Varicose veins
MEDICINE JOHN ROWAN WILSON
One of the enemies of a good community medical service is the melodramatic approach. Because medicine is an exciting subject going through a period of spectacular technical de- velopment there is a tendency to believe that its most important aspects are those concerned with research and innovation and that ordinary straightforward treatment can take care of itself. Attention is constantly focused, not on the prosaic conditions which trouble the large majority of the population, but on the elaborate and the extraordinary. Artificial hearts and transplanted kidneys are news. Varicose veins are not.
Yet the truth is that very few of us are ever going to benefit from transplantation of organs or cardiac reconstruction. On the other hand, the chances are that something like one reader in five of this column is suffering from varicose veins which are a significant impedi- ment to his comfort and efficiency. What is more, he is likely to be stuck with them for some considerable time, since the waiting list for operative treatment tends in many hospitals to be up to two years. The patient may be par- doned for wondering whether this represents adequate value for the £1,000 million a year he pays out for the Health Service.
One must also face the fact that the treat- ment he finally receives is likely to be less than ideal. When I was a young doctor train- ing to be a surgeon, one of the first responsi- bilities delegated to me was the varicose vein clinic. Here I was confronted with an intimi- dating array of men and women of all ages, displaying every conceivable type of varicosity. There was a general rule in those days that if the veins were confined to that part of the leg below the knee you injected them; if they extended above the knee as well, injections were a waste of time and you put them on the waiting list for operation. A year or so later you might see them again when their turn came up. They would be put on the end of the operating list. The surgeon would exhaust him- self with a four-hour tussle against a cancer of the stomach, a gall bladder and the removal of stones from a kidney. The varicose vein cases would be left to the registrar.
There is nothing wrong with a registrar, even one who has had most of the heart taken out of him by standing for four hours holding retractors at a temperature of 70° Fahrenheit. Many of them are just as good as their chiefs and do a wonderful job. But it is surely un- desirable that certain operations should always be done by the most junior person under the least favourable circumstances. One cannot place the blame for this on the consultants. Because the demand for treatment is greater than the supply they are reduced inevitably to thinking in terms of priorities. And these priorities are necessarily worked out in terms of the degree of illness of an individual patient rather than the magnitude of the social problem.
Why are varicose veins so common? The most likely reason is that they are part of the price we have to pay for adopting the erect posture, which places a considerable gravi- tational strain on the veins of the leg. Added to this, a considerable proportion of people suffer from a weakness of the valves of the big veins, an abnormality which tends to run in families. When the patient stands for any length of time, the gravitational pressure goes up, the weak valves give way, and blood flows out of the deep veins of the leg to dilate the veins just under the skin. The force which pushes the venous blood back to the heart is muscular contraction, and since there aren't any muscles just under the skin, the veins dilate and stay dilated. This causes aching and swelling of the ankles on long standing and can lead to worse complications such as ulcers; or even infection of the vein itself, which is known as phlebitis.
Varicose veins can be effectively cured. In- jection of an irritant fluid can cause a clot which effectively blocks the vein. But this is effective only when there is no great pressure from the deep veins and its usefulness is con- fined to small groups on the lower leg. By far the majority of patients need the standard operation, which is based on the principle of dividing all communication between the super- ficial veins and the high-pressure deep system, and of removing the most dilated and obtru- sive varicosities. This is not a difficult opera- tion, but it requires a certain degree of knowledge of normal and abnormal anatomy, and a great deal of care. Done properly, it is very time-consuming. And the time is simply not available.
What is the answer to this? As far as the Health Service is concerned, it is more surgeons and more operating theatres, not just in the big centres but all over the country. It is in Crumblethorpe General that the waiting lists are longest, the results of surgery worst, the follow-up of patients least effective. It is noticeable that in heavily staffed teaching centres so-called minor conditions of this kind are treated with far greater seriousness than they are in the busier and less advanced pro- vincial hospitals.
Judging by past experience, one cannot be very optimistic about the solution of this problem within the Health Service, at least not in the near future. In the meantime, there is really only one thing the sufferer can do, if he is not satisfied with the situation I have outlined. That is to put his hand in his pocket and have private treatment, preferably from a vascular surgeon or one who has taken the trouble to make himself a specialist in this kind of operation. In the nursing homes, vari- cose vein operations are regarded as extremely important. One eminent vascular surgeon was heard to say to his registrar, 'When you're a consultant, my boy, you make your reputation from the arteries. But this'—he tapped the bonnet of his Rolls-Royce—'comes out of the -Mine
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