Albucasis evidently copies our author’s account, recommending us to break or divide the membrane, and introduce a canula of lead into the opening to prevent adhesion. (Chirurg. ii, 79.)
Haly Abbas, in like manner, directs us to make an opening and introduce a leaden tube or a piece of sponge. (Pract. ix, 63.)
SECT. LXXXII.—ON THE EXCISION OF VARICES.
The varix is a dilatation of a vein occurring sometimes in the temples, sometimes in the hypogastric region below the navel, sometimes in the testicles, but more especially in the legs. For the most part it derives its origin from a melancholic humour. The operation for those of the testicle we have already described when treating of cirsocele, and those in the leg may be operated upon in a similar manner, making the attempt upon those in the inner parts of the thighs, where they generally arise; for below this, as they are divided into many ramifications, they are more difficult to succeed with. Wherefore, having washed the man, and applied a ligature round the upper part of the thigh, we are to direct him to walk about, and when the vein becomes distended we are to mark its situation with writing ink or collyrium, to the extent of three fingers’ breadth or a little more, and having placed the man in a reclining posture with his leg extended, we apply another ligature above the knee; and where the vein is distended we make an incision upon the mark with a scalpel, but not to a greater depth than the thickness of the skin, lest we divide the vein; and having separated the lips of the wound with hooks, and dissected away the membranes with crooked specilla, like those used in the operation for hydrocele, and laid bare the vein, and freed it all around, we loose the ligatures from the thigh, and having raised the vessel with a blind hook, and introduced under it a needle having a double thread we cut the double of it, and opening the vein in the middle with a lancet, evacuate as much blood as may be required. Then having tied the upper part of the vessel with one of the ligatures, and stretched the leg, we evacuate the blood in the limb by compression with the hands. Then having tied the lower part of the vein, we may either cut out the portion intermediate between the ligatures, or suffer it to remain until it drop out of its own accord with the ligatures; then we have to put a dry pledget into the wound, and apply over it an oblong compress soaked in wine and oil, and secure them with a bandage, and accomplish the cure by the treatment applicable in cases of suppuration. I am aware that some of the ancients do not use ligatures, but cut out the vessel immediately after it is laid bare, whilst others stretch it from below and tear it out by force. But the mode of operating now described is of all others the safest. Varices on the hypogastrium may be treated in like manner, and those on the temples as described in the operation of angiology.
Commentary. Hippocrates directs us to make small punctures in varices of the leg, but forbids to open them freely. (De Ulceribus, 16.) In the Hippocratic treatise entitled ‘Hippiatrica,’ it is recommended to burn varices in the legs of horses.
Celsus treats ingeniously of varices on the head (aneurism by anastamosis) on the belly (cirsocele?), and on the leg. With regard to the treatment, he says, in a word, that they are all either to be burnt or cut out. If the varix be straight, or if, although transverse, it consist of a single vein of moderate size, it will be better, he says, to burn it. If crooked and convoluted, and if it consist of a multitude of veins, it will be more useful to cut them out. He directs us, in burning them, to make an incision in the skin, and having laid bare the vein to touch it with a slender blunt piece of iron red-hot, taking care not to burn the edges of the wound which are to be drawn aside with hooks. This is to be done at intervals of about four fingers along the whole extent of the varix, and then the dressings for burns are to be applied. The varix is cut out in this way. The vein is to be exposed as above directed, and dissected with a scalpel from the surrounding parts (care being taken not to hurt it); a blunt hook is then to be introduced below it; and the same thing is to be done at the same interval as mentioned above. When this has been performed wherever there are varices, the vein is to be cut asunder at one of the hooks, and drawn towards the next hook, and then torn out. The leg being in this way cleared of the varices, the lips of the wound are to be united, and an agglutinative plaster applied above. (vii, 31.) It will be remarked that our author makes mention of this method of treatment but disapproves of it.
Aëtius describes the excision of varices in exactly the same terms as our author. He also makes mention of the treatment by the actual cautery. (xiv, 84.)
The operation of extracting varicose veins is briefly described in the ‘Isagoge’ of Galen. Albucasis describes accurately the different modes of operating upon varices. He says there are two methods of performing the operation with the knife, that is to say, by incision or by extraction. The former method is done by applying a piece of fillet round the upper part of the thigh, and at the inferior part near the knee, and then opening the vein in one, two, or three places, and evacuating the blood in it: the limb is then to be bound up. In performing extraction, the veins are first to be made to swell by putting the limb into hot water, applying fomentations, and taking strong exercise; and then a longitudinal incision is to be made in it, either at the knee or the ankle. The vein is afterwards to be dissected from the neighbouring parts and suspended with a blunt hook. The vein is to be laid bare in like manner at the distance of three fingers’ breadth, and in more places if required. At last, it is to be cut asunder at the ankle and drawn out. Afterwards wool dipped in wine and rose-oil is to be applied. When the varix consists of a congeries of tortuous vessels he recommends us to dissect it out entire. (Chirurg. ii, 92.)
Haly Abbas briefly inculcates the same treatment as Albucasis. (Pract. ix, 64.) Avenzoar considers the complaint nearly incurable.
Rhases directs us, in the first place, to bleed and purge, and then to expose the vessel or cut it out. He also approves of compression. (Cont. xxviii.)