The Medicinal Treatment of Diseases of the Veins.
GENERAL SURVEY OF VARICOSIS AND VARICOSE VEINS.
VARICOSE veins may owe their dilated state either to (1), a blood disease; (2); to weak vein walls or valves; (3), to a mechanical obstruction to the flow of the blood heartwards; (4), heart disease; or (5), it may be part and parcel of what might be called the “ptosic” constitution.
Where the origin is merely due to (3) topic obstruction, the best plan is to find out the obstruction and remove it, and then the veins return, more or less, to their proper size; and there then only remains a loss of tone in the vein walls; here such remedies as Arnica, Bellis, Ferrum, Pulsatilla, and Hamamelis will suffice to finish the cure. Where the obstruction cannot be found, or having been found cannot be removed, Fluoric acid has most frequently helped me.
But the obstruction can very frequently be found and remedied radically, and then a very beautiful cure is the end result of the treatment.
HOW TO UNDERSTAND VARICOSIS FROM OBSTRUCTION
If we dam up a given river at a certain place, all the little streams and rivulets that debouch into it above the dam will fill up and swell in volume, and very likely overflow their banks and flood the environs. Now, if we want to get rid of this overflow of the banks, we may certainly raise the banks and so hem in the water, but in this way we increase the volume of the rivulets, and the heightened banks need much and constant attention; but if we go down to the dam and remove it, we have no further difficulty with the streams and rivulets, for they will run on and empty themselves into the river, just as the latter will run on into the sea.
Now so it is with varicose veins from obstruction; the obstruction if the dam that prevents the smaller veins from duly emptying themselves into the larger ones. We may, to continue our simile, heighten the banks by putting on elastic stockings, but the better plan is to go down to the obstructive dam and remove it, for just as the rivulets with the higher banks increase in volume, so do banks increase in volume, so do varicose veins that are merely held in by mechanical support.
The support afforded by bandages and elastic stockings to the varicose veins has no other effect than such support: the ailment goes on developing just the same, and, as a matter of fact, the support often does much harm. Let me explain. As I have already made use of the damming up of the river to illustrate the nature of obstructive varicosis, so the same simile will serve to show the ultimate and further effects of elastic stockings or other support, viz.:-
1. Dam up a river and all its above-dam tributaries will increase in volume until the dam is overcome, or until the volume of water in the river reaches the level of the top of the dam.
2. If the dam is strong enough and high enough, the beds of the said tributaries will presently no longer suffice for the volume of water contained in them, and the banks of the tributary streams will overflow : now here, if we raise and strengthen these banks, we merely remove the overflow further up stream, and the feeders of the tributaries will in their turn increase in volume and overflow their banks, -i.e., the increase in volume of the water dammed up is extended further up stream, it is not got rid of. So it is with the elastic stocking or bandage; it gets rid of no varicosis, but removes the influence of the obstruction further up heartwards, just as the heightened and strengthened above-dam banks remove the danger of overflow further up stream. Of course, this may under circumstances be a good thing to do, but such is its limitation.
Hence in every case of varicosis I am in the habit of first trying to find out the mechanical cause of the varicosis. Above the level of the heart we do not often meet with varicose veins, because gravitation is sufficient to overcome any moderate obstruction. Below the diaphragm, on the other hand, varicose veins are very common, because here gravitation tends to increase any tendency to varicosis.
A swelled or enlarged liver is a frequent cause of varicose veins of the right leg; a swelled spleen has a similar effect on the venous circulation of the left lower extremity.
Constipation has a like effect on either lower extremity, according to where the accumulated faeces lie. In ladies, uterine enlargement and displacement act similarly. One-sided varicosis is often caused by ovarian enlargements. Thus, I was once consulted for a young lady whose left lower extremity was the seat of very severe varicosis : the veins were so badly dilated that the limb had a hideous aspect,-so much so that all idea of marriage had been given up; the well-fitting stocking certainly supported the veins, but otherwise only tended to render the whole limb varicosic. I readily ascertained the location of the dam or obstructive element in the case, viz., there was a considerable enlargement of the left ovary, with severe concomitant leucorrhoea. This ovarian enlargement appeared to me to be due to chronic inflammation of a sycotic nature. I set to work with antisycotics, and in a few months the enlargement lessened, and finally disappeared entirely; and in proportion as the enlargement lessened so the varicosis likewise diminished, and also the leucorrhoea, and finally the varicose veins could no longer be found. The young lady re-appeared in society, and she presently married and had her first baby last year.
