War Surgery and Medicine
CHAPTER 22 — Varicose Veins
FIRST WORLD WAR
DURING the First World War varicose veins did not loom largely as a disability in 1 NZEF, in spite of the fact that the soldier at that period was a ‘foot-slogger’, having to march whenever his unit changed its position. The prolonged periods in trenches, and very often wet and muddy trenches, contributed to any leg disability. Treatment at that time consisted in operative removal of the affected veins with ligature of the internal saphenous vein at the saphenous opening. Often the main vein was removed by a stripper or pulled out by means of a probe. The operations were prolonged and tedious. The results were, on the whole, satisfactory, but some recurrences inevitably occurred. The severe cases, with involvement of the deep veins, ulceration and eczema, were uncommon in the soldier.
Between the wars intravenous injections of various sclerosing agents were introduced in the treatment of varicosities and, largely because of their simplicity and relative non-interference with the normal activity of the patient, became very popular. They were specially suitable for the smaller localised bunches of dilated veins in the leg. The tedious operative procedures were to a great extent discarded in favour of the injections. The simplicity of the injections tended to encourage patients to have small symptomless varicosities dealt with, partly for the mere sake of appearance. Repeated injections became quite common, and at times the deep veins were damaged. It became clear, however, that in the case of incompetence of the main valves with dilatation of the main saphenous trunk injections were of no avail. The Trendelenberg operation became the standard method of treatment of these cases, with injections as an adjunct to deal with the localised varicosities, and also to sclerose the main vein after ligature had been carried out.
There was a tendency to simplify the Trendelenberg technique and to employ local anaesthesia for its performance. The treatment in the main was looked upon as a minor matter to be carried out as an ambulatory measure in the consulting room.page 419
In the code of instructions issued to medical boards, regulations with regard to varicose veins were drawn up as follows:
No varix, unless very slight, should be placed in Grade I until cured. More serious cases will be placed in Grade II or III, according to the disability entailed. Cases of chronic ulceration or thin scars of healed ulcers associated with varicose veins should not be placed higher than Grade III. Cases with evidence of recurrent phlebitis should be placed in Grade IV.
The regulation that ‘No varix, unless very slight, should be placed in Grade I until cured’, must be taken to mean that every prominent vein had to be looked upon as a disability and that till treatment had been carried out the man had to be down-graded. Refusal of treatment necessarily meant escape from overseas service. Boards were encouraged to look for enlarged veins, and it can readily be understood that busy practitioners, with possibly little experience of the problems, were inclined to pay too much attention to the veins. The recruit naturally had his attention drawn to the slight enlargement of the veins and thereby incalculable psychological harm was done. A mountain was made out of a molehill.
The only reviews of gradings carried out after the original board were of the Grade IV cases, so that if a recruit had been placed as Grade III because of varicose veins he was lost to the army forever, and many men of fine physique were undoubtedly in this category.
The degree of disability brought about by varicose veins was difficult to assess, and the presence of dilated veins might denote no disability whatever. The practitioner, accustomed to treating minor degrees of varicosity, and often merely for beautifying purposes, would tend to lay too much stress on the condition. It was common knowledge that vigorous men, showing prowess in athletics of all kinds, were turned down on enlistment because of varicose veins. There was undue stress laid on minor anatomical abnormalities and insufficient attention paid to the all-important question of function. It was impossible for the large number of boards, operating throughout the length and breadth of New Zealand, to develop suddenly a military outlook and to shed their outlook as civilian practitioners. There was also little elasticity permissible, as is rendered possible under the Pulheems system.
Cases with moderate degrees of varicose veins were graded as temporarily unfit and referred to hospitals or their own practitioners for treatment so as to bring them up to Grade I.page 420
It was clearly laid down, however, that remedial treatment should only be given to recruits who could be made fit for full duty in one month. Two injections only were to be given, and those below the knee, and operation was not to be carried out. In spite of recommendations to lengthen the period of treatment and enlarge its scope, particularly by operation, the original regulations were adhered to. The whole question was thereby given a wrong bias, one quite contrary to army experience. Dr D. Macdonald Wilson stated that many keen territorials graded II for varicose veins were mobilised when Japan entered the war, underwent rigorous training, and having had no symptoms were up-graded and sent overseas.
Middle East Force
The heat and debilitating conditions associated with camp life in Egypt tended to aggravate any disability due to varicose veins, especially if there was any tendency to the development of eczema.
Treatment: Men were referred to the New Zealand hospitals for both in-patient and out-patient treatment. From Base cases were referred to the hospital at Helwan. The more marked cases were admitted, but the minor cases were treated by injection as out-patients, and the injections repeated till satisfactory relief had been obtained.
Operation: The operative treatment almost universally carried out was the Trendelenberg operation, consisting of ligature of the internal saphenous and its branches at the saphenous opening, or occasionally, ligature of the external saphenous, at the lower part of the popliteal space.
There was a tendency to carry out this seemingly minor operation under local anaesthesia, and articles had been written describing this procedure. The result, perhaps inevitable, of this seeming simplification was frequently an incomplete and unsatisfactory operation. The vein was tied well below the saphenous opening and the smaller branches not tied at all, with the result that the condition was unrelieved. This led to serious administrative and psychological difficulties. It had to be explained to the soldier that a repetition of the operation was necessary for the cure of the condition and consent had to be obtained from him. The operation also tended to get an undeservedly bad name amongst the men. This skimping of operative techniques by unskilled or irresponsible operators—I purposely do not use the word ‘surgeon’ —was even more serious in its effects in the army than in civilian practice. In conjunction with the Trendelenberg procedure, injection of sclerosing solution was frequently made into the distal portion of the saphenous vein at the site of the operation.page 421
Injections: Apart from the injection of the main vein at the time of operation, as mentioned above, injections were given into localised varicosities involving branches of the main veins. These were usually given in an out-patient clinic, and repeated as considered advisable.
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.
Experience of the War Pensions Department
A great many men who had injection treatment had recurrences later and the same applied to many who had the Trendelenberg operations. If recommended by an examiner, operation and injections were offered to, but not pressed upon, the pensioner. Usually he declined with a statement that he or his friends had undergone previous treatment without success. Dr D. Macdonald Wilson considered that the profession as a whole was far too optimistic as to the results of treatment.
Recommendations as to the Future
Varicose veins do not as a rule cause any serious disability and their presence should be ignored unless definite signs or symptoms do arise.
Grossly dilated saphenous veins, associated with a congenital inefficiency of the normal valvular action, which give rise page 424 to symptoms, should be treated by an efficient Trendelenberg operation carried out under general anaesthesia, and with the tying off of all the venous branches at the saphenous opening. Partial operations are useless. The sites of ligature, other than at the saphenous opening, should be determined by tests beforehand.
Injections in cases such as the above are useless without operation. Injections generally are fraught with the grave danger of blocking the deep venous circulation— a disastrous condition. Any repetition of injections should seldom, if ever, be carried out. Beautifying injections are quite out of place in the army.
Before any treatment is undertaken the presence of thrombosis of the deep veins must be ruled out.
When deep thrombosis has taken place, varicose ulcers and eczema are prone to develop, and naturally all such cases are useless in the army and should be discharged.
It was agreed early in the war that operative treatment for varicocele was unnecessary and undesirable in the army. Operation was therefore banned overseas. It was remarkable how little was seen or heard of varicocele in the 2 NZEF, which went to prove that there was very little real disability associated with the condition. Operation undoubtedly also was associated with some danger of atrophy of the testes and certainly with the exaggeration of any psychoneurosis, which was so frequently associated with the condition.