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During the past sixteen years a technique has been developed in Dublin by which patients suffering from venous disorders of the lower limb can be treated successfully without their admission to hospital. This technique I have chosen to call 'compression sclerotherapy'. By rigid adherence to the basic principles involved, and with proper attention to the various technical details, results are consistently obtained which compare favourably with those of surgery. Because of this, and in view of the obvious advantages offered to clinicians who have to deal with a large waiting list of patients for whom bed space is not available, the method is now being adopted by workers in numerous centres outside this country. This book has been written to provide a detailed description of the methods of diagnosis and treatment as practised in the clinics of the Rotunda and Sir Patrick Dun's Hospitals.
It is necessary at the outset to emphasize that the apparent simplicity of the technique unfortunately encourages modification; modifications are frequently reflected in a greatly reduced success rate. This technique has gradually evolved to its present state; all the details which are included are those which trial and error have shown to be essential if a lasting cure is to be obtained.
The development of this technique began in 1950. In that year, having completed a traditional surgical training, I commenced consultant practice in Dublin. Like other young surgeons in similar circumstances, I found myself with time on my hands, and when the Master of the Rotunda Hospital invited me to take charge of the varicose vein clinic in that hospital I readily accepted his offer. In this clinic I found myself each week confronted by at least thirty patients suffering from varying degrees of varicose veins, and their complications. Since my surgical training had been strictly conventional, I was convinced that the only acceptable treatment of varicose veins was operative. However, no hospital beds were available, and I was forced to continue the method used by my predecessor, and use injection treatment.
During the following weeks I was to observe the various results of injecting varicose veins. Some patients developed a widespread florid thrombophlebitis, some showed no reaction at all to the sclerosant, and a few produced a reaction which fascinated me. Instead of a region of tender, red, painful phlebitis, the vein was hard, painless and cord-like. Two thoughts occurred to me; firstly, that it might, in some way, be possible to induce this reaction in every case; and secondly that this reaction might not recanalize as readily as the thrombus produced by the standard injection method. At the same time I wondered about the possibility of localizing such a reaction to a selected segment of vein, in order to preclude injury to adjacent normal valves. As a first step towards this objective, I applied compression immediately after injection using the empty vein technique. Later on, I further modified this by limiting the spread of sclerosant within the injected vein, by applying digital pressure. A comprehensive record system was established. Details of each injection and the resulting reaction were noted on record cards, and the effects of various modifications in technique were evaluated as they were introduced. The establishment of a clinic at Sir Patrick Dun's Hospital resulted in a rapid increase in the number of patients being referred for treatment. As the clinic continued to expand, it became apparent that a major reorganization was required, and in 1960 a substantial portion of day-to-day routine of the clinics was delegated to registrars who had been trained in the technique. The results of their treatment closely resembled my own, and thus it was clear that success could be obtained by any doctor who was prepared to acquire the technique and apply it conscientiously. The present 'assembly line' clinic was thus evolved, and nursing and clerical staffs, stocking fitters, etc., were increased as required. At present about three thousand new patients are treated in the clinics each year.
Examination of the early clinical results showed convincingly that immediate, adequate, uninterrupted and prolonged compression of the injection site was essential if a long-term occlusion of the vein was to be obtained. In order to assess in detail the effect of compression, and to correlate the microscopic changes in the vein with the clinical end-results, a histological investigation was instituted some years age. The results of this are presented in Chapter V. This was, in fact, the inception of our present research activities, which now embrace the direct investigation of the haemodynamics of the various components of the peripheral venous pump, normal and deranged; the basic structure, function, and control of the venous valves; the effects of hormones on different aspects of venous dysfunction, and a study of the aetiological factors involved in the development of varicose veins. If certain features of venous physiology and pathology appear to be given undue attention in this monograph it is largely due to the fact that these represent fields of investigation which have attracted the attention of our group.
I have deliberately devoted a separate chapter to the treatment of varicose veins during pregnancy. While some controversy may exist with regard to the necessity, and indeed the advisability, of this, it is my firm belief, based on our experience, that it is of great value and importance. Treatment contributes greatly to the patient's comfort during pregnancy, and markedly reduces the incidence of venous complications during the puerperium.
It must now be clear to the reader that while this technique originated from a personal venture, the success of the clinics is entirely due to the efforts of an efficient, and fully trained team. I am completely convinced that one can achieve a high standard of results in the majority of cases only in a clinic devoted entirely to the diagnosis and treatment of venous disorders. It is essential that such clinics have at their disposal proper follow-up facilities, for it is particularly easy for any doctor to be misled into thinking that he is achieving good results in this field, because most patients treated, irrespective of the method used, are improved for at least three months. It is only the examination of the long-term results which will differentiate between the man who is really giving effective treatment and the man who is not.