Madelung Propose To Remove Varicose Veins

Henschel and Eichenberg


FIGURE 1.9 Schiassi's method to inject the Great Saphenous Vein at the same time of its interruption (1909).

varicose veins after high ligation of the saphena. In order to avoid innumerable skin incisions, Benedetto Schiassi, from Bologna (1909), performed multiple injections of a combined iodine and potassium iodide immediately after saphe-nous interruption (see Figure 1.9). Linser (1916) suggested to use compression to reduce complication and to enhance the effects of the therapy. Ungher (1927) used a urethral catheter to perfuse varicose veins with sclerosing agents. Mc Ausland recommended in 1939 to empty the vein to be injected by elevating the leg and to bandage the leg after treatment.

Modern sclerotherapy developed in the 1960s. The tactics and the techniques to obtain even safer and more effective venous obliterations varied greatly between countries: the Swiss technique was proposed by Sigg; the French method by Tournay; Fegan popularized the so-called Irish technique and Hobbs the English method. These techniques differed with relation to: 1) position of the patient; 2) progression of injections (from larger to smaller veins, or vice versa); 3) sclerosant agents, their concentrations, and quantity; 4) modalities, duration, extension, and strength of compression; 5) size of the needle and modalities of injection.

In the last years, safety and accuracy of sclerotherapy greatly enhanced thanks to the introduction of real-time control of needle position and wall reaction by echoto-mography (echosclerosis, according to Schadeck). More recently, the effectiveness of sclerotherapy further improved thanks to the use of sclerosing foams, obtained by mixing slerosants with air (Tessari, Monfreux) or inert gas (Cabrera). However, the use of gas-sclerosant mixtures dates back to 1939 (Stuard Mc Ausland) and to 1944 (the "air-block technique" of Egmont James Orbach).


In older civilizations, surgery of "serpent-shaped dilatations of lower limb veins" was advised to avoid dangerous hemorrhages and death (Papyrus of Ebers, 1550 bc). Only minimally invasive procedures were performed: ". . . the varix itself is to be punctured in many places, as circumstances may indicate . . ." in order to avoid that ". . . large ulcers be the consequence of the incisions . . ." (Hippocrates). This detracting convincement persisted along the centuries. As an example, Wiseman (1676) discommended surgery of varicose veins ". . . unless they were painful, formed a large tumour, ulcerated, or bled . . ." or when ". . . purging and bleeding, not once or twice, but often repeated, fail . . ."


First described by the Roman Celsus, hook extraction of the varicose vein, double ligation, and venectomy (or cautery) is the rough operation performed for centuries. Galenum used the hook to perform multiple ultra-short stripping of varicose veins. Great boost to varicose vein surgery come from the Byzantine physician Oribasius of Pergamum (325-405 ad), who devoted three chapters of his book to the treatment of varicose veins, operated by a special hook, called cirsulce. Many of his recommendations are still valid:

1. Remove the veins, because if only ligated, they can form new varices.

2. Shave and bathe the leg to be operated.

3. When the leg is still warm, the surgeon has to mark varicose veins with the patient standing.

4. Extirpate varicose veins of the leg first, then at the thigh.

5. Remove clots by external compression of the limb.

Further important contributions were from Paulus of Aegina (seventh century), who described the main anatomy of varicose veins and identified the great saphenous as their source. He isolated the varicose veins at the thigh by a longitudinal incision, and, after bloodletting, ligated them at both ends. The tied-off portion was excised or allowed to slough off later with the ligatures.

In Arab medicine, treatment of varicose veins was dominated by cautery. However, the Spanish El Zahrawi (Albucasis of Cordova) (936-1013) is credited by Anning as the first to use an external stripper. Williams of Saliceto advocated in his Cyrurgia (1476) the reintroduction of the knife into surgery and, a few decades later, Amboise Paré (1545) abandoned definitively external cauterization of varicose veins to reintroduce their ligation: ". . . the incision must be placed a little above the knee, where a varicose vein is usually found to develop . . . Ligature was needed for the purpose of cutting the channel and making a barrier against the blood and the humors contained within it which flow to varicose veins and fill any ulcer . . ."A similar technique was used by Sir Benjamin Collins Brodie (1816): ". . . after the skin over a varix was incised, the varix was divided with a curved bistoury and pressure was applied to prevent haemorrhage . . ." Lorenz Heister (1718) placed a wax thread transcutaneously around the distal end of a varicose vein. Eight to ten ounces of the grumous and viscid blood was allowed to escape as the varix was laid open longitudinally. The wound was then bandaged and compressed. This technique was reproposed one century later by Alfred Armand Louis Marie Velpeau (1826) who ". . . introduced a pin or needle through the skin, which is passed underneath the vein, and at right angles to it. A twisted suture is then applied round the two ends of the pin, so as to compress the vein sufficiently to produce its obliteