I have no doubt that this book would stand as reference textbook on venous diseases among our physicians, surgeons and especially those interested in vascular diseases.

Sir Benjamin Brodie (1814), while lecturing at the beside of a patient suffering from varicose ulceration remarked, “This is a case in which there is no question of patient's life or death, and I think it is probable that many among you may pass by the bedside of such a patient without thinking worthy of attention. But I am not disposed to regard it in this manner. Although the patient will not die of the disease, yet, without great care, it may render him/her very miserable. The disease may be very much relieved by art and it is one of very common occurrence…such a case as may meet you at every turn of your practice; and your reputation in early life will depend more upon your understanding a case of this kind, than upon your knowledge of one of more rare occurrence.”

Even after centuries, even with surprising advances in Medicine and Surgery, we could not offer anything substantially better for the varicose vein sufferers. We never analyzed into the depths of the core problem for the recurrences and the sufferings due to ulcerations following repeated surgeries. The principle behind the surgical intervention was always overlooked. We were thinking only of modifications of instruments to make the interventions to get qualified to be called ‘minimally invasive’, which is the passion of the day.

“The future is only the past again entered through another gate”—Sir Arthur Pinero (The Second Mrs Tanqueray, Act IV), still holds well. But it is high time to revalidate the re-entry. An introspection into the cause of surgical failures based on a deep search into the cause of the disease and treatment designed on that basis can only solve this enigma.

While going into the various historical landmarks of treatment for varicose veins to pay tribute to the great men who made their challenging contributions, I was surprised to find, the surgery we do today, is just a modification of the procedure practiced in early 1st century AD, revised in the early 19th century by Sir Benjamin Collins Brodie, who stated, “I always observed that, if I cured one cluster of veins surgically, two smaller ones appeared, one on each side and that, ultimately, I left the patient no better than I found him”. Even the internationally celebrated surgeon, Friedrich Trendelenburg, after whose name the surgery for varicose vein is still known and is still considered the ‘gold standard’, found the procedure falling into disrepute over a period of 4 years due to high recurrence and complications.

I was inspired by Sir Benjamin Brodie and Trendelenburg, as I experienced the same problems in my early days of surgical practice. So I was always reluctant to do any procedure for varicose veins. In 1995, one patient who was referred to a reputed surgeon, very well known for treatment of varicose veins, was refused of surgery due to poor surgical fitness, old age and other coexisting problems, came back to me and asked, “Should I die of this misery of non-healing eroding ulceration of foot, which is pouring out fowl smelling pus?.” I was terribly moved by the feelings and started thinking of doing something for the patient to find a way out. I did sclerotherapy for the first time and even now the patient is perfectly alright with no venous problem. He started referring patients and now I could develop an institute of research on venous diseases catering surgical service to more than 3,000 patients a year from various places in the world with an outpatient attendance of an average of 150 patients per day. We are doing genetic studies also in collaboration with Rajiv Gandhi Centre for Biotechnology (RGCB), Thiruvananthapuram, Kerala, the premier biotechnology research institute of the Government of India (Science and Technology Department).

I did just the opposite of what others throughout the world do. I was privileged to treat around 17,000 patients by sclerotherapy. Out of this, more than 15,500 patients were treated with a Modified technique of Microfoam Sclerotherapy (MMFST), based on the concept of Microscopic Venous Valves (MVVs), the principle being just the opposite of the current day procedures. It turned out to be very much acceptable to patients and they were demanding for the procedure. I analyzed the basics for the evolution of varicose veins. The structural, etiological and pathophysiological evaluations were done. The biophysics behind the pathology was well evaluated and the principle of treatment was 13restructured to suit to the natural functioning of the body. The response of the patients with chronic venous disease, especially after venous surgery, was so encouraging that I could develop a major research institute on venous diseases.

In 2012, I started a research foundation “Dr N Radhakrishnan Foundation for Advanced Research on Venous Diseases” to promote genetic studies and to prevent the disease in the future studies under the guidance of RGCB.

‘Treat the cause with a physiological basis’ is the lesson I learned. The veins of the legs are just rivers flowing against gravity. The pathology is the failure of the uplifting mechanism and not the reverse flow of blood. A flooding in a river cannot be controlled neither by making dams across the river (multiple ligation or excision of truncal veins) or at the estuary (junctional blocks) or at any exit points (perforator blocks) or by filling the whole river with sand (truncal ablation, like stripping or endovenous laser treatment or radiofrequency ablation therapy or truncal sclerotherapy). The tributaries are most important. Divert the tributaries especially at the lowermost level where the venous pressure is at maximum. Remember, no instrument can be passed through any small tributaries. Also remember, no fluid will flow from a lower pressure gradient to a higher pressure gradient compartment. So never block the exit points. Make a physiological atmosphere. Flooding in a river is never due to a high tide from the sea; the tributaries are the most vital and hence never try to make a dam across the river or at the estuary to prevent flooding in the river.

Before I conclude, let me quote my spiritual master, Swami Vivekananda:

I am blessed if the new generation gets enlightened by these newer thoughts.

The great support offered from Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India, is highly commendable. Professor Radhakrishna Pillai M, Director; Kartha CC, Professor, Eminence of Cardiac Molecular Biology Division, and Sumi S, Research Fellow, require special mention. Our joint research in the molecular analysis gave me great enthusiasm to dive into the depths of venous diseases and prompted me to write this book.

I am particularly thankful to the Management of St Thomas Hospital, Changanassery, Kottayam, Kerala, India, for offering me all help in building up a Research Institute for Venous Diseases.

I would be failing in my duty, if I do not remember my coworkers, who have toiled too much for this cause.

I would also like to thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director) and Mr Tarun Duneja (Director-Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi and the Bengaluru Branch.