- Email: [email protected]
Varicose Veins
391
in all his varicose-vein patients; and he reports that in a seventh of all cases (a rather higher proportion than that mentioned by other investigators 45 -) this vein was abnormal. Moreover, as more and more of these veins are explored, " two other features are emerging: first, because of the variability of its termination, there may be difficulty in exposing its ending, except with a large incision; and second, in arteries in cases of lung disease associated with finger some patients, after it has been divided flush at its clubbing. In patients with finger clubbing differential union with the popliteal vein, and its trunk stripped out catheterisation of lobar branches of the pulmonary artery at the ankle, considerable varices remain ". In a passage has shown that the oxygen content of blood samples of wit and wisdom HENRY 4’ has described the crucial taken from unwedged catheter positions in a branch close region where the short saphenous vein-the blue to a tumour or bronchiectatic lobe is more highly to the midline the guide "-joins popliteal vein; but arterialised than blood obtained in similar positions from the first knife-strokes in his bloodless approach are combranches supplying normal lobes. 38 This suggests an monly a signal for torrential haemorrhage. The fault increased bronchial arterial blood-flow, entering the lies not with HENRY; for the " normal " venous pattern pulmonary artery bed proximal to the capillaries in of the limbs is but a point of departure to almost infinite diseased parts of the lung. FISHMAN et al.,39 using a variations. KOSINSKI 48 gave a good account of the most modified Bloomer technique,4° recorded abnormally important of them in 1926; and, whereas " until high flows in the bronchial arteries of patients with recently these were seldom found because they were idiopathic clubbing of the fingers. The significance of seldom looked for ... now that a full dissection of the high bronchial arterial flow through precapillary broncho- popliteal space is being made, they are being increaspulmonary anastomoses in patients with bilateral club- ingly recognised ". 4a But such a full dissection demands bing or osteoarthropathy is undecided. HALL 41 has time; and time it seldom gets. Usually the surgeon, lately suggested that clubbing is associated with reduced having dealt with the long (internal) saphenous vein, ferritin passing unchanged through pulmonary arterio- has two alternatives. He can either turn the patient on his face, rescrub, and retowel; or, with the aid of sandvenous shunts; while DOYLE 42 believes that hyperis an oedema bags, spotlights, and elastic bandages, he can insinuate trophic pulmonary osteoarthropathy resulting from excessive stimulation of volume receptors a scalpel and an artery-forceps or two where textbooks in the pulmonary artery. The evidence for these say the short saphenous joins the popliteal vein. Unfortunately the most effective surgical therapy is hypotheses is by no means complete; but the discrepancy between them underlines the need to regard also the most difficult. The original high ligation of the these two disorders as separate entities. long saphenous vein and its branches (whether or not supplemented by a course of injections) had an early recurrence-rate of over 50% 48-50; but it was simple, safe, Varicose Veins OPINION on the management of varicose veins is and capable of being standarised. The gradual realisasharply divided. Some surgeons do not believe that tion since the 1930s that varicosities often develop from much can usefully be done, so content themselves with sources other than an incompetent saphenofemoral a brief patching-up operation or pass the patient on to junction (coinciding with the introduction of stripping, a junior colleague. To other surgeons varicose veins venography, and other technical advances) has inaugurated a more rational therapeutic era but has also created are a mechanical problem, pure though complex, that new problems.51-53 Previously patients suspected of can be solved-given knowledge, skill, care and time. How much benefit surgery can really provide is unlikely having deep-vein thrombosis were excluded from surto be known until some of the attention now concengical treatment. But LINTON, DE TAKATS, and others trated on flow mechanics is diverted to the underlying began to ask whether