Circulatory System

 

The circulatory system sustains and nourishes all the cells in the body with oxygen and nutrients and takes away all waste. The actual exchange of waste for nutrients and oxygen takes place at the capillary level. Blood flows through the arterial system to the cells and back to the heart via the venous system.

There are 3 types of circulatory system in the body: heart, pulmonary and portal vein.

The heart system is the standard system which transports nutrients and blood to the cells and cleans up waste out of the intercellular fluid so that it can be excreted. Oxygen rich blood flows through the arteries and oxygen poor blood flows through the veins. The blood circulation starts in the left ventricle and ends at the right atrium in the heart.

The pulmonary system pumps oxygen poor blood out of the heart and into the lungs so the gas exchange can take place. Oxygen rich blood is then pumped by the pulmonary veins back into the heart.

The portal vein system is a secondary capillary system and transports nutrient rich and oxygen poor blood to the liver, after passing through the viscera, where oxygen is delivered to the internal organs. Nutrients are absorbed by the digestive system and transported to the liver. Any toxins are filtered out in the liver before the blood enters the blood stream. Once the blood flows through the liver, it empties into the hepatic veins and reenters the heart via the inferior vena cava.

The arteries are responsible for transporting oxygen rich blood around the body and oxygen poor blood to the lungs. Each artery has an arterial wall. The wall is made up of three layers: intima layer made of squamous endothelium; the media layer made of smooth muscle cells; and the externa layer made of connective tissue.

Intima: the flat endothelium (a type of epithelium) sits on a membrane and is nourished by passing blood. Media: vessel width is controlled by hormones and nervous system. Between the smooth muscle cells are elastic fibres. The more elastic, the more flexible. The largest percentage of these types of arteries are near the heart, participating in the ventricular ejection function. Arteries out of muscle are away from the heart, such as the arteria brachialis. The thickness of the media depends on its job and position. Externa: connective tissue give the vessels their moveability. Blood vessels also nourish these blood vessels (vasa vasorum), and sit inside the arterial wall. They nourish the externa and media.

Arteriosclerosis of the vessels. Can affect the large and small vessels. When it affects the large vessels then the damage radiates from the heart outwards. It is the depositing of excess fat into the arteries. Various causes available. The smaller vessels have less elastic fibres and therefore are exhausted by any increase in workload. High blood pressure creates an increased workload on the arteries and the sclerosis radiates from the periphery inwards.

The veins are responsible for transporting oxygen poor blood back to the heart and work using low pressure. Their construction is similar to the arteries; however:

Intima: forms the venous valves which prevent blood backflow; they have two flaps. The valves are found in the superior and inferior vena cava, the portal vein system, kidney and cerebral veins. Media: same as the arteries but contain less pressure and therefore thinner walls. Externa: same as the arteries.

Veins have a large storage capacity, because of their flexibility and low pressure. They are the best reservoirs of blood. The active pumping of the heart has no effect on the blood in the venous system. So what sends the blood back to the heart? What helps it overcome gravity? The venous pump. The venous pump is made up of:

Muscle contraction and muscle movement is vitally important in venous flow. Breathing Active heart pump Stomach-intestinal peristalsis Vein-artery relationship: veins surround every artery, and when the heart activates the artery, this sends a ripple on effect to the veins.

Capillaries are where exchanges take place. They are about 1 mm in size. A red blood cell can swim through one. They connect the venules and arterioles. The capillaries are very thin and have a single layer of endothelium. The cells of the capillary build an endothel pipe.

The capillaries form a massive network in the body as there are many of them. Cells are nicely placed near the capillaries in the intercellular space. This space is filled with fluid. Substances exiting the capillaries swim through this fluid to the cells. Nice link here. There are three types of capillary:

Continuous endothelium: most common type; contains no breaks in the lining of the vessel. Consists of cells with nuclei and blood vessels running through the pipe. Around the cells is the basement membrane which holds the cells together. Along the lining there is a kind of mucous membrane called a glycocalyx, which is made up of sugars. This kind of endothelium is found in the muscles, brain and lungs. Fenestrated endothelium: contains pores all over the capillary, which act like windows, releasing substances out of the vessel via the process of diffusion. The glycocalyx which covers the pores is called a diaphragm. The diaphragm doesn’t cover the intercellular cleft. This kind of endothelium is found in areas of heavy capillary exchange, like in the intestinal villi, pancreas, hormone glands. Sinusoidal (discontinuous) endothelium: found in metabolically active organs, where a fast exchange is necessary, like liver, spleen, glomeruli of the kidneys, and bone marrow. These are the largest type of capillary, and have heaps of intercellular clefts, which make them leak. Sometimes missing some basement membrane.

