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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.

The coagulation factors and components of the fibrinolytic system were examined in 31 women with a previous history of phlebographically-verified thrombosis during the use of oral contraceptives of the combined type. Special attention was given to the histochemically-determined fibrinolytic activator content of the wall of biopsy specimens of superficial veins. None of the patients was taking contraceptives at the time of the investigation. Pathological changes, particularly in the fibrinolytic defence system, were found in most of the patients. They may be regarded as predisposed to thrombosis, and one might wonder whether these patients would sooner or later have had their thrombosis even if they had not used contraceptives. The concentration of antithrombin III was normal, indicating that this test is of no value for detecting patients predisposed to thrombosis, who should preferably not take oral contraceptives.

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.

Forty-four patients who had a deep vein thrombosis detected with the fibrinogen uptake test were followed up three to four years later. The mild aching pains and ankle swelling that were present at the time of the thrombosis persisted or got worse in many, but there was no increase in the incidence of varicose veins. The minor self-limiting thrombosis detected with the fibrinogen uptake test should not be considered innocuous, for it can cause long-lasting symptoms.

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.

A single injection of hexoestrol, 45 mg., is effective in suppressing lactation. Given in this way hexoestrol causes a small rise in plasma factor IX levels, of shorter duration than that produced by a customary and equally effective oral course of stilboestrol. With hexoestrol the plasma factor IX levels reverted to normal by the sixth day of the puerperium.

An ultrasonic technique has been used to diagnose deep-vein thrombosis, the venous system being examined from the calf to the inferior vena cava. The method is quick, simple, and repeatable, and the results compare favourably with those from phlebography.

Review of the 74 patients undergoing aortic valve replacement with a Starr–Edwards ball-valve prosthesis between October 1963 and December 1967 showed that 16 died during surgery or within the first month after operation, usually owing to myocardial failure; and there were nine late deaths. The remaining patients developed few major complications, and the long-term results of operation are considered satisfactory, no patient being grossly incapacitated and most of them are leading active, symptom-free lives.

A study was made on the effects of oral contraception on blood coagulability in women being treated with a variety of commercial preparations. The results were compared with those in a group of normal female controls and they were also contrasted with the effects of exercise on coagulability in normal women using the same techniques and with the results in patients with deep-vein thrombosis who presented during the period of the trial. It was found that oral contraceptives caused a rise in factor 7 levels significant from Month 3 onwards. No significant changes in cephalin times or antihemophili antihemophilic globulin (AHG) levels were recorded in the oral contraceptive group unlike the physiological changes found after physical exercise in normal women. Increases in factor 7 levels were detected also in a concurrent study of patients with deep-vein thrombosis but these were also associated with shortened heparin clotting-times not found in the women on oral contraceptives. It is considered that this increase in factor 7 levels which is also found in normal pregnancy and the postpartum state as well as in venous thrombosis is an undesirable side-effect of oral contraception. No woman in the study had been on treatment for more than 2 1/2 years and further study is necessary to determine whether different changes occur at a later date. In future investigations it should be determined whether all the preparations available are equally liable to produce raised factor 7 levels.

A total of 76 “high-risk” surgical patients were studied for evidence of venous thromboembolic disease. Episodes of deep vein thrombosis and of pulmonary embolism were related to changes in blood levels of fibrin degradation products (F.D.P.). When diagnosed either by ordinary clinical means or by venography and isotope scanning significantly raised F.D.P. levels were found in all cases. Serum F.D.P. estimations are unlikely to help in detecting deep vein thrombosis, but may prove valuable in diagnosing pulmonary embolism.

The occurrence of infection in the tissues surrounding external arteriovenous shunts was studied and die important relationship of pyogenic infection to clotting was confirmed. The local application of fusidic add tulle and lanolin greatly reduced the occurrence of both infection and clotting and the need for cannula replacement. Urokinase used for declotting shunts when standard procedures had failed, restored blood flow whether dotting was related to infection or to local vascular factors. This treatment is not advised when clotting is associated with a local abscess, as it may make cannula replacement necessary. Severe local vascular factors, such as metastatic calcification, Raynaud9s phenomenon, and venous stenosis, may lead to poor blood flow, so that despite clot lysis elective cannula replacement or the creation of a subcutaneous arteriovenous fistula is required.

3 healthy women aged 35 22 and 28 years developed intravascular thrombosis while receiving oral contraceptive therapy (Case 1 took Anovlar for 1 years Case 2 took Conovid for 18 months and Case 3 took Enovid for 1 month). Cases 2 and 3 had chest lesions and were treated as pulmonary embolic disease. Case 1 was fatal and directs attention to the possibility that arterial thrombosis (in this case carotid) may also exist in addition to the more thrombophlebitis of the legs and pulmonary embolism.