patent but incompetent deep veins, pathology of the veins-and perhaps of all vessels. On far from conveying blood, did not aggravate venous stasis; the other hand, even if complete and permanent cure LINTON 54 55 and his group went so far as to advocate cannot yet be guaranteed, operation can result in great ligation of the femoral vein in order to prevent reflux and long-lasting symptomatic relief. through incompetent perforators into superficial chanDODD 43 has done a valuable service in once again nels, and BAUER 56 applied the same principle at the drawing attention to the short (external) saphenous vein. popliteal level. Results were not altogether encouragSince 1953, stimulated by the work of CocItETT and 45. Foote, R. R. Varicose Veins. London, 1949. 46. de Takats, C. Vascular Surgery. Philadelphia and London, 1959. JONES,!4 he has made a special study of the short 47. Henry, A. K. Extensile Exposure applied to Limb Surgery. Edinburgh,
MENDLOWITZ 36 has suggested that the key to the phenomenon of clubbing lies in the pulmonary circulation. Whilst this concept does not account for unilateral or unidigital clubbing, there is evidence of a left-toright shunt through the lung in patients with bilateral clubbing. By injection studies at necropsy, CUDKOWICZ and ARMSTRONG 37 detected precapillary anastomoses between the bronchial arteries and peripheral pulmonary
saphenous system
"
36. Mendlowitz, M. The Digital Circulation; p. 125. New York, 1954. 37. Cudkowicz, L., Armstrong, J. B. Brit. J. Tuberc. 1953, 47, 227. 38. Cudkowicz, L., Wraith, D. Thorax, 1957, 12, 313. 39. Fishman, A. P., Turino, G. M., Brandfonbrener, A., Himmelstein, A. J. clin. Invest. 1958, 37, 1071. 40. Bloomer, W. E., Harrison, W., Lindskog, G. E., Liebow, A. A. Amer. 41. 42. 43. 44.
J. Physiol. 1949, 157, 317. Hall, G. H. Lancet, 1959, i, 750; ibid. p. 1151. Doyle, L. ibid. pp. 989, 1253. Dodd, E. Brit. J. Surg. 1959, 46, 520. Cockett, F. B., Jones, D. E. E. Lancet, 1953, i,
17.
1945. 48. Kosinski, C. J. Anat., Lond. 1926, 60, 131. 49. de Takats, G. J. Amer. med. Ass. 1930, 94, 1194. 50. Orbach, E. J. in Diagnosis and Treatment of Vascular Disorders (edited by S. S. Samuels). Baltimore, 1956. 51. de Takats, G. J. Amer. med. Ass. 1931, 96. 1111. 52. Dodd, H., Cockett, F. B. The Pathology and Surgery of Veins of the Lower Limbs. Edinburgh, 1956. 53. Myers, T. T. J. Amer. med. Ass. 1957, 163, 87. 54. Linton, R. R. Ann. Surg. 1938, 107, 582. 55. Lmton, R. R. ibid. 1953, 138, 415. 56. Bauer, G. Angiology, 1955, 6, 169.
392 of confinement in an institution are increasingly evident, there are often real advantages, both for the mother and her child, if she " lies in " at home. Provided domestic surgeons have come to the conclusion that bad veins help can be arranged, many mothers could and should are better than no veins; and the accurate localisation be sent home by ambulance 24-28 hours after delivery, and ligation of all incompetent perforators (what DE before their milk comes in. The objection always raised TAKATS 46 calls the " third era " in the surgical treatto this suggestion is that midwives do not like " secondment of varicose veins) seems to offer a reasonable hand " cases; and in this they are not unreasonable, compromise. Reasonable, and successful, too; but though sometimes the objection may have to be overtechnically not easy. To explore the gastrocnemial veins, ruled. But once the principle of immediate return home the veins of the biceps and semimembranosus, the calf were accepted, it should not be impossible to organise a communicating veins, as well as the short saphenous maternity service in which the midwives or general pracvein 43 is no task for the beginner or even for the master titioners took their own patients to hospital, delivered them there with whatever assistance might be needed, and in a hurry. Under favourable conditions venous dissections are continued to attend them on their return home. These suggestions can no longer be dismissed as the ideal exercise for young surgeons; but conditions, In various forms they have already been impracticable. far from being favourable, are usually appalling. To tried and have worked. The present system in London, the harassed registrar to " polish off " a couple on the other hand, is expect not working in a way that clearly of " v.v.s " at the end of a long operation list is bad we can continue to accept.
