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Surgery on Varices in Byzantine Times (324-1453 CE)

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Surgery on Varices in Byzantine Times (324-1453 CE) View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector HISTORICAL REVIEW Surgery on varices in Byzantine times (324-1453 CE) John Lascaratos, MD, PhD,a Christos Liapis, MD,b and Maria Kouvaraki, MD,b Athens, Greece Objectives: The purposes of this article are to describe Byzantine varicose vein surgery and to note its influence on the devel- opment of these operations after that time. A study and analysis of the original texts of the Byzantine physicians, written in Greek and containing the now mostly lost knowledge of the earlier Hellenistic and Roman periods, was undertaken. Results: The Byzantines paid special attention to varicosis surgery from the early period of the empire. The famous fourth-century (CE) physician Oribasius meticulously described a number of surgical methods of confronting varicosis, some of which were derived from the texts of earlier Greek surgeons, to which he added his own keen observations. Later, eminent Byzantine physicians developed these techniques further and evaluated their usefulness. Conclusions: The study of Byzantine medical texts proves that several surgical techniques on varicosis were widely prac- ticed in Byzantine times and were derived from the work of ancient Greek and Roman physicians. The techniques described had a great influence on western medieval and later European surgery, thus constituting significant roots of modern angiology. (J Vasc Surg 2001;33:197-203.) Medical practice and surgery seem to have been highly work of the ancient Greek physician Antyllus (second cen- developed during the early Byzantine period, from the tury CE). These remained unchanged until the 16th cen- fourth century to the sixth century of the common era.1 tury.11 However, this was not the only topic concerning Byzantine doctors were exposed to and greatly influenced the specialty of angiosurgery with which Oribasius dealt. by the knowledge of the physicians of antiquity. They were His famous book Synagogue Medicae, a complete medical also able to acquire personal experience through study and encyclopedia of his era,1 contained special chapters dealing practice, which resulted in the description of new tech- with surgery on varices. The techniques of Oribasius rep- niques and innovations.2 Surgery during the Byzantine era resent the first surgical methods in the Byzantine medical was so greatly developed that skillful surgeons dared to literature, and they seem to have influenced all of the later carry out complex procedures such as lithotripsy in the physicians of the medieval era and, later still, the pioneer- bladder,3 undertake the separation of Siamese twins,4 and ing European surgeons.12 apply special techniques for plastic and reconstructive Later Byzantine physicians, especially Paul of Aegina surgery of the face.5 (seventh century CE), also dealt with this subject, clarify- It seems that these operations were carried out under ing the earlier techniques and adding new remarks (eg, on difficult circumstances, though the use of some analgetic or the use of tourniquets in preparation for surgery).13-14 hypnotic drugs, such as Papaver somniferum, Hyoscyamus, and mandrake, was well known from Dioscorides (first cen- HISTORICAL MATERIAL tury CE),6 and these were used by Byzantine physicians.7 Oribasius’ contribution Aetius (sixth century CE) supplied wine to women before gynecologic operations.8 But some literary sources reveal In his Book XLV, Oribasius (Figs 1 and 2) devotes that the operations and cauterizations were extremely three chapters (18-20) to the subject of varices. The first painful because the anesthesia was very primitive.9-10 and most extensive of these chapters is entitled “On In addition, the eminent physician of early Byzantium, Varicose Veins.”15 He begins the chapter by defining vari- Oribasius of Pergamum (c 325-405 CE), described the first cose veins, writing that the condition is a broadening of techniques of surgery on aneurysms, derived from the lost the veins in such a way that they contain increased blood, and he notes that varices form in the head, abdomen, scro- From the Department of the History of Medicinea and the Department of Propaedeutic Surgery,b Medical School, National Athens University. tum, or legs. Most cases are located in the legs, and it is Competition of interest: nil. for that reason, he states, that he begins his chapter with Reprint requests: John Lascaratos, MD, 164b Hippocratous St, 11471 varicose veins in the legs. Athens, Greece. Surgery on varices of the legs Copyright © 2001 by The Society for Vascular Surgery and The American Preparation of the patient. One day before the con- Association for Vascular Surgery. 