HISTORY OF VARICOSE TREATMENT

Diseases of the vein and particularly varicose veins have been recogni zed since antiquity. The Ebers papyrus, dated 1550 b.c., mentions serp ent-shaped dilatation of the lower limbs. The Acropolis tablet of the IVth century b.c. concerning Dr Amynos allows us to visualize an enlar ged lower limb clearly showing a varicosity. From 460-377 b.c., Hippoc rates noted that a loose tourniquet leads to haemorrhages but that whe n the tourniquet is tight gangrene ensues and finally that standing up can exaggerate leg ulcerations. Of course much progress has been made since Hippocrates. The school at Alexandria, with Herophilus and Eras istrates speak of vascular ligatures. Their work was unfortunately los t in the fire of the Alexandria library in 391 a.d. Galien himself des cribed varicose vein ligatures in 200 a.d. Leonardo de Vinci's magnifi cent anatomic studies of veins are widely known. In 1525, Ambroise Par e described leg bandaging for ulcers beginning from the foot up to the knee. In 1585, Fabrice d'Acquapendente described venous valves. In 16 76, Wiseman invented the first supportive stockings made of leather an d in 1854, Unna described in Vienna the supportive boot which now carr ies his name. Shortly thereafter new medical and surgical techniques w ere developed for the treatment of varicose veins. Pravaz, in 1860, in vented a syringe which now carries his name and initiated sclerotherap y. At the end of the XIXth century, Trendelenburg performed the first ligatures of the greater saphenous veins. In 1905, and 1906, Keller an d Mayo performed the first ablation of the greater saphenous vein and in 1906, Carrel reported the first venous transplantation. The first t hrombectomy was performed in France in 1926 by Bazi. In 1938, Gregoire proposed thrombectomy for blue leg phlebitis and the first phlebograp hy was done by Cid Dos Santos in 1939. In 1938, Linton proposed a subf acial ligature of varicosities and in 1958, Palma proposed suprapubian bypass. Modern advances have included the progressive development of sclerotherapy, which in expert hands can be used to treat practically all types of varicosities. Surgeons have developed classical stripping and cryosurgery to freeze the vein which is left in situ. This led to new techniques of ligature of the internal saphenous vein under local anaesthesia and ambulatory phlebectomy using the Muller technique. Fi nally, haemodynamic cure of ambulatory venous insufficiency has been p romoted by Franceschi and immortalized under the name of CHIVA. The ha rd-working inventive character of these clinicians and surgeons greatl y helped in the development of combined techniques. Their mutual criti cisms were all the more severe since no controlled study has confirmed or infirmed the results obtained. In conclusion, the development of t he different techniques can be divided into four general periods. The pre-Hippocratic and Hippocratic period when the disease and its conseq uences were recognized and led to the development of simple concepts s uch as the deteriorating effect of orthostatism and the improving effe ct of compression. This period lasted from the XVth century b.c. to th e XIVth century a.d. The most remarkable characters in this period wer e the Acropolis tablet and Hippocrates who, together with the work of Galien and later Ambroise Pare foresaw the anatomic descriptions given by Leonardo de Vinci. In the XVth century, the second period saw much progress in the description of venous anatomy and pathophysiological conceptions inducing interest in elastic support. This period lasted t o the middle of the XIXth century. From the middle of the XIXth centur y up to the end of World War II, surgery and sclerotherapy were the ba sis of treatment for varicose veins. Audacious operations were sometim es not much different than some war surgery operations. Starting in th e 1960s, the fourth period saw the development of more and more ingeni ous sophisticated techniques and the subsequent debates between the di fferent protagonists, each persuaded that his technique was the only o ne which could solve the problems related to the disease of varicose v eins (J Mal Vasc 1994; 19: pages 210-215).