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Veins and Lymphatics 2015; volume 4:5600

[Veins and Lymphatics 2015; 4:5600] [page 67]

Post-thrombotic syndrome
in the Middle Age
Paolo Zamboni
Vascular Diseases Center, University of
Ferrara, Italy

Post-thrombotic syndrome (PTS) is a dis-
abling disease, which often leads to chronic
venous leg ulceration. It can be treated and/or
prevented after deep vein thrombosis (DVT) by
the use of elastic stockings, because surgery is
a highly selected option. Symptoms and com-
plications of PTS appear several years after
DVT. While varicose veins and ulcerations
were extensively described in antique art and
literature, the first medical case truly compati-
ble with a PTS story was depicted in the man-
uscript of Guillaume de Saint-Pathus, in the
Middle Age.
The manuscript titled La vie et les miracles

de Saint Louis1 tells us that in 1271 Raoul, a 20-
year-old young man, suffered from a monolat-
eral acute edema in the right calf. Some days
later, the swelling extended up to the thigh
(Figure 1A). He was a Norman shoemaker and
underwent to a medical consult. In 1271
Raoul’s phlebologist was Henri de Perche. This
confirms us that French physicians were
absolute beginners in phlebology. Henri sug-
gested him to lie supine, as well as to wait and
see. What happened some months later, with
big surprise of Raoul and his relatives, was the
disappearance of the swelling (Figure 1B). For
some years the leg was slim and he resumed to

work. However, some years later Raoul again
worsened in the right lower limb, and suddenly
developed an ulceration at the medial aspect of
the right ankle (Figure 1C).
At that time St. Eloi’s shrine was the hub

center for venous leg ulceration. Raoul under-
went to additional unspecified treatment
attempts, but everything was unsuccessful.
The last hope was to visit the tomb of King
Saint Louis, where Raoul spent days after days
in praying the saint. Finally, he collected the
dust found below the stone covering the tomb,
and applied it directly to the ulcer. This was not
the first description of an advanced dressing
for venous leg ulcer. In the Bassi library,
Glauco Bassi’s typewritten notes report other
previous descriptions, starting from the Bible.2

However, the manuscript reports that the
wound miraculously healed. We do not know
about the big problem of ulcer recurrences in
Raoul’s rest of the life, as in modern PTS hap-
pens. However, it has been reported that Raoul
was still alive 11 years after the Saint Louis
miracle. I came curious to deepen the story of
Raoul, after reading a monograph on the histo-
ry of DVT. The story of Raoul was also, accord-
ing to Galanaud et al., the first medical report
of DVT.3 In ancient Greece, neither
Hippocrates nor Oribasius, reported clinical
cases resembling DVT; this is also true looking
to the art of ancient Egypt, Persia, and South
America. Even Roman physicians such as
Galen or Caelius, did not report something
suggesting a diagnosis of DVT.3 We can con-
clude that, to the best of our knowledge,
Raoul’s story is the first medical report on both
DVT and PTS.

References

1. De Saint Pathus G. La vie et les Miracles
de Saint Louis. Paris: Bibliothèque
National de France; 1330-1340.

2. Bresadola M. The Bassi Historical
International Library of Phlebology at the
Ferrara University Hospital. Veins and
Lymphatics 2014;3:4150.

3. Galanaud JP, Laroche JP, Righini M. The
history and historical treatments of deep
vein thrombosis. Thromb Haemost
2013;11:402-11.

Correspondence: Paolo Zamboni, Vascular
Diseases Center, University of Ferrara, via Aldo
Moro 8, 44124 Cona, Ferrara, Italy.
E-mail: paolozamboni@icloud.com

Received for publication: 22 October 2015.
Revision received: 11 December 2015.
Accepted for publication: 1 February 2016.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

Figure 1. A) Acute lower limb edema in Raoul’s lower right extremity; B) edema resolu-
tion; C) ulcer development several years later. Modified from De Saint Pathus, 1330-
1340.1

A B C

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