Veins and Lymphatics 2020; volume 9:9250

Edmondo Malan his whole self to us, a totally naked heart for us. A master, indeed, always asks the learn- Correspondence: Giovanni B. Agus, Vascular er to do what he does not yet know, and not Surgery, University of Milan, Italy. Giovanni B. Agus what he already knows.2 E-mail: [email protected] Vascular Surgery, University of Milan, Italy Key words: Italian Phlebolymphology; history; Masters of the past; phlebology; lymphology.

Edmondo Malan, forty years Conflict of interests: the author declares no An introductory note later potential conflict of interests. The lack of masters, in all fields, is a The birth of angiology and vascular This paper is part of the monographic issue: ‘Did major concern in Italy today. Fortunately, surgery, not only arteries and veins: the Masters of the past know the future? History and update of Italian Phlebolymphology’ - Guest we are offered opportunities to explore from kidney transplantation to the ideas and read publications that can com- editor: Alberto Macciò (Phlebology - Part I focus on vascular malformations edited by G. Agus; Phlebology - Part II edited by pensate for this deficiency. I may mention a Pilgrimage across universities, once a P. Bonadeo; Lymphology edited by F. Boccardo). couple of considerations that have shaped common custom that enriched the my thought, together with the memory of Academy, was a precious practice in the Received for publication: 30 June 2020. the two great clinicians: Edmondo Malan opinion of Professor Malan, who consid- Revision received: 10 July 2020. and Giorgio Agrifoglio. ered it useful to follow trends in the athero- Accepted for publication: 15 July 2020. In medicine, the process of hyperspe- sclerotic disease both in time and (geo- cialization of disciplines, with the creation This work is licensed under a Creative graphical) space. His experience in Catania, Commons Attribution 4.0 License (by-nc 4.0). of sub-specialties within the same special- reviewed several years later, appears to ties, has deeply changed the nature of the have been extremely significant from the ©Copyright: the Author(s), 2020 relationship between the physician’s work point of view of changes in the disease. Licensee PAGEPress, Italy and the means, the instruments required for Atherosclerotic arteriopathy was almost onlyVeins and Lymphatics 2020; 9:9250 the practice (formulation of diagnoses and non-existent. I only saw diabetic arteri- doi:10.4081/vl.2020.9250 treatment of patients). Until the 70’s, those opathies and Buerger’s disease. Today it’s means were themselves a constituent of the the opposite. Buerger’s disease has almost medical profession, and diagnostic and ther- disappeared; atherosclerotic diseaseuse is apeutic skills were acquired with a long largely a function of time, and partly of learning path that passed through semiotics space, meaning that different eating habits (from inspection to palpation) and training and other local factors have an undoubted ducted with the Professor of Anesthesiology at the patient’s bed under the guidance of a epidemiological dimension (Malan, 1973). Rinaldo Trazzi. As a testimony of this new master. Great clinicians were distinguished After 11 years, in the early afternoon of a focus on the surgical patient, we are left by their capacity to observe the symptoms day of April 1949, a line of cars set out from with his excellent report on the Evaluation and signs of a disease by using traditional Catania and headed to Messina for the first of the resistance of the surgical patient semiotic tools - the sole option available at stretch of Professor Malan’s journey (Trieste, 1952) and with Surgery in the eld- the time: the confirmation of clinical suspi- towards new academic achievements in erly. cion. The clinical eye was the capacity to equally prestigious locations: Parma, The need to add instrumental assess- correlate the clinical signs observed in the Genoa, Milan. ment methods to basic clinical medicine for real patient, even when they were minimal Edmondo Malan, born in Turin, gradu- a better hemodynamic balance led him to or barely perceptible, with specific medical ated in 1933. He studied with Uffreduzzi, advocate - together with a South African conditions and syndromes. The insight of and followed Dogliotti in Modena and surgeon, Goetz - for the study of vascular the master was the result of years of expert- Catania. And it was in the Sicilian city, diseases by using a plethysmograph, the ise built at the patient bedside, and on where he stayed from 1938 to 1949 (with a equipment that would be called Goetz- autopsy findings when the causeNon-commercial of a death break of two years spent in war, on the Malan plethysmograph for many years to could not be determined. As the founder of Greek-Albanian front), that he started to come. Clinical Medicine, Augusto Murri, said: take an interest in angiology. He studied But it was certainly in Milan that the The secret of success in the medical prac- Buerger’s disease and set out to deliver most important research and clinical case tice is not so much in the acquisition of a endoarterial vasodilation treatments with study results in Europe became known to huge knowledge, nor in having seen a large excellent results. all, first in the old Zonda pavilion, and since number of patients. These are certainly two His most significant work is described 1967 in the very modern and pioneering very useful requirements, but the most in Surgical treatment for chronic peripheral Institute of Angiology and Vascular Surgery essential challenge lies half-way, that is to obliterating arteriopathies, which Malan of the University, in the Mangiagalli pavil- say in the capacity to apply the acquired published, together with his master ion of the glorious Milan medical and aca- notions to each individual case.1 Dogliotti, in 145 pages and 24 tables. At demic institution ICP (Istituti Clinici di But I will draw an even more difficult that time, presentations were not short sum- Perfezionamento). That was the very origin meaning of the term master from the words maries or reviews, as we would say now, but of the young University of Milan, founded of a great artist, Giovanni Testori, who said: original works.3 by Prof. Mangiagalli, gynecologist of the A man begins to become our master when In Parma, thanks to his eclectic nature, University of Pavia, and then a Senator and he makes us understand that he has trav- he was among the firsts to understand the Mayor of Milan. elled all the roads of the world to reach us, importance of a specific study of the prob- Kidney transplantation would start to be and not vice versa. A master is not a sub- lems of anesthesia and resuscitation, and performed in Milan, but Malan, with great lime service provider, but a man who gives reorganized surgery in a team work con- modesty, shared his merits with others when

