
Burning pain, Hot sensation in both feet as Coals of fire
Blow outs present
Associated with blackish discoloration in the lower part of both legs
with intense itching
2. Bleeding from vagina 3 years after menopause (Since 3 years)
associated with pain in left groin.
HISTORY OF PRESENTING COMPLAINTS
1. Dialated veins in both legs started during her 3ed pregnancy and
aggravated since 3-4 years. She used to have recurrent ulcers and skin
abscess in the lower part of the legs. She use to apply allopathic
ointment when there is active ulcer and gets temporary relief.
2. Post-menopausal bleeding started since 3 years. She consulted in W and
C. Under went D and C. Advised for regular follow up and test Pap
smear once in every year.
HISTORY OF PAST ILLNESS
FAMILY HISTORY
Fibroid uterus: Sister
Hypertension: Mother, Father.
CAD: Mother
PERSONAL HISTORY
PLACE OF
TVPM
BIRTH
EDUCATION
Nil
OCCUPATION
House Wife
MARITAL
STATUS
Married, have 3
children
SOCIAL STATUS
Low class
RELIGION
ECONOMIC
STATUS
NUTRITIONAL
STATUS
Muslim
BPL
Moderate
94
PHYSICAL GENERALS
APPETITE Good
URINE
THIRST
BOWELS
SLEEP
Decreased
SWEAT
REACTION TO
THERMAL REACTION
CONSTITUTION
PSYCHIC FEATURES
Hot Patient.
Desire to lie on cold floor.
Desire sour,
Pungent, Salt
Hot patient + +
Delicate, obese, fair complexion
Mental tension about children
Financial Problem
MENSTRUAL HISTORY
Menarche- 13 years.
Menopause -52 years
Post-menopausal bleeding since 3 years
Duration : 7 days
Associated with pain in left groin
Leucorrhea Pale Yellow discharge
OBSTETRIC HISTORY
G3P3L3A0
Varicose vein duringpregnancy.
Measles during 3ed pregnancy.
3erd child is congenitally deformed
PHYSICAL EXAMINATION
No pallor
Not cyanotic
Not icteric
No clubbing
No lymphadenopathy
Afebrile
B.P-160/90mmHg
95
INVESTIGATIONS
Ultra Sound Scan Abdomen and Pelvis
Balk uterus with endometrial growth 5.2 cm X 2.5 cm filling the cavity.
Renal Calculi left kidney, Fatty liver and Fatty Abdomen.
Left kidney -2 calculi 4 mm x 2mm and 2mm X 2 mm
Left ovary-Cyst
PROVISIONAL DIAGNOSIS
Varicose Vein
Endometrial CA
DIFFERENTIAL DIAGNOSIS
FINAL DIAGNOSIS
TOTALITY OF SYMPTOMS
Mental tension about children
Hot Patient.
Desire to lie on cold floor.
Desire sour,
Pungent, Salt
desire cold drinks
Dilated vein in both legs
96
Analysis
relief
Remedy
Rx
Sac lac
97
CONCLUSION
Homeopathy works very well for mild to moderate cases of varicose
veins. But treatment should be started at the earliest to cure it completely.
Medicines should be administered after proper analysis of the disease (nature
and origin) and sufferings.It helps to reduce pain, control further varicosity,
reduces swelling. It also helps significantly in the cases which have varicose
ulcers. The remedies often help to relieve discomfort that comes with varicose
veins, and may help to prevent their worsening.
Time taken for complete cure of the varicose vein depends on the stage of
the disease. So the diagnosis of the different stages of the varicose vein and
deciding the plane of treatment is very important. Recurrence rate can be
reduced by long term systematic and regular follow up with miasmatic and
constitutional remedy.
Alone with medicinal administration, general management and removal
of the maintaining cause is very important. Reference of the case complicated
with DVT at the correct time also needs to be appreciated as it may prevent life
threatening situations like pulmonary embolism or MI.
A physician high and only mission is to restore the patient to health, to
permanent cure. A physician should excel in the knowledge of the disease, its
maintaining cause and also the knowledge of medicine, dose, potency to be
administered, and its repetition, he is then the true practitioner of the healing art.
AUDAE SAPERE
Dr.SHARY KRISHNA.B.S.
98
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Bailey and Loves short practice of surgery, by Rains , Mann, 20th edition
A Concise Text book of Surgery S. Das
A Manual on Clinical Surgery S. Das
Borger Boenninghausens characteristics and repertory
Murphys Repertory
Repertory of the homoeopathic MateriaMedica J.T.Kent.
Allens keynotes
Leaders in Homoeopathic therapeutics Dr.E.B. Nash
Pocket manual of Homoeopathic materiamedica and repertory William
Boericke
Organon of Medicine by Samuel Hahnemann
Organon of Medicine by Samuel Hahnemann , Introduction and
commentary on text by B.K. Sarkar.
Ruddocks Homoeopathic Vade-Mecum-by E.Harris Ruddock .M.D
Lectures on homoeopathicmaterial medica J.T. Kent
A Dictionary of Practical MateriaMedica- Clarke
ComparativeMatericaMedica E.A. Farrington
The genius of homoeopathy, lectures and essays on homoeopathic
philosophy-Stuart Close, M.D. Chapter 8,page no:183
Lectures on homoeopathic philosophy J.T. Kent
The principle and practice of homoeopathy by Richard Hughes
The principles and art of cure by homoeopathy by Herbert. A . Roberts. (
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Homoeopathy The science of therapeutics by C.Dunham.
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99
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Scand J Work Environ Health 2000;26(5):414-420
doi:10.5271/sjweh.562
Standing at work and varicose veins
by Tchsen F, Krause N, Hannerz H, Burr H, Kristensen TSThis article in
PubMed: www.ncbi.nlm.nih.gov/pubmed/11103840
Assessment of Venous Insufficiency in Patients with Chronic Venous
Leg Ulcers.VenousHemodynamics before and after Surgery
Akademiskavhandling
Risk factors for chronic ulceration in patients with
varicose veins: A case control study
Lindsay Robertson, BSc,a Amanda J. Lee, BSc,b Karen Gallagher,
BN,c Sarah Jane Carmichael, BSc,c
Christine J. Evans, MBChB,d Brian H. McKinstry, MBChB,a Simon
C. A. Fraser, MBChB,c Paul L.
Allan, BSc,a David Weller, MBChB,a Charles V. Ruckley, MB,aand
Francis G. Fowkes, MBChB,a
Edinburgh and Aberdeen, United Kingdom