ing. Uncertainty still prevails about where, when, and what can be ligated with impunity 46 5%-so; but most
enough; but " v.v." casualty theatre are
sessions still not
by house-surgeons just a memory.
in the TEACHING PATHOLOGY
Annotations BEDS FOR CONFINEMENT
IN London many women who are told to have their babies in hospital are also told that no bed can be booked for them in advance. With hospitals so hard-pressed, this arrangement is understandable; but it is also intolerable. Repeatedly the Emergency Bed Service has drawn attention to the plight of the woman in labour for whom a bed -somewhere-has to be found at the last moment; and on p. 398 Dr. Abercrombie shows again that this is happening more often-not less often as one would expect. Far from being just an occasional administrative accident, it seems to be accepted as something normal and inevitable. Of course it is not inevitable at all; and there are at least three possible ways of avoiding it that need to be considered by obstetricians, midwives, and administrators - jointly determined on effective action. The first is to find more beds. Difficult though this may sound, it should not be dismissed out of hand. If the demand were really accepted as a matter of urgency, old houses in some areas could be rapidly transformed into maternity homes for " normal cases ", staffed by midwives and general practitioners genuinely interested in obstetrics. Secondly, the conditions on which a woman qualifies for a hospital bed could be made stricter. This again is difficult, because obstetrically the list of indications for admission grows . ever longer, and the circumstances of many homes make them unsuitable for confinements. Nevertheless some: hospitals, feeling that only the best is good enough for. their own patients, are inclined to admit women whose claims to hospital confinement are tenuous; and therer may be room for a little economy here. What would transform the whole situation, however, would be a change of attitude toward the use of hospitals for " lying in ". After a normal, or even a moderatelyy abnormal, labour there is no need for the mother to stayv in hospital for ten or twelve days. Though the advantages ,
r
57. Schneewind, J. H. Ann. Surg. 1954, 140, 137. 58. Straffon, R. A., Buxton, R. W. Surgery, 1957, 41, 471. 59. Sherman, R. S. Ann. Surg. 1944, 120, 772. 60. Sherman, R. S. ibid. 1949, 130, 218.
ANxioUs to encourage the introduction of the preventive aspects of medicine at an early stage into the undergraduate curriculum, the World Health Organisation has set inquiries in motion into how this may be achieved. Last year a study group explored the possibilities in physiology, and now an expert committee has reported2 on its deliberations into what can be done in this direction in the teaching of pathology. The committee held that the presentation of pathology as an undergraduate subject should not be confined to any single year but should be spread over the greater part of the entire curriculum. By ample treatment of general and experimental pathology, the teacher could lay a proper foundation for the two fundamental studies of aetiology and pathogenesis, on a proper understanding of which the scientific application of preventive measures depended. Pathology should form part of a course which was closely integrated with microbiology, radiobiology, and immunology on the one hand, and with clinical medicine and surgery on the other. In the committee’s view the teaching of the preventive aspects of pathology gained much if it was depicted against a historical background of concurrent social and medical advances. Such illustrations could not fail to impress the student with the possibilities inherent in a preventive approach. Although modern pathology now had a very broad scientific basis, its morphological aspects still retained, the report declares, a central position. A comprehensive necropsy service made an invaluable contribution to the health of any community; and the postmortem examination was one of the most appropriate stages in the medical course for the inculcation of ideas of prevention in the minds of both clinicians and students. For these and other reasons, the development of an effective necropsy service should be encouraged in all countries as an adjunct to both medical teaching and practice. The importance of collaboration between pathologists and epidemiologists was one of the committee’s main points. In time, social changes in many countries, especially those now relatively undeveloped, would 1. FitzGerald, T. B. Lancet, 1959, i, 403; see also 1959, i. 397. 2. Preventive Aspects in the Teaching of Pathology Seventh Report of the Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel. Wld Hlth Org. techn. Rep. Ser. 1959, 175. Pp. 30. 1s. 9d. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1.