[Veins and Lymphatics 2020; 98:9250] [page 41] Phlebology - Part II he told the press: We are neither among the As to the unregulated practice of saphe- disease that suggested to him to count the most advanced nor among the most back- nous stripping and regarding the need for meters he could walk before the inevitable ward countries. A lot of progress has been accurate diagnostics in phlebology, Malan cramp due to intermittent claudication - just made, but much remains to be done. The stated, in an important international sympo- like the pragmatic North-American sugges- excellent performance of the Milan, Rome sium in 1970: Nous effectuons le stripping tion for the patient to count feet when walk- and Verona centers allows us to nourish seulement quand nous avons une certitude ing around their blocks. hope for the near future. clinique; dans le doute, nous faisons une In his teaching activity for the training His relations with the élite of the enthu- phlébographie (there were no Doppler and of the best doctor, he taught: Learning sur- siasts of vascular diseases, and particularly ultrasound in medicine yet!) Nous estimons gery is a challenging task, one that requires with the French Fontaine and Reboul, and que l’indication du stripping doit être posée great commitment in long hours of study with the Portuguese Dos Santos (Figure 1), d’une façon précise, sur la base d’une très and intense physical work, combined with spread the news of this tiny group naming bonne anamnèse et d’une recherche clin- an unbiased attitude and strong will. These them The Four Musketeers of European iques bien suivie. qualities may lead a young man to become Vascular Surgery. Their expertise gave life Another chapter that had a wide interna- a great surgeon, but to be a complete sur- to the European Cardiovascular Society and tional resonance among angiologists and geon there is one fundamental trait he led to the first international cardiovascular vascular surgeons was that of syndromes should acquire: human understanding. In surgery meeting in Turin.4 During his aca- derived from arterial-venous anastomosis many cases, the surgical intervention is an demic period in Genoa, two events took and the notions on the importance of hemo- act of faith of the patient and surgeon, and place that represented a very significant dynamics (Malan syndromes). As another it can be well accomplished only through 8 milestone for the new medical Vascular great Master, the French Georges Arnulf, mutual understanding. branch: the creation of the Journal of wrote: Je ne peux personnellment qu’attirer Another interest he had, although little Cardiovascular Surgery, published in l’attention sur la valeur des documents de known, was that on the influence of climate English with the Italian publisher Minerva Malan sur la physio-pathologie des affec- on the human being and on vascular dis- Medica of Turin (the famous green jour- tions vasculaires et tout spécialement sur eases intended, as they sometimes are, as nal), and the opening of the first les fistules et anasomoses artério-veineuses meteoropathies.only He wanted to study this Specialization School of Angiology. - sans omettre le beau livre - véritable chef with the meteorological service of the Malan, in fact, as we said, was not only d’œuvre sur les malformations vasculaires Linate Airport. interested in surgery. He had vast horizons auxquelles ils ont réservé le nom We already mentioned his interest in in medicine, starting from methodology and d’Angiodysplasias (this is the famous red Buerger’s disease, but it is worth recalling 5 epidemiology, but always with a special book of the Carlo Erba Foundation). useBut the malariotherapy he would develop fondness for vascular diseases. In the early already in 1967 Malan’s work had been rec- together with Professor Corelli of Rome. 1970s he was one of the promoters of a ognized in this difficult area of vascular A summary and critical work of all the wide-ranging debate and work on conditions in the classical treaty of scientific work carried out by Professor 6 Angiological nosology. Classification of Angiology by Fernando Martorell. Malan and his School from 1943 to 1978 vascular diseases of the limbs (Florence We could continue for a long time also was given to us in 1983 by his first student 1974), which later converged into a docu- by talking about his attention to every Guido Tattoni, head of a Vascular Surgery patient, as shown in the beautiful image cre- Division, the first in time and among the ment that was published in Italy and global- 9 ly by Minerva Cardioangiologica and ated by Guido Crepax for him (on Tempo best Italian vascular surgeons. through the Journal of Cardiovascular Medico - cover and central article of issue n. In 1976, another important publication 113, available at: http://www.aiap.it/cdpg/ of 330 pages was dedicated to him by his Surgery - the same that happened many 7 10 years later with the Consensus Statement by ?ID=7127&IDsubarea=169&IDsez=225). students. the Anglo-Saxon Consensus Conference. It was that attention to the needs of each Celebrating the Master through his In vascular epidemiology he played an individual patient with a peripheral arterial works and ideas is highly praiseworthy, important role in the field of phlebology with the fundamental epidemiological con- tribution on Varicose disease of theNon-commercial lower limbs, which was published in the Archives of Mutual Medicine of 1961 (with V. Giabbani) and definitely shed light on the socio-economic importance of chronic phlebopathies. He had a great interest in phlebology, the Cinderella of medicine. His enthusiastic forward to the work of Glauco Bassi, an eminent phlebologist, was an opportunity for him to call for a dignity and seriousness of commitment that reprimanded, for exam- ple, the rampancy of pseudo-scholars, clumsy stingers of veins, even though he was not against a serious and well-executed sclerotherapy. At the Zonda, he called peo- ple like the Irish George Fegan to teach, not Figure 1. Two of The Four Musketeers of European Vascular Surgery, Malan and Dos from the chair but in practice, the modern Santos on the side, with in the center Michael De Bakey and Achille Mario Dogliotti. sclerosis of truncal veins.

