Modern treatment of varicose veins in general practice with records of thirty cases

Abstract

After considering the results of treatment of varicose veins by intra-venous therapy in these few cases, and in fresh cases which are always coming under treatment, I can come to no other conclusion than that here is a new and powerful weapon in the armamentarium of the practitioner, with which he can do much to alleviate a very common complaint. I submit that there is no question of the efficiency of this treatment; and that, it is now the accepted method of treatment. A significant fact is that it is now accepted by the National Health Insurance Committees in this country, and that its application is ,!within the range of treatment expected of the Panel practitioner."When first introduced, many objections were raised; chiefly mooted being the possibility of sepsis and embolism. As agents and technique have improved, however, and clinical results have been noted and summarised, it appears that these dangers are now more suppositious than real. In this connection, Bouthwaite, 0 8 ) has recorded that he has given over 6000 injections without embolic mishap; and he concludes that this is testimony to the intravenous treatment.Literature on this subject is rapidly accumulating, but few, if anv. of the authors give a guide to the inexperienced as to the choice of drug. Each, author appears to stress the claims and advantages of one ding to the almost total exclusion of others. To my mind, this point is one which requires more authoritative conclusion and research. From the standpoint of the general practitioner, no definite lead has been given in the methods of selection of the drug to be used. The modern treatment, having been introduced on the large scale, with quinine and urethane, and sodium salicylate, I have naturally used these agents in my practice, and in my opinion, this choice has so far been justified. The end - results of the exhibition of these has been equally effective in both instances.THE EFFECT OF TREATMENT ON THE GENERAL SYMPTOMS. Without exception, I have found that all the patients who have undergone this treatment have reported that the sensations referred to the lower extremities,- such as cramp, heaviness, and fatigue, have been cleared up completely. As a consequence, they have been fitter for their work, and have felt less fatigued at the end of the day. A feeling of improved well-being was reported by some of the patients, and it is my belief that this was due to partly the relief obtained from their previous symptoms, and also partly from the psychological effects of "treatment with a needle." It is interesting to note in this connection that Colt makes the suggestion that "possibly, the obliteration of the varices may have a definite effect on the blood pressure, and especially on the diastolic pressure in older people" (37).Itching and redness of the skin over varices definitely cleared up, and did not return, and this relief was described by the sufferers as being great. Further, as the direct result of treatment, oedema of the lower thirds of the legs disappeared. In three cases in which varicose ulcers were present, there resulted cure in two, and great improvement in the third. The latter was a case of many years' standing.From the figures which I have given, it will be noticed that a greater number, on the average, of injections with quinine and urethane, is necessary to produce the same amount of sclerosis. as in the case of sodium salicylate. This experience I have also found to have been borne out by fellow practitioners. Another point, in my opinion, although it is a minor one, is that the total amount of fluid to be injected is smaller in the case of the former than the latter. Finally, it is my experience that, taken all round, the results with quinine and urethane are better than those obtained with sodium salicylate.In the light of the available clinical pathology of the treatment, it is impossible to conclude 55- ¿ 6 . whether the extended action is due to the sodium salicylate itself, or to the larger body of fluid injected. There may be some difference in their respective actions which is controlled by the "blood variables" referred to by Colt (39), the blood volume and current at the point of injection. From a perusal of the literature of the subject, it is obvious that it is upon their high concentration in the vessels at the point of injection, that the efficiency of the results depend.With this point in view, therefore, it is easy to appreciate the importance of keeping the walls of the injected vessel in as close approximation as possible, during, and after, the injection.As regards the use of sodium chloride solutions, while Barber asserts that this drug does not produce pain, the two cases in which I used it, suffered sufficient pain to induce me to discontinue its use. I have further found this very limited experience to be borne out by other practitioners, who likewise have discontinued its use. This is an age in which pain, in association with medical and surgical treatment, is badly tolerated, by patients, who, naturally, look for its elimination, where possible. The inclusion of urethane with quinine solution has not in any of my cases led to mishap, and it is interesting to note that Sicard and Gaugier employ both cocain and novocain in a salicylate solution for the treatment of haemorrhoids, (8).Up to the present, the use of quinine and urethane, or sodium salicylate, in my practice, has not been productive of any untoward results.I think it will be agreed that, at the present time, at any rate, that the ideal method of standardising this treatment has not been produced. Also the ideal agent has yet to be discovered and the exact clinical pathology standardised.Perhaps, in these days of instruments of precision, it is not too much to hope for the calculation of the relative volumes and carrying capacities of the deep and superficial veins, developed, as suggested by Colt (13) along the lines of the plethysmograph.The merits of this intravenous method of treatment may be shortly summed up in the following: -1. The treatment is ambulatory, and the injections take up little time of either patient or medical man.2. It does not require special apparatus.3 . If sufficient attention be paid to the technique, the treatment is a "safe" and practical method.4. I have found quinine and urethane to be the most suitable preparation for use in general practice to date.5 . The treatment is an economic one; that is, it is "prophylactic," as well as curative, in the vast majority of cases, as treatment may he commenced at an early stage of the condition; and the possible Bequelee of varicose veins prevented.6. The results are permanent.7. It replaces the older methods of surgery with their greater risks.I submit, therefore, that the time is not far distant, when the crippling and very prevalent condition of varicose veins of the legs, will become one which its sufferers will not tolerate as they do at present, and one for which they will quickly seek relief. To both the patient, and the doctor, the relief and satisfaction will be mutual.