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Before describing the various treatments of these ulcers, the author discusses their etiological process. He emphasizes that superficial venous insufficiency is the result of a deep venous insufficiency which alters and deteriorate the cellular metabolism. In fact, the chronic hypertension is transmitted to the capillary network, often with irreversible consequences. The author analyzes the healing process: inflammatory phase followed after 2 weeks by the appearance of fibroblasts, wound contraction and epithelialization. The third phase, so-called stabilization phase, lasts between 6 and 12 months. The treatment varies according to the etiology. It is mostly a matter of experience in order to avoid allergenic treatments.

By way of analysing the leg ulcers treated at his consulting rooms during six months, the author introduces the dermo-epidermal graft, simplified in a way that makes it practicable in the framework of an ambulatory treatment, with maximum ease for both practitioner and patient. The results, altogether satisfactory, prompt him to suggest that this technique be used in the context of routine treatment of leg ulcers of all aetiologies and sizes. The time gain is considerably more significant than the simplicity of the technique would lead one to suppose. The incidence of the method is quite high as it has been used in 15% of cases, but this frequency could easily be increased further with more daring. To all accounts there are no significant accidents to be feared and the author, describing the technique, urges those of his colleagues who have not yet tried the ambulatory dermo-epidermal patch graft to familiarize themselves with it.

Surgery occupies only a restricted position in post-phlebitic illness. The authors analyse 157 surgical operations carried out on 138 patients between 1969 and 1983. A detailed report is always given pre-operatively as a matter of course by Functional examination and phlebography, in order to locate the predominant physiopathological disorder or disorders: superficial venous deficiency--reflux via the perforators--the obliteration syndrome or devalvulation syndrome of the deep venous system. After a short listing of the surgical methods, the results of these different operations are analysed. They are hard to assess. Where there is a relapsing ulcer, surgery of the perforators produces 70 percent good results. The therapeutic indications are discussed, finally, on the basis of recently published series and the authors' experience.

Despite a correction as complete as possible of the venous stasis, certain ulcers prove resistant to treatment. In these cases, grafts, whose active mechanism is still not well known in many respects, can turn out to be effective.

The hunterian and juxtahunterian perforators, which communicate with the deep system on the inner thigh, either with the trunk of the long saphenous vein, single or bifurcated, or with one or several separate trunks, correspond to three schematic anatomical types. They play a major part in the post-surgical relapse of varicose veins, as the author's statistics show. Indeed, out of 157 post-surgical varicose relapses, clinical examination and phlebography have proved that perforator incontinency on the inner thigh contributes to the process in 40 p. cent of the cases, with the exception of 10 p. cent of the cases; normally it is associated with a redeveloped long sapheno-femoral junction, as well as with incontinence of the short sapheno-femoral junction which also relapses eventually. In approximately two out of three cases, sclerosant treatment is enough, but when these perforators are very large they must be operated, following minute examination using a good phlebographical technique.

The varicose or incompetent short saphenous vein is solely responsible for the ulcers with typical localizations. These ulcers, which are especially painful and less frequent than those caused by the long saphenous vein alone, or by the joint role of both saphenae, are easily cured, like any varicose ulcer, by direct action taken on the vein responsible. The author's conclusions are based on a study of 634 cases of venous ulcers.

The role of the perforating veins in the physiopathology and treatment of varicose disorder and of post-phlebitic syndromes is the subject of this study, based on the results of 5 000 observations of surgery of the veins in the lower limbs. Neglect of the perforators is responsible for a sizeable percentage of relapse after the simple stripping of the saphenous axes. In post-phlebitic syndrome and, more particularly, in trophic disorders, they play a major part, and ought to be the object of thorough investigation, using clinical examination, the Doppler and phlebography.