[page 42] [Veins and Lymphatics 2020; 98:9250] Phlebology - Part II maintained Giuseppe Zannini when he founding by Professor Malan and an 5. Malan E, ed. Vascular Malformations recalled Edmondo Malan as a bright enlightened hospital president as Mrs. (Angiodysplasias). Milano: Carlo Erba researcher and clinician, capable of arous- Erisia Gennai Tonietti was, in favor of mod- Foundation; 1974. ing the interest of young people for a field ern departmentalizations with a single cost 6. Martorell F. Angiologia. Enfermedades that was opening up to knowledge and center - because today economy prevails vasculares. Barcelona: Salvat Ed.: looked particularly attractive. One most over patients, teaching and research, even 1967. compelling thing was the way in which up to the abolition of university faculties. 7. Tempo Medico, Rivista di attualità per Malan approached problems and faced As we know, today we live in a liquid soci- il medico, n. 113. In copertina è ritratto ety and nothing is safe and durable any- knowledge, as Zannini recalled in describ- Edmondo Malan, chirurgo. Copertina di more, as Zygmunt Bauman taught us. ing his work method, always discussed in Guido Crepax. Editrice Pierrel S.p.a; These few considerations came to my depth in his conference contributions. 1973. Then we should mention his treaties on mind during my descent of the Kilimanjaro on 24 January 2008, exactly thirty years 8. Malan E. In: V. Ghetti (a cura di), Guida vascular surgery, which remained a mile- CIBA per il Giovane Medico. Milano: stone in learning for a long time.11 after the death of a Master. CIBA; 1969. Another surgeon of a different school, 9. Tattoni G. La Scuola del Prof. E. Malan Piero Pietri, twenty years after the passing e le malattie vascolari periferiche. of Malan - rightly recalled in the Treccani References Maniago (PD): Off Grafiche LEMA; Encyclopedia -12 could and would write of 1. Murri A. Quattro lezioni e una perizia. 1983. him, who had not been his teacher but still a Il problema del metodo in medicina e 10. AAVV. Scritti degli Allievi in onore del mentor: when one thinks of his masters, the biologia. Bo-logna: Zanichelli; 1973. prevailing sentiment is almost always ven- Prof. Edmondo Malan nel 26° anno del 2. Doninelli L. Una gratitudine senza deb- suo ordi-nariato. Osnago (CO): Off eration, often regret and nostalgia. iti. Giovanni Testori, un maestro. Grafica Morell; 1976. These feelings are even more appropri- Milano: La nave di Teseo; 2018. 11. Malan E. Trattato di Tecnica Chirurgica. ate today for us, dwarves on the shoulders 3. Dogliotti AM, Malan E. Terapia chirur- Chirurgia Vascolare. Torino: UTET; of giants, in an epoch that can instanta- gica delle arteriopatie obliteranti per- only neously erase the memory of experiences iferiche croniche. Archivio e Atti 51° 1980. where the physician was the real protago- Congr Società Italiana di Chirurgia. 12. Franchini AF. Edmondo Malan – nist. In recent historical works, we need to Roma: EMES; 1949. Dizionario Biografico degli Italiani. remember Malan, and the other masters of 4. AAVV (presentazione di E. Malan).use Atti Roma: Treccani; 2007. international vascular surgery.13 della prima riunione internazionale di 13. Chiesa R, Melissano G, Setacci C, Being the last director of the Institute of angiocar-diochirurgia. Torino 30 mag- Argentieri A. History of aortic surgery Vascular Surgery and Angiology, I wit- gio-1 giugno 1951. Milano: Mellon; in the world. To-rino: Ed. Minerva nessed its liquidation 40 years after its 1951. Medica; 2015.

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