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Sir,

It is essential to establish whether Dr. Rivlin (Jan. 31, p. 247) thinks he is able to diagnose deep-vein thrombosis with any degree of accuracy. Does he think that deep-vein thrombosis and varicose veins are two unrelated diseases? The two, in our experience, coincide in a very considerable number of cases.

We do not think the differentiation is of any importance, since patients with varices and good leg pumps are symptomless, while those with no varicosities and inadequate pumps have symptoms (the group in which ulcers develop). Maintaining nutrition of the skin and the healing of an ulcer are the same problem; both are dependent upon catabolite clearance, which, in turn, is dependent on improved venous hypotensionn brought about by walking or by elevation of the limb.

The method of achieving this satisfactory state of tissue-fluid clearance - whether it be by competent bandaging, injection-compression sclerotherapy, or surgical operation - is of no importance because the method does not significantly influence the healing of the ulcer. The important considerations, therefore, are the patient's comfort, the morbidity, and the economics. In some cases a reduction in the amount of standing, and more walking exercise, can effect and enhance healing without any other treatment.

In a review of 129 patients with varicose ulcers treated by surgery over a 10-year period Lofgren et al.¹ established a 30% recurrence-rate. In our own clinic, where 33,000 patients have been treated to date, and where the ulcer-ratio is higher than anywhere else in the world, we report approximately a 30% recurrence over a 5-10 year period in the general intake of those with ulcers treated by compression sclerotherapy. Therefore I feel that there is no room for dogmatism, but I think it is clear from Dr. Rivlin's letter that he does not understand the fundamentals of the problem with which he has been dealing for so long. As an analogue, recurrence in the treatment of hernias is more dependent on raised intra-abdominal pressure than on the operator or technique used. Most people can cure 100% of ulcers but, despite the operator or technique, the recurrence-rate is about 30% after 5 years. This does not reflect on operator or technique, but reflects gross damage in the deep-vein valves, without satisfactory compensation by the muscle pumps.

We are satisfied that the most important single cause of chronic leg ulcers is damage to valves in the perforating veins of the foot and leg, with or without associated damage to the valves in the deep veins. The incompetent-perforating-vein theory, which in fact was postulated in 1938 by Linton,² is far from "blown".

In the minds of many people there are two entities - deep-vein thrombosis and superficial vein thrombosis - both followed by recanalization and primary valvular damage. Experience has taught us that all degrees of deep-vein thrombosis are possible and can be followed by partial or complete recanalization.

1. Lofgren, K. A., Lauvstad, W. A., Bonnemaison, M. F. Proc. Staff Mut. Mayo Clin. 1965, 40, 560.

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