Compression ratio in intercellular space ….

All arteries originate from the aorta. It begins in the left ventricle and ends at the 4th lumbar vertebrae, where it splits into the left and right iliac arteries. There are 3 parts of the aorta:

Ascending aorta Aortic arch Descending aorta Thoracic and abdominal aortas

The diaphragm separates the chest and the pelvic organs.

The first artery out of the ascending aorta is the coronary artery, which has a right and left coronary artery.

Out of the aortic arch stems 3 large vessels:

Brachiocephalic artery: splits into the right subclavian and right common carotis arteries. Left common carotid artery: splits into the interna and externa carotis arteries which travel to the brain and along the face. Left subclavian artery: this artery splits into the axillaris artery and the brachialis artery. The brachialis further splits into the lower arm arteries of the radialis and ulnaris.

The descending aorta is divided into the:

Thoracic aorta: out of this artery originates the posterior intercostal artery. Abdominal aorta: five important outflows start here, 1) celiac artery which later runs into the liver, spleen and stomach arteries; as well as 2) the superior mesenteric artery, 3) kidney artery, 4) testicular and ovarian arteries, and 5) the inferior mesenteric artery (this is where the aorta ends).

Most veins are close to the arteries. They benefit from the pump effect of the arteries. Most arteries have a corresponding vein and vice versa. The biggest veins are the superior and inferior vena cava. They transport blood back to the heart.

Superior vena cava: stems from the left and right brachiocephalic veins. Transports blood away from the head and arms to the heart. The brachiocephalic veins follow on from the subclavian and jugular veins. Inferior vena cava: stems from the left and right common iliac veins. They transport blood away from the legs and abdominal-pelvic area to the heart. Portal vein: transports blood from the viscera to the liver, it is about 5 cm long. Formed by the spleen and superior mesenteric vein.

Checking the circulatory system

When there is not enough blood pumped to the brain, because of arteriosclerosis, then a patient can feel: exhausted, dizzy, low on energy, headachy, experience sleep problems and tinnitus.

Skin colouring: if the patient has pale skin, pale eye lining, oral mucosa, but red lips, it is a sign of low blood pressure. Could also be caused by deep blood vessels which cannot be seen at the skin surface. If the kidneys are not working, then there can be a lot of fluid in the skin, which overshadows the blood vessels. Reddening of the skin is a sign of high blood pressure or blood disease. Cyanosis is a circulation problem, where there is not enough oxygen in the cells.

Auscultation: in a free flowing artery there are no noises to be heard (you can check this at the elbow). Arteriosclerosis causes noises in the blood circulation. A closed vessel also has no noise. So it can be deceiving. If the fat deposits have dissolved, then you can test this with a walking test.

Pulse: choose the radial artery, place your index and middle fingers on it for at least one minute. You can also try the carotid (check one at a time), abdominal (slightly to the left of the belly button), femoral (in the groin, only one at a time) and posterior tibial artery (between the ankle and achilles), and the dorsalis pedis artery (between first and second toe, dorsal side). Pulse can be affected by narrowed or closed arteries, and blood pressure. Pulse can give you info on frequency, regularity, hardiness, and size:

Frequency: the heart beat rate. Normal is between 60-80 bpm. Women and children have a faster rate. Also untrained persons. Regularity: are there any extra systole? Hardiness: if you press as hard as you can against the pulse, you can’t feel it anymore. If you can feel it, then the pulse has no hardiness. It tells you about the systolic value. High systolic = hard pulse / hypertension. Low systolic = weak pulse / hypotension. Size: this is the blood pressure amplitude, which is the difference between the systolic and diastolic values. Normal is 120/80. The amplitude is 40 mm Hg. High difference = hyperthyroidism and aortic valve failure, low difference = hypothyroidism and aortic valve stenosis.

