War Surgery and Medicine
There was a tendency to develop special clinics for this purpose in the base hospitals, just as there are such clinics in civilian hospitals. An enthusiastic surgeon can attract a big clientele in civil life, and it can be readily understood that it was still easier to do so in the army. The out-patient visit to the hospital could be a welcome break in the monotony of military camp life, and if a period of excused duty was also available, the outing became still more attractive. A symptomless varicosity can thus become a useful abnormality to the soldier.
This condition only arose in a minor degree in 2 NZEF, but in some of the British hospitals it became a matter of importance. Investigation carried out showed that men had been attending the clinics regularly for months, even up to periods of well over a year, with the consequent man wastage. Still more serious was the effect of the repeated injections. In many cases gradual obliteration of the deeper veins had occurred, with impairment to the circulation of the limb and still more serious effects on function. In some cases even amputation had finally resulted. The result of the investigation was the abolition of the clinics and a complete re-orientation of viewpoint as to the management of these cases in the army, and I am sure this viewpoint will spread to civilian practice.
It was finally realised that the well-developed case with congenital dilatation of the saphenous vein, associated with incompetent valves, must have operative treatment to prevent gravitational loading and swelling of the veins, and that the results on the whole were good.
On the other hand, the indiscriminate injecting of veins was often unwarranted, had little effect in cases where the saphenous system was at fault, and was associated with grave danger of blocking the deep veins and so causing dangerous interference with the vascular supply of the limb. The majority of smaller varicosities give rise to no symptoms and are no disability, the less notice taken of them the better, physically and psychologically. At the beginning of the war varicose veins led to a considerable loss of manpower through time spent on treatment both in hospital, page 422 and especially in varicose clinics and out-patients departments. With a fresh orientation to this problem and the discontinuance of clinics, the problem became much less important.
A review of the problem in 2 NZEF was carried out in March 1943 by the consultant surgeon.
There had been 237 operations performed and 101 injections given for varicose veins in the operating theatres in 2 NZEF. The operations had consisted almost entirely of the Trendelenberg operation, with injections of the main vein in the thigh as an added measure in a large number of cases. (There might have been injections given apart from those recorded in the operation book.)
Of these patients treated by operation or injection in 2 NZEF only three were invalided to New Zealand (one with involvement of deep veins), and only four others down-graded. Apart from this group only eight cases were invalided to New Zealand with disability of varicose veins (though in four of the cases other marked disabilities were present) and eleven others down-graded for the disability, mostly men near or over the age of forty years.
This showed that there had not been any serious disturbance with manpower in the 2 NZEF and that there had been little or no serious after-effects following injections, such as had been experienced in the RAMC. It showed that the majority of cases invalided to New Zealand and of the graded men consisted of men of the older age group, and that frequently other disabilities were associated with the veins, as one might expect.
Only 11 men had been sent back to New Zealand and only 15 cases were down-graded—a very small number in such a large force. The problem was not therefore a serious one if handled conservatively.
There were seven more cases invalided back to New Zealand later from 2 NZEF: two of these had thrombosis of the deep femoral veins not associated with varicose veins; two cases had thrombosis of deep veins, one with definite oedema of the leg and foot; another had varicose veins with oedema of the leg; another had bilateral varicose veins with ulceration; another had bilateral varicose veins and internal derangement of the knee.
It is obvious that all these cases, except the one complicated by a disability of the knee, had involvement of the deep veins. Two of them had femoral thrombosis not associated with varicosity, and another two were probably of the same nature as no reference is made to varicosity. This means that no case of varicose veins without serious damage to the deep veins was invalided back to page 423 New Zealand after March 1943. In addition, the number of men down-graded with varicose veins in 2 NZEF at any one time was under ten.
In December 1943 the Consultant Surgeon 2 NZEF made the following observations, which give a clear indication of the opinion at that period after nearly four years' experience of the management of these cases:
The disability produced by varicose veins is generally very slight, as shown by soldiers with a severe degree of varicosity, carrying on in the line for long periods.
If producing marked symptoms, cases with incompetency of the main valves of the saphenous veins should be referred to hospital for Trendelenberg operation, with or without sclerosing injection at the time of operation.
Cases with competent valves and no dilatation of the main saphenous veins should, except in very exceptional cases, have no treatment, and carry on their full duties.
Cases with obstruction of the deep veins generally require grading and should not on any account have any operative or injection treatment.
The injection treatment of varicose veins is to be deprecated in the treatment of soldiers, except when associated with operation, and very exceptionally under (c), and even then, local removal of a varicose clump may be preferable.
Serious disability can be caused by repeated injections of sclerosing fluids.
Early in 1945 a British Army medical bulletin gave expression to opinions identical with our own, calling attention to the damage inflicted by unnecessary or over-injection and advising operative treatment when any real disability was present.