Less than two years ago a Commander in the Royal Navy, a very healthy, well-preserved man, about forty years of age, consulted me in regard to an enormous varix of the right groin as big as a small orange, and the thing was all the more alarming as the wall of the varix had become thin, and being in the bend of the groin, mechanical support was practically impossible, so of course it appeared that patient would have to quit the service. There being no heart affection, no blood disease, no primary vein disease and no history of any local lesion or disease of any sort, I made a careful examination of the abdominal organs, and could only make out a not very considerable enlargement of the left lobe of the liver. I therefore set about curing the liver, though I did not think the said enlargement sufficient to account for such an enormous varix. However, as soon as the liver had been brought back to the normal, the varix was reduced to a mere nothing, and in a few months the delighted patient hastened off on active service, looking forward to becoming in due course an Admiral.
The remedies which cured this case were Carduus Mariae 0, Chelidonium majus 0, and Chelone glabra 0. For an account of the two former remedies see my “Greater Diseases of the Liver.” and my “Diseases of the Spleen and their Remedies” respectively. As to the last-named remedy-Chelone glabra-I should like to say that its seat of action is the left lobe of the liver, and it line of action is in the direction of the navel, bladder, and uterus, while the “line of action” of Carduus is horizontal from liver to spleen, or conversely. At the first blush this looks fanciful, but the competent can readily verify it clinically.
Where the varicosis of the lower extremities preponderates on one side, but is present in both, it is useful to trace the history of the origin of the varices, and find out where it began and how it developed, and thus a diagnosis of the dam, if any, is greatly facilitated.
Where the lower extremities are both equally involved, and the hypogastric veins are also dilated, it is often due to indurated abdominal glands. Thus several years since a city merchant consulted me for such a state, he being desirous of getting married. Almost all the superficial veins of the extremities were dilated, and also the hypogastric veins; the largest varicose veins were about the size of goose quills, the smaller ones about that of crow quills, so the aspect was ugly indeed. After about two years’ treatment the veins were reduced about three-fourths, and the marriage has now been fixed for the near future.
I was led to diagnose indurated abdominal glands, from the visible and feelable hypertrophy and induration of his inguinal glands, which were clearly inherited and not acquired. Nosodes were the chief remedies.
The diagnosis of the seat of the dam is of very great importance in these cases. Where one lower extremity is enlarged from perturbed circulation in the deep-lying veins of the limbs, looking like phlegmasia alba dolens, but occurring in the made and not necessarily with any increase of sensation-the left leg is most commonly involved-the condition would appear to bear some relationship to the spleen, and may, perhaps, be to the spleen what myxoedema is to the thyroid.
Thus, a gentleman consulted me early in the current year (1894) for a considerable enlargement of the left leg, in aspect very much like the ordinary white leg. He was also suffering from scarring acne, and the skin of his face was very shiny. The spleen was notably enlarged. Patient dated the swelling of the leg to an attack of mountain fever which he had four years ago in Colorado, since when his enlargement had existed. He had had gonorrhoea years ago, and had also been twice vaccinated. Vaccination at times, perhaps always, causes a certain amount of tumefaction of the spleen, as does also gonorrhoea, and I have over and over again seen varicosis follow common gonorrhoea; examples of this I could cite in numbers.
Urtica urens 0 in small material doses greatly lessened the enlargement of the leg in a few weeks. I cite this case thus quite shortly, to exemplify the usefulness of diagnosing the dam in cases of obstructive varicosis.
Haemorrhoids are essentially varicose veins of the anus and rectum. Here the first point to elucidate in each new case is the place of the dam-a not always easy task-but the anal region is very apt to harbour piles of obstructive origin, but which at the same time have become a substantive disease, and the vicarious outlet for the divers constitutional taints to which man is liable.
There is no such a thing as primary piles,-they are all either hypostatico-obstructive or merely obstructive, or from constitutional ailments, which, all lumped together, constitute the haemorrhoidal diathesis, notably of German authors.
The frequent haemorrhages from the haemorrhoids are, in my judgment, all of constitutional treatment will cure such, but the constitutional cause must be got rid of before a radical cure can be effected either of the haemorrhoids or of the haemorrhoidal bleedings. To stop the bleeding by operation on the veins or on the part, is a proceeding that, in my judgment, should land the 3 operator into a medical court of inquiry. And quelling the bleeding with remedies without regard to the constitutional cause or causes, is not infrequently followed by constitutional disaster : anal bleedings are very often disease-outflows.
Now let any one of ordinary common-sense and understanding, whether medical or lay, tell me- How can it be seriously maintained that diseases of the veins are to be dealt with by surgery? The surgical aid in vein affections only comes in as a last resort where nothing else can be done, and even then it is but a sorry uncertain old crutch.