Circulatory tests

Do you want to check your patient’s circulation? These tests are recommended:

Schellong test: test for low blood pressure. Check their pressure and pulse first while lying down (min 10 minutes). Then ask them to stand for 10 minutes. For those with no problems, there will be no increased pressure or pulse. Any drop in the systolic value will indicate hypotension, and the pulse will increase. If both diastolic and systolic decrease then there is a problem overall and not enough oxygen in the brain. Schellong test 2: climb up and down 25 steps. For those with no problems, the systolic value will increase by up to 80 mm Hg and the pulse by up to 30 bpm. Everything will return to normal after 2 minutes of rest. For those will hypotension, the pulse will race of 100 bpm, and there won’t be any return to normal values after rest. Ratschow test: checks for arterial problems in the legs. Lie on their back, lift their legs up, and rotate their feet for about 2-5 mins. One rotation per second. A healthy person can do this without any problems. Pain may occur in those with circulatory problems. You may need to stop the test. Let the person sit upright and dangle their legs from the bench. There should be reactive blood flow after 5-10 mins. There will be a delay for those who have problems. Is there any paleness in any part of the leg, foot, toes? Closed fist test: checks the arterial problems of the arms. Do the same as above, but this time raise the arms above the head and open and close their fists for about 60 times. Is there any paleness in any part of the arms, fingers, hands? Check for reactive circulation after dropping the arms. Walking test: 60/80 paces per minute, walk along a variety of pathways. How long can your patient walk without pain. Four different stages of pain. If the patient has pain in stages 3 and 4 (at rest), then don’t do the test.

Technology

Doppler ultrasound: soundwaves bounce back after hitting tissue. Can test circulatory behaviour of the arteries and veins. Angiograph: a contrast solution is injected and observed using an xray. Can check veins, arteries and lymph. Solution may cause an allergic reaction, so be prudent. Oscillograph: measures arterial pulsations. The higher the oscillation, the higher the blood pressure amplitude. Used to check small stenoses.

Disorders of the circulatory system

Hypotension: can be a primary symptom. Values are low if for women below 100/60 and men below 110/60. People with low blood pressure have a low risk of heart attack and stroke. Secondary symptoms can be caused by other diseases such as hypothyroidism, anterior pituitary gland failure, heart failure, adrenocortical failure, aortic valve stenosis. Symptoms: sweating, racing heart, dizziness, fainting, tiredness after waking, tinnitus, cold extremities, headaches. Treat the underlying cause. Particularly helpful are Kneipp treatments, physical activity, brush massage, contrast showers, herbal medicine.

Hypertension: there are three types - arterial, pulmonary and portal (no flow back to the heart from the liver). Also known as red (many patients have normal colouring even with high blood pressure), blue (cyanotic), white (kidney pressure, dark rings around their eyes, renal anemia or edema). Pressure is influenced by age. The higher the age, the higher the pressure. Primary and secondary causes. Primary: most cases are this essential kind. Secondary: renal (kidneys are most common cause, diastolic over 95 mm Hg), endocrinal (too many blood increasing hormones - cortisol, T3, T4, adrenaline, aldosterone, STH) and cardiovascular (arteriosclerosis, caused by loss of muscle cells and increased calcium deposits). Progress can be benign (slow, reacts well to treatment, organs can be damaged) or malign (diastolic 120 mm Hg). Any systolic increase over 200 mm Hg should be sent to a doctor because the organs can be damaged. Most symptoms occur when the organs start breaking down, and include: headaches, dizziness, tinnitus, restlessness, discomfort in heart, visual problems, breathing problems. Heart and kidneys are especially affected, such as left heart hypertrophy and eventual failure due to increased workload. The kidneys can develop stenosis in the vessels used to transport blood to the kidneys and also in the glomeruli. With no blood in the kidneys, there is a RAAS reaction and increased pressure which affects the entire body. The brain is also affected with undersupply of oxygen and nutrients to the brain cells leading to dementia or embolism. Eyes experience bleeding of the retina and leg arteries are closed.

Therapy: high blood pressure should be sent to a doctor for medication. Anything else can be treated by the HP. Learn to cope with stress. Be more physically active, get enough sleep, reduce weight.

Arterial disease

Arteriosclerosis: hardening and thickening of the arteries. Loss of elasticity. High blood pressure and fat content are causes. Smoking can contribute. Plaque can occur which is the buildup of calcium and fat deposits between the intima and media layers of the vessels. Vessels will narrow, pressure increases, and small sensitive vessels will die and be replaced by hardness. Increased risk of thrombosis too, as damage to the vessels causes blood platelet build up. Risk factors: fatty diet, smoking, high blood pressure, diabetes, hypothyroidism, age, men, lack of exercise, and the reduced amount of homocysteine in the blood. Homocysteine damages the endothelium and increases blood clotting. It increases when there is not enough vitamin B12, B6 and folic acid in the body. Usually it is broken down in a healthy body into methionine. Arteriosclerosis is often concentrated around the cerebral, carotid, cornary, aortic bifurcation and femoral and tibial arteries. The main problem with arteriosclerosis is tissue death and hardening of vessels.

