Ambulatory Phlebectomy PDF

Foreword

The "Present," inexorably, changes the "Future" into the "Past," the dream into a victorious reality or into a defeat. This reality should not be mistaken with truth. It is the "acquired knowledge," fully submitted to different interpretations, that become illusory. Even if accepted in a general consensus it needs constant revision. Men are extraordinarily lazy; their spirit, fighting against a metaphysical anguish, opposes with doubts the comfort of stability of the so-called acquired verities. Dogmas provide security. Those who try to abolish them are heretics. These same men, paradoxically, are adventurers with the need to advance knowledge. This is why, as much as we go back in history, there is always a conflict between religion and science.

It is Hippocrates' glorious merit to tear up medicine from religion. From the beginning of his teachings, he refused traditional knowledge and burned, symbolically, the Asclepiades medical treatises that were the dogmas dominating all medical schools of that time: everything must be rediscussed. Doubt must shake-up every doctrine. This is the base of science. Do believe only on what you can verify personally. Hippocrates was a great revolutionary. However, destiny's irony stated that Hippocratic writings would be sacred and they became dogmas themselves and a cause of stagnation. The scholastic, Great Spirit's enemy, fixed the knowledge. So, the same ideas along the centuries were copied, repeated, and recalled.

The history of medicine shows us a peculiar aspect of its evolution. In places far away from each other in time and space, wrong theories have inspired therapeutic acts that were salutary or disastrous. "Humoral" theory, followed by Hippocrates and Ambroise Pare´, inspired the bleeding which was salutary for pulmonary edema due to heart failure but disastrous in other patients, causing exhaustion or even death. The total immobilization of operated patients helped in recovering body and mind, but predisposed them to deep veins thrombosis and pulmonary embolism. Ambulatory phlebectomy (AP) of the 2nd century BC was less dangerous than that of the 8th century ACE.

When studying a doctrine, we must compare it with the other contemporary doctrines—it is the horizontal comparison—or with the development of historic times—it is the vertical comparison.

AP was performed with success long before Christ, like in Marius, the uncle of Julius Caesar, in 107 BC, cited by Plutarch in the "Vitae Parallelae." Marius was concerned about frivolity, as he was ashamed to exhibit his ugly and ridiculous varicose veins. He preferred to show the more virile and honorable scars. It is interesting to recall that in those times, it was believed that veins carried blood and arteries air. No idea of blood circulation was present. It was thought that blood impurities caused nearly all the diseases. The same great Ambroise Pare´ shared this knowledge in the 16th century.

Time flew slowly. Two centuries after Marius' operation, the famous Aulus Cornelius Celsus first described a true AP. But as the humoral theory was strongly believed, before the cauterization, a "reasonable" amount of impure blood was evacuated (which was absurd). In opposition to the doctrine, the practice showed that an exaggerated hemorrhage harmed the patient. AP ended by a compression that permitted immediate walking.

History proceeds at an irregular speed. At Hippocrates' times it was slow, following the diffusion of knowledge. Ideas evolved along a long, lazy river. At present, mass media takes only a few hours to extend worldwide those experiences that, once, needed centuries.

Horizontal comparison is done nearly in real time. A false or wrong theory is rapidly rejected. In the 6th and 7th centuries, Aetius of Amida and Paul of Egina, the famous surgeons of Constantinople, favored the total immobilization of varicose operated patients. This was absurd and harmful for the patients. Immobility caused blood circulation stasis and that same thrombosis that it ought to prevent. The circulation was completely ignored and this nonsense became dogma, lasting for 14 centuries.

I remember that in 1950 my teacher, Professor Robert, chief of the dermatologic department in Berne (Switzerland), used to state preemptorily that we should not touch the varicose veins of men over 60 or women over 40 and of subjects having experienced a deep veins thrombosis. These absolute decrees had no sense and were based only on incompetence and ignorance.

History is filled with such notions damaging patients and harming medicine's progression, particularly phlebology. It is humanly difficult or even impossible for a chief or a "Mandarin" very qualified in a particular field, to refrain from giving advice regarding fields that are closely related, if he ignores them. Let us take the example of Ambroise Pare´ who is cited for his modesty, honesty, and wisdom. In spite of the lack of pathophysiologic data, he did not give up pontificating that the cause of varicose veins was the "melancholic blood": "Pregnant women often develop varicose veins, as the suppression of the menstrual blood evacuation fattens this blood. It is better not to deal with, as those varicose veins are untreatable."

I dare think about the solidity of both the doctrine and the execution of the AP technique. After 1957, it was improved vastly, but the main principles had to resist strong oppositions, deviations, and even perversions.

In opposition to winds and tides, AP went through the trial of vertical comparison (50 contemporary years worth several past centuries) and horizontal comparison (worldwide extension by the media). I had the luck of meeting extremely good pupils. Some of them enhanced the diffusion of AP so that now all over the world patients can benefit from a simple surgical treatment of their varicose veins.