I
.1
in all his varicose-vein patients; and he reports that in a seventh of all cases (a rather higher proportion than that mentioned by other investigators 45 -) this vein was abnormal. Moreover, as more and more of these veins are explored, " two other features are emerging: first, because of the variability of its termination, there may be difficulty in exposing its ending, except with a large incision; and second, in arteries in cases of lung disease associated with finger some patients, after it has been divided flush at its clubbing. In patients with finger clubbing differential union with the popliteal vein, and its trunk stripped out catheterisation of lobar branches of the pulmonary artery at the ankle, considerable varices remain ". In a passage has shown that the oxygen content of blood samples of wit and wisdom HENRY 4’ has described the crucial taken from unwedged catheter positions in a branch close region where the short saphenous vein-the blue to a tumour or bronchiectatic lobe is more highly to the midline the guide "-joins popliteal vein; but arterialised than blood obtained in similar positions from the first knife-strokes in his bloodless approach are combranches supplying normal lobes. 38 This suggests an monly a signal for torrential haemorrhage. The fault increased bronchial arterial blood-flow, entering the lies not with HENRY; for the " normal " venous pattern pulmonary artery bed proximal to the capillaries in of the limbs is but a point of departure to almost infinite diseased parts of the lung. FISHMAN et al.,39 using a variations. KOSINSKI 48 gave a good account of the most modified Bloomer technique,4° recorded abnormally important of them in 1926; and, whereas " until high flows in the bronchial arteries of patients with recently these were seldom found because they were idiopathic clubbing of the fingers. The significance of seldom looked for ... now that a full dissection of the high bronchial arterial flow through precapillary broncho- popliteal space is being made, they are being increaspulmonary anastomoses in patients with bilateral club- ingly recognised ". 4a But such a full dissection demands bing or osteoarthropathy is undecided. HALL 41 has time; and time it seldom gets. Usually the surgeon, lately suggested that clubbing is associated with reduced having dealt with the long (internal) saphenous vein, ferritin passing unchanged through pulmonary arterio- has two alternatives. He can either turn the patient on his face, rescrub, and retowel; or, with the aid of sandvenous shunts; while DOYLE 42 believes that hyperis an oedema bags, spotlights, and elastic bandages, he can insinuate trophic pulmonary osteoarthropathy resulting from excessive stimulation of volume receptors a scalpel and an artery-forceps or two where textbooks in the pulmonary artery. The evidence for these say the short saphenous joins the popliteal vein. Unfortunately the most effective surgical therapy is hypotheses is by no means complete; but the discrepancy between them underlines the need to regard also the most difficult. The original high ligation of the these two disorders as separate entities. long saphenous vein and its branches (whether or not supplemented by a course of injections) had an early recurrence-rate of over 50% 48-50; but it was simple, safe, Varicose Veins OPINION on the management of varicose veins is and capable of being standarised. The gradual realisasharply divided. Some surgeons do not believe that tion since the 1930s that varicosities often develop from much can usefully be done, so content themselves with sources other than an incompetent saphenofemoral a brief patching-up operation or pass the patient on to junction (coinciding with the introduction of stripping, a junior colleague. To other surgeons varicose veins venography, and other technical advances) has inaugurated a more rational therapeutic era but has also created are a mechanical problem, pure though complex, that new problems.51-53 Previously patients suspected of can be solved-given knowledge, skill, care and time. How much benefit surgery can really provide is unlikely having deep-vein thrombosis were excluded from surto be known until some of the attention now concengical treatment. But LINTON, DE TAKATS, and others trated on flow mechanics is diverted to the underlying began to ask whether patent but incompetent