Occlusion of the internal carotid or middle cerebral artery was seen in 44 young adults of both sexes from a rural population in Ceylon over a period of four years. None had hypertension, diabetes, prediabetes, or hypercholesterolaemia. There were 19 men with internal carotid occlusions, most being due to atherosclerotic thrombosis. The high incidence of atherosclerosis in these patients on a marginal diet remains an enigma, and we suggest that carbohydrate-induced hyperlipidaemia might be an important aetiological factor. There were 13 men with middle cerebral occlusions, the aetiology of which remains obscure. Occult embolism or atherothrombosis are suggested as possible causative factors. Of the 12 women five had middle cerebral artery occlusions in the last trimester of pregnancy and two had internal carotid artery occlusions in the puerperium. The pattern of ischaemic strokes in women aged 15-45 was similar to that observed in Western countries, though our patients differed ethnologically and in dietary habits.

Blood coagulation and fibrinolytic factors have been measured in 13 patients treated by liver transplantation. During operation intravascular coagulation and fibrinolysis were increased, but seldom to a degree which would cause abnormal bleeding. Measurement of the catabolism of radioactive fibrinogen showed that increased intravascular coagulation continued for long periods after the operation. Despite secondarily increased fibrinolysis, there was a high incidence of thrombosis. Treatment with anticoagulants or with fibrinolysis inhibitors may be valuable in these patients.

One hundred and two patients with clinical signs indicating a possible diagnosis of deep vein thrombosis were studied with the fibrinogen uptake test and phlebography to assess the reliability of the test as a means of diagnosing established venous thrombosis. The test gave a correct diagnosis in 78% of the 85 legs shown to contain thrombus by phlebography and only 19 (10%) false-negative results in the 195 legs examined. The duration of the symptoms, the administration of anticoagulants, and mild leg swelling did not affect the accuracy of the test. Very old thrombus, phlebographically more than 11 days old, was associated with an increased false-negative rate. The fibrinogen uptake test is accurate enough to make it a valuable method of clinical investigation.

Seven cases of erythraemia following successful renal transplantation are described. This complication was not necessarily associated with clinical evidence of rejection of the transplant, and the prognosis so far as rejection was concerned was excellent. Four patients, however, developed thromboembolic pulmonary complications, and two other patients had thrombotic episodes. Hence it is suggested that treatment either by anticoagulation or by venesection is indicated.

Investigation in the postoperative period of 75 patients by means of the radioiodinated fibrinogen uptake method, by the use of the Doppler ultrasonic flow detector, and by clinical assessment revealed an incidence of deep vein thrombosis of only 12%. This is distinctly lower than has been reported by other investigators using the same techniques both in Australia and elsewhere. It appears from this study and associated work that the Doppler ultrasonic technique is sufficiently accurate to be of value in the clinical diagnosis of significant deep vein thrombosis.

A trial of continuous intravenous heparin in the prevention of deep vein thrombosis was undertaken in 48 patients who had suffered a myocardial infarction. Of the 24 control patients who did not receive heparin seven (29%) developed calf vein thrombosis as detected by the radioactive fibrinogen technique. None of the 24 heparinized patients had any evidence of venous thrombosis. This difference is significant at the 1% level.

The area ratio of the abdominal aortic bifurcation is defined as the ratio of the sum of the cross-sectional areas of the common iliac arteries to the cross-sectional area of the aorta. Abnormality of the area ratio is associated with initiation of atheroma of the lower aorta. Hypoplasia of the abdominal aorta predisposes to early occlusion as the atheromatous process advances. In five out of six women with thrombosis at the aortic bifurcation the area ratio was low. Hypoplasia of the abdominal aorta was present in two of these patients. All six patients were successfully treated by aortoiliac disobliteration and reconstruction.

Two West Indian men with no previous history of diabetes mellitus developed hyperosmolar non-ketotic diabetic coma. Intra-abdominal catastrophes secondary to mesenteric thrombosis played a major part in the death of these patients, in both of whom control of the hyperosmolar state had been achieved. Both patients had evidence of infarction of intestine at necropsy. Vascular thromboses are a major complication of this form of coma and must be considered when such patients develop signs of an acute abdomen.

The incidence of postoperative deep vein thrombosis diagnosed by radioisotope scanning in 100 Sudanese patients aged 40 or over was 12%. This compares with an incidence of nearly 30% in 542 patients reported from British hospitals using the same diagnostic technique. The reason for the difference is obscure and needs further investigation.