The consequences of arteriosclerosis include: peripheral arterial occlusive disease (90% legs affected), acute arterial occlusive disease (heart, brain, legs), arteriosclerotic aneurysm (lifethreatening bleeding and rupture, saggy vessel walls), coronary heart disease and stroke.

Diagnosis includes: hard radial pulse, noises, pulse differences, skin colour change and changes to interior surface of the eye.

Symptoms depend on extent, severity, speed and location. Multiple organs are affected. Two stages: beginning and advanced. Beginning includes: cyanosis, tingling in legs, tire easily. Advanced: wounds don’t heal, fungal infection, pain while resting, hypersensitivity to stimuli, muscle pain while walking, which is relieved by rest (intermittent claudication). Oxygen is needed during movement. Narrow vessels cause pain during circulation to get oxygen around the body. This is relieved by rest or standing (less need for oxygen).

Terminal arteries: are the arteries that supply a specific area. If this artery is closed, the supply is shut down and the area dies. However, each main artery has collateral arteries which branch off. When an area dies, the collaterals receive a greater workload and they will get stronger. They usually take over the supply to the specific area. Terminal arteries feed the brain, lungs, eyes, kidneys and spleen.

Therapy: try to increase activity, reduce weight, stop smoking, boost diet,

Atheromatosis: this is when the vessel walls build up with fat deposits only. Arteriosclerosis is the same but in addition, the muscle cells die. Atheromatosis can be healed with lowered blood fat content.

Embolism: is when a substance gets stuck and blocks a blood vessel. The substance can be a blood clot, fat particle, air, or tumor fragments. The difference between embolism and thrombosis is that thrombosis is when a blood clot attaches to the wall of a vessel. Normally found in veins, but also in arteriosclerotic affected arteries.

Cause: an embolus from an artery or left heart half. Embolus can develop from a thrombus which has been caused by a heart attack or bacterial endocarditis.

Origin: arterial embolism stems from the left heart half or an artery. Pulmonary embolism stems from the right heart half or vein. An embolus can also come from a vein and enter the left heart half and block an artery.

Symptoms include: cerebral embolism which leads to stroke, mesenteric embolism which leads to colic like problems, and arterial embolism which affects the legs, can lead to gangrene and lack of feeling, coldness, no circulation, etc.

Therapy: send the patient to emergency. Medication will try to dissolve the thrombus. If this cannot be done, then heart bypass or similar.

Winiwarter-Buerger Disease: the intima of small or medium extremity arteries are affected. Affects men but the % of women is increasing due to the pill and smoking. Smoking is mostly the cause. Thromboses lead to arterial closure. The difference to arteriosclerosis is that larger arteries are affected and mostly the legs, whereas in this disease the hands and feet are affected.

Symptoms: starts in the distal vessels of the extremities, develops into gangrene, but first there is coldness, numbness, burning, tingling and also instances of Morbus Raynaud and intermittent claudication. Pain in the foot can occur, which is misdiagnosed, which develops into ischemia, ulceration and gangrene. If there is phlebitis (inflammation of the veins), then edema and cyanosis can develop.

Diagnosis: no radialis pulse in the foot, change in colour, cyanosis, segmental stenosis of affected artery.

Prognosis: as the organs are not affected, there is no severe risk. If the smoker does not quit, then the disease progresses and amputation may be required.

Therapy: smoking ban. Protect extremities against cold, pressure, injury. Women to stop taking the pill. Physical training can reactivate the collateral arteries. Severe form: send patient to a clinic. Light form: walking is the best therapy and naturopathic remedies and also bandaging of the extremities.

Vasculitis: inflammation of the blood vessels. Caused by immune disease.

Symptoms: Different vessels can be affected, and therefore different symptoms show up.

Panarteritis nodosa: rheumatic disease, middle aged men, small and medium arteries affected, lead to closure and aneurysm, organs are affected, fever, weight loss, fatigue and cachexia (wasting syndrome).

Wegener granulomatosis: middle aged men, inflammation of the upper respiratory vessels, can affect the lungs and kidneys.