deep veins, pathology of the veins-and perhaps of all vessels. On far from conveying blood, did not aggravate venous stasis; the other hand, even if complete and permanent cure LINTON 54 55 and his group went so far as to advocate cannot yet be guaranteed, operation can result in great ligation of the femoral vein in order to prevent reflux and long-lasting symptomatic relief. through incompetent perforators into superficial chanDODD 43 has done a valuable service in once again nels, and BAUER 56 applied the same principle at the drawing attention to the short (external) saphenous vein. popliteal level. Results were not altogether encouragSince 1953, stimulated by the work of CocItETT and 45. Foote, R. R. Varicose Veins. London, 1949. 46. de Takats, C. Vascular Surgery. Philadelphia and London, 1959. JONES,!4 he has made a special study of the short 47. Henry, A. K. Extensile Exposure applied to Limb Surgery. Edinburgh,
MENDLOWITZ 36 has suggested that the key to the phenomenon of clubbing lies in the pulmonary circulation. Whilst this concept does not account for unilateral or unidigital clubbing, there is evidence of a left-toright shunt through the lung in patients with bilateral clubbing. By injection studies at necropsy, CUDKOWICZ and ARMSTRONG 37 detected precapillary anastomoses between the bronchial arteries and peripheral pulmonary
saphenous system
"
36. Mendlowitz, M. The Digital Circulation; p. 125. New York, 1954. 37. Cudkowicz, L., Armstrong, J. B. Brit. J. Tuberc. 1953, 47, 227. 38. Cudkowicz, L., Wraith, D. Thorax, 1957, 12, 313. 39. Fishman, A. P., Turino, G. M., Brandfonbrener, A., Himmelstein, A. J. clin. Invest. 1958, 37, 1071. 40. Bloomer, W. E., Harrison, W., Lindskog, G. E., Liebow, A. A. Amer. 41. 42. 43. 44.
J. Physiol. 1949, 157, 317. Hall, G. H. Lancet, 1959, i, 750; ibid. p. 1151. Doyle, L. ibid. pp. 989, 1253. Dodd, E. Brit. J. Surg. 1959, 46, 520. Cockett, F. B., Jones, D. E. E. Lancet, 1953, i,
17.
1945. 48. Kosinski, C. J. Anat., Lond. 1926, 60, 131. 49. de Takats, G. J. Amer. med. Ass. 1930, 94, 1194. 50. Orbach, E. J. in Diagnosis and Treatment of Vascular Disorders (edited by S. S. Samuels). Baltimore, 1956. 51. de Takats, G. J. Amer. med. Ass. 1931, 96. 1111. 52. Dodd, H., Cockett, F. B. The Pathology and Surgery of Veins of the Lower Limbs. Edinburgh, 1956. 53. Myers, T. T. J. Amer. med. Ass. 1957, 163, 87. 54. Linton, R. R. Ann. Surg. 1938, 107, 582. 55. Lmton, R. R. ibid. 1953, 138, 415. 56. Bauer, G. Angiology, 1955, 6, 169.
392 of confinement in an institution are increasingly evident, there are often real advantages, both for the mother and her child, if she " lies in " at home. Provided domestic surgeons have come to the conclusion that bad veins help can be arranged, many mothers could and should are better than no veins; and the accurate localisation be sent home by ambulance 24-28 hours after delivery, and ligation of all incompetent perforators (what DE before their milk comes in. The objection always raised TAKATS 46 calls the " third era " in the surgical treatto this suggestion is that midwives do not like " secondment of varicose veins) seems to offer a reasonable hand " cases; and in this they are not unreasonable, compromise. Reasonable, and successful, too; but though sometimes the objection may have to be overtechnically not easy. To explore the gastrocnemial veins, ruled. But once the principle of immediate return home the veins of the biceps and semimembranosus, the calf were accepted, it should not be impossible to organise a communicating veins, as well as the short saphenous maternity service in which the midwives or general pracvein 43 is no task for the beginner or even for the master titioners took their own patients to hospital, delivered them there with whatever assistance might be needed, and in a hurry. Under favourable conditions venous dissections are continued to attend them on their return home. These suggestions can no longer be dismissed as the ideal exercise for young surgeons; but conditions, In various forms they have already been impracticable. far from being favourable, are usually appalling. To tried and have worked. The present system in London, the harassed registrar to " polish off " a couple on the other hand, is expect not working in a way that clearly of " v.v.s " at the end of a long operation list is bad we can continue to accept.
