War Surgery and Medicine
FIRST WORLD WAR
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.