15 0741-5214/2001/$35.00 + 0 24/1/107990 frontation of the disease, he writes, the surgeon should doi:10.1067/mva.2001.107990 shave the leg and bathe the patient; then, while the patient 197 JOURNAL OF VASCULAR SURGERY 198 Lascaratos, Liapis, and Kouvaraki January 2001 Fig 1. Oribasius from Pergamum (left) and Philip, ancient physician (right). From Codex 3632, 14th century; University Library of Bologna, f. 97v. is still warm from the bath, the surgeon should stand him down a hook which has not a sharp point, called by up so that he is supported only by the varicosed leg and surgeons τυϕλαγκιστρον´ (typhlangistron, “blunt mark all of the swellings with small superficial incisions hook”; in Latin, hamus retusus16), we lift the vari- (Fig 3). “In this way, if during the surgical intervention cosis up [Fig 4, B]. the veins remain invisible for various reasons, we shall not If this procedure proves difficult then we fail,” as the varicosis sites can be identified from the marks pass through a second similar hook in the same way, that were made.15 These incisions are made straight—not but proceeding in a contrary direction with the sec- parallel to the leg, but rather in the direction taken by the ond hook the other way round. After we have encir- varicosis, because the marks are thus more superficial. cled the varicosis with the two hooks, we draw it up. The technique of extraction by pulling up. Oribasius con- If the vein has not been raised, as often happens tinues his description with the following technique, which because it is located very deep or because it has slipped we quote in a free English translation of the original Greek to the sides of the incision, using the hook we first text (from Raeder’s15 edition): search along these sides, placing it at right angles. Before starting the operation, we place the patient Then, slowly reclining the end of the hook, we bring face-down, bind all his members to the bed with a it to the surface of the skin while from outside, with bandage, except the varicosed member so that the the little finger of the left hand, we press the skin assistants can turn this, sometimes facing down and towards the hook so that it facilitates the secure grasp- sometimes up, according the needs of the opera- ing of the vessel, which often slips due to the pressure. tion. After that, we take hooks, called cirsulce [that If once again the vein has not been successfully is, in Greek, instruments that pull up the varicosis— grasped, the hook is turned to the opposite direction “varix extractors,” a type of forceps16], which have and the procedure is repeated in such a direction. If a slight curve like the Greek letter Γ. With those we even after this the procedure fails, we take two sharp pierce the surface of the skin on the highest part of pointed hooks which we give to our assistants, so that the swelling, next to the incision mark. Then we with those we can hold the wounds of the incision pull the hook along the leg, at the same time turn- open and, with a third extremely curved hook, we cut ing it so that the skin folds over, becoming tense and separate the membranes until we find the varico- and curved. Then we make an incision in the skin sis; then we draw it up with either one or two of the [Fig 4, A], short in length, and separate the skin “blind” hooks referred to before. without reaching the varicosis, which we can easily Then we place under the varicosis a feather or recognize because it is smooth and with azure any other soft object or a blunt needle armed with shade, due to the blood it contains. If, after the inci- thread [Fig 4, C]. This procedure can only be per- sion in the skin, white and strong membranes formed if we have already raised the vein with the appear, with the hook we previously used, we per- “blind” hooks; it is otherwise impossible. forate the membranes and pull them up, separate After the first incision and isolation of the vari- and tear them until we reach the vein. If there are cosis, we continue with the remaining incisions in many membranes, the procedure can be repeated the same way; not, however, from the lowest part of three or four times. Then after we have turned the leg. JOURNAL OF VASCULAR SURGERY Volume 33, Number 1 Lascaratos, Liapis, and Kouvaraki 199 If the varicosis is straight, these incisions are made at intervals of no less than two finger-lengths [one finger = 1.8 cm]. Cirsotomy. There follows the main cirsotomy [removal of the varicosity] which starts from the lowest parts of the leg upwards. If we have used only one hook, we then pass through a second from the opposite direction using our hands so that the varix is pressed strongly between the two. The lower hook is turned toward the malleolus, the upper hook towards the calf, and in this way we pull up the varix, which is located in the malleolus, and cut it from the top.
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