Horton syndrome: women over 50, inflammation of superficial temporal artery, artery is swollen and thick, one sided headaches, risk of blindness, and stroke if cerebral vessels affected.

Henoch Schoelein Purpura: preschool kids, result of infection, medication or food, bleeding in skin, small spotted bleeding is petechia, and blemish bleeding is purpura. Fever, joint and stomach pain, intestinal bleeding and glomerulonephritis.

Functional circulatory disorder

Functional diseases are different to organic diseases. The organ is not physically changed. Only the function of the organ is affected.

Morbus Raynaud: vessel cramps, not enough supply to the fingers, one or all fingers affected (but not thumb), 80% of young women affected.

Primary: cause unknown, harmless, caused by vibration, cold, stress. After cramping, the blood returns to the fingers.

Secondary: result of sclerodermia, arteriosclerosis, or other like smoking, lupus erythromatosus, etc. Tissue is neglected and can die. More common type.

Symptoms: 10-20 mins, paleness in fingers, cramping, cyanosis of tissue, pain as blood circulates again. Pain can be severe.

Diagnosis: pulse is weak in affected area.

Therapy: avoid cold, circulatory training, bandages, skin brushing, water treatment, temperature, etc.

Migraine: one sided severe headache, with vomiting and nausea, visual and neurological problems.

Simple: without aura, no neurological complaints, but vomiting, nausea, hypersensitivity to light and sound.

Classic: with aura, neurological complaints before migraine.

Cause: not known, change in weather, mental stress, food, cervical spine changes, eating and sleeping is unrhythmic, disorders of internal secretions from gall and liver, oral contraceptive, menstruation cycle due to drop in estrogen

Symptoms: medication given in conventional medicine which leads to dependency; naturopathic medicine finds the cause of the symptoms and patients can feel worse before feeling better.

There are many reasons why a headache develops. Find out what the trigger is and treat that cause.

Congenital Vessel Deformation

Morbus Osler: skin, mucous membrane and inner organs affected. Expansion of small vessels (spider veins). Tangled blood vessels (angiomes).

Cause: mutation of the chromosome. Appears around 40 years of age. Nose bleeds, blood in stool, urine, coughing and skin. Also deformed vessels in the organs can lead to bleeding.

Venous diseases

Varicosis: The inflammation of the veins. Varice and varicosis are two different things. Varice is the widening of the vein. Vein can be curled or knotted. Place specific. Can also affect the artery and lymph. The varicosis is the presence of many varices in the legs. Very popular and affects women more than men.

Cause: venous valve failure, and congenital connective tissue weakness. Sitting, standing, obesity and pregnancy.

Types: primary - this is inherited - and secondary - the result of a venous disease, mostly caused by deep vein thrombosis.

Process: deep veins receive blood from the superficial veins. They are connected by perforans veins. But despite there being more pressure, the deep veins cannot send the blood to the superficial veins due to a defect of the venous valves. The veins cannot handle the pressure, so they blow out.

Classification: 1) spider veins - small veins that expand after a deep vein valve leaks, a cosmetic problem, not an illness, can become cyanotic ; 2) reticular varicosis - affected veins lie deep under the skin; 3) trunk varicosis - saphenous veins affected in the leg, perforating veins also affected.

Diagnosis: palpation and inspection, patient must stand, localised venous explosion, Perthes and Trendelenburg tests can be done, and Doppler Ultrasound test.

Perthes test: checks penetrability of the perforating and deep veins, apply tourniquet above affected veins, patient stands, walks around, if the veins empty, then it is a healthy sign.

Trendelenburg test: great saphenous vein tested, patient lies down, raises leg 90 degrees, then tourniquet applied where great saphenous vein moves into minor saphenous vein, then patient stands up. If vein is intact, there will be no filling of blood or only slowly into the great saphenous vein, from bottom to top. If perforating vein helps varicose veins to fill up, then the test is positive. If after the tourniquet is removed the great saphenous vein is coiled, it is a double positive.

Symptoms: light means no pain, sometimes sensitive; heavy means there is pain, swelling, and heaviness, especially night cramps.

Complications: rupture and bleeding, skin changes, thrombophlebitis, lower leg ulcers.

Therapy: walking and putting one’s feet up, hydrotherapy helps alot, compression socks while standing, witchhazel and chestnut herbal medicine. Conventional medicine uses laser surgery, surgical removal, sclerotherapy.

Thrombophlebitis: the inflammation of the veins with thrombus formation. Important to differentiate between superificial and deep vein versions.

Thrombus: is a blood clot that attaches to a vessel wall narrowed by arteriosclerosis. Can cause complete or partial closure of the vein or artery.

Embolus: is a blood clot or fat particle or air bubble or tumor fragment that has detached from a vessel wall and blocks a vein or artery.

Types: 1) separation thrombus - thrombocytes gather at the site of endothelium injury, fibrin causes them to be white; 2) agglutinative thrombus - thrombus develops where blood flow is slow or sluggish, can detach and become an embolus, erythrocytes and leucocytes get stuck here and give a red colouring; 3) mixed thrombus - most thrombus are a mix of the two above.

Cause: three factors cause thrombus build up - 1) endothelium injury caused by smoking; 2) increased clumping tendency caused by an increase in all blood cells or only some; 3) slowed blood flow or stasis. Other factors include obesity, vascular inflammation, hormonal changes, lack of movement, cancer, operations and varicose veins.

Body’s reaction: tries to break down the clotting with plasminogen, which needs to change into plasmin so it can break down the fibrin. Vessel scarring after the inflammation can lead to venous valve failure. This leads to thrombophlebitis and the cycle begins. Varicose veins help further formation of thrombi, which causes more stasis and so on.

Check: if the veins are swelling, painful to touch and if any edema is building up (deep veins are mostly at work).

Therapy: if the venous valves are affected, the damage is irreversible. But treatment can help. Raise the legs, go out and walk, drink in fresh air. Anti inflammatory compress helps. Leeches help to purify blood, reduce congestion and more. Hirudin is released by the leeches which helps reduce stasis. Wear compression socks of class 2 or 3. If risk of embolus don’t use therapy.

Phlebothrombosis: is deep vein thrombosis. Can develop into pulmonary embolism and chronic venous failure. Left leg and abdominal veins mostly affected because of the bottleneck where the iliac vein and artery cross over.

Cause: stasis, tendency to coagulate and endothelium injury. Sometimes the arm is affected in male athletes due to heavy lifting and movement.

Symptoms: extremities feel heavy and tense, and painful along affected vein. Fever, cramps and unwell feeling. Thrombus can dislodge after 3-5 days. Symptom free at beginning, only diagnosed when there is pulmonary embolism. Later stages there is cyanosis, swelling and overwarm feeling.

Danger: lung embolism within 3-5 days. After danger dissipates. Chronic vein insufficiency is another risk. Needs to wear compression socks to reduce this risk.

Diagnosis: patient to stand. Measure circumference of legs and compare them.

Payr’s test: pressure test of inside sole, test both feet and ask patient if affected foot is more sensitive.

Homan’s test: dorsiflexion test, bend bridge back to shin, is calf muscle painful?

Mayer’s test: calf muscle pain. Apply pressure to calf muscle against shin bone.

Lowenburg’s sign: blood pressure cuff around calf muscle, and pump slowly. In the case of phlebothrombosis pain will be felt at low pressure.

Be aware that any of these tests could dislodge the thrombus. If you suspect anything, your patient should stay lying on the bench and an ambulance should be called for.

Therapy: avoid pulmonary embolism, back flow of veins to be improved, thrombus controlled using compression socks, heparin is given to avoid coagulation, thrombolysis should be performed and later surgery if needed.

Chronic venous insufficiency: venous related drainage problem, thanks to long standing primary or secondary varicosis. Two types available - deep and superficial.

Diagnosis: backlog of blood, stuck in large and small venous vessels, capillaries cannot absorb intercellular fluid, edema is a result, lymph system has to work harder, increased fluid can eventually led to hardening of the skin and tissue, cells cannot be nourished properly, tissue damage and ulceration.

Stages: three stages - 1) cells and skin not affected, signs of varicosis; 2) varicosis with malnourishment and congestion, skin changes, eczema, induration, discolouring; 3) ankle ulceration.

Symptoms: calf and ankle feel heavy, worsens if sitting or standing all day, edema is light, but later becomes permanent with induration.

Therapy: avoid sitting and standing for long periods, reduce weight, stop smoking, compression socks, movement and activity. Ulcers can be treated well when the blood flows normally. Use camomile baths, with hydrocolloid bandages for wet ulcers and hydrogels used for dry ulcers. White cabbage leaf compress is very effective. Leave the cracked leaf on the wound for 12 hours.