ing. Uncertainty still prevails about where, when, and what can be ligated with impunity 46 5%-so; but most
enough; but " v.v." casualty theatre are
sessions still not
by house-surgeons just a memory.
in the TEACHING PATHOLOGY
Annotations BEDS FOR CONFINEMENT
IN London many women who are told to have their babies in hospital are also told that no bed can be booked for them in advance. With hospitals so hard-pressed, this arrangement is understandable; but it is also intolerable. Repeatedly the Emergency Bed Service has drawn attention to the plight of the woman in labour for whom a bed -somewhere-has to be found at the last moment; and on p. 398 Dr. Abercrombie shows again that this is happening more often-not less often as one would expect. Far from being just an occasional administrative accident, it seems to be accepted as something normal and inevitable. Of course it is not inevitable at all; and there are at least three possible ways of avoiding it that need to be considered by obstetricians, midwives, and administrators - jointly determined on effective action. The first is to find more beds. Difficult though this may sound, it should not be dismissed out of hand. If the demand were really accepted as a matter of urgency, old houses in some areas could be rapidly transformed into maternity homes for " normal cases ", staffed by midwives and general practitioners genuinely interested in obstetrics. Secondly, the conditions on which a woman qualifies for a hospital bed could be made stricter. This again is difficult, because obstetrically the list of indications for admission grows . ever longer, and the circumstances of many homes make them unsuitable for confinements. Nevertheless some: hospitals, feeling that only the best is good enough for. their own patients, are inclined to admit women whose claims to hospital confinement are tenuous; and therer may be room for a little economy here. What would transform the whole situation, however, would be a change of attitude toward the use of hospitals for " lying in ". After a normal, or even a moderatelyy abnormal, labour there is no need for the mother to stayv in hospital for ten or twelve days. Though the advantages ,
r
57. Schneewind, J. H. Ann. Surg. 1954, 140, 137. 58. Straffon, R. A., Buxton, R. W. Surgery, 1957, 41, 471. 59. Sherman, R. S. Ann. Surg. 1944, 120, 772. 60. Sherman, R. S. ibid. 1949, 130, 218.
ANxioUs to encourage the introduction of the preventive aspects of medicine at an early stage into the undergraduate curriculum, the World Health Organisation has set inquiries in motion into how this may be achieved. Last year a study group explored the possibilities in physiology, and now an expert committee has reported2 on its deliberations into what can be done in this direction in the teaching of pathology. The committee held that the presentation of pathology as an undergraduate subject should not be confined to any single year but should be spread over the greater part of the entire curriculum. By ample treatment of general and experimental pathology, the teacher could lay a proper foundation for the two fundamental studies of aetiology and pathogenesis, on a proper understanding of which the scientific application of preventive measures depended. Pathology should form part of a course which was closely integrated with microbiology, radiobiology, and immunology on the one hand, and with clinical medicine and surgery on the other. In the committee’s view the teaching of the preventive aspects of pathology gained much if it was depicted against a historical background of concurrent social and medical advances. Such illustrations could not fail to impress the student with the possibilities inherent in a preventive approach. Although modern pathology now had a very broad scientific basis, its morphological aspects still retained, the report declares, a central position. A comprehensive necropsy service made an invaluable contribution to the health of any community; and the postmortem examination was one of the most appropriate stages in the medical course for the inculcation of ideas of prevention in the minds of both clinicians and students. For these and other reasons, the development of an effective necropsy service should be encouraged in all countries as an adjunct to both medical teaching and practice. The importance of collaboration between pathologists and epidemiologists was one of the committee’s main points. In time, social changes in many countries, especially those now relatively undeveloped, would 1. FitzGerald, T. B. Lancet, 1959, i, 403; see also 1959, i. 397. 2. Preventive Aspects in the Teaching of Pathology Seventh Report of the Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel. Wld Hlth Org. techn. Rep. Ser. 1959, 175. Pp. 30. 1s. 9d. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1.
I
.1