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T'he introduction of injection methods of treating varicose veins focused attention on an important and rather neglected disease which is responsible for much ill-health, disability, and inefficiency. During the past fifteen years or so not only has the stimulus of the newer methods shown the value of injection treatment but the experience gained has clearly indicated the place of operation in deal ing with varicose veins. At the present time it is true to say that every case of primary uncomplicated varicosity, however severe, can be " cured." By " cure " is meant the obliteration of the entire varicose circulation either by in jection or by operation, or by a combination of these two methods. Using the word " cure " in this restricted sense, then, there are few cases which cannot be " cured " rela tively quickly and completely. This paper is based upon the personal experience gained in treating over 1,300 patients for varicose conditions of the lower limbs. An evaluation of the place of operation must not, however, be taken to i-mply any serious criticism of the efficiency of injection for the majority of cases. But time has shown that if all cases are to be treated efficiently, irrespective of the nature and extent of the disease, then operation must still have a place in the scheme of treatment. Untreated varicosity is almost always a progressive con dition. -The speed of progress is determined by many factors: family history, build, age at onset, pregnancies, the nature of the veins themselves, the patient's occupation, etc. If the condition remains untreated, complications such as congestive phenomena, dermatitis, ulceration, bone involve ment, the various types of phlebitis, and disabilities due to scarring, etc., may develop. With existing methods of treatment it should be possible to avoid all varicose compli cations. The cause of varicosity is still unknown, but the evidence suggests that hereditary and endocrine factors are probably the most important ones. The surgeon cannot cure or influence this innate tendency to varicosity, but by treatment he can bring about a cure of existing varicosities, and by obliterating the varicose circulation the progress of the disease can be slowed. This paper is particularly concerned with the operative treatment of primary varicosity in the uncomplicated stage. Uncomplicated cases include all those up to the congestive stage but exclude those beyond this-namely, dermatitis, ulceration, phlebitis, etc. Surgical treatment may, of course, be required for some of these complicated cases, and although many of the principles which are described are also applicable, with modifications, to the advanced group of cases, the complicated ones are not considered here in detail. The term " primary varicosity " excludes all cases in which the varicosity develops, secondarily to an obstruction of the deeper vessels-e.g., femoral thrombosis (Payne, 1938). Varicose veins may be treated by injection in most cases, by operation alone in a few, and in some by operation and subs quent injection. The proportion of cases requiring either operation or operation and injection will, of course, be determined by the severity and nature of the condition.

Thirty-six patients have been studied clinically and phlebographically three years after a major deep vein thrombosis. Twenty were treated surgically and 16 medically. The incidence of post-thrombotic symptoms was similar in the two groups. The use of superficial femoral vein ligation to prevent embolism will not worsen the prognosis of a leg which is already the site of deep vein thrombosis.

Out of 102 patients with cardiac infarction admitted to the coronary care unit at this hospital and not treated with anticoagulants 30 (29%) developed isotopic evidence of deep vein thrombosis. Of the 65 smokers only 7 (11%) developed a deep vein thrombosis, whereas of the 37 non-smokers 23 (62%) developed a deep vein thrombosis. This difference is highly significant (P < 0·00001).

The effect of a low-dosage regimen of ancrod in the prevention of postoperative deep vein thrombosis was assessed in 24 patients having surgical repair of fractured neck femur and compared with 25 control patients who did not receive therapy. The objective of the therapy was to lower the preoperative fibrinogen level and produce a low concentration of fibrin degradation products yet avoid the haemorrhagic complications of total defibrination. Ancrod therapy proved feasible to carry out, was not associated with haemorrhagic complications, and produced sustained, predictable reductions in fibrinogen concentration. There were seven thromboembolic complications in the control patients compared to one such complication in the ancrod-treated patients. Five deaths occurred in the control group and one in the treated group. Though the incidence of deep vein thrombosis was not apparently affected by ancrod it appeared on venography that the thrombi in the treated patients were less extensive than those in the control patients. Finally, some discrepancies in the diagnosis of deep vein thrombosis by the three techniques of clinical examination, (125)I-fibrinogen scanning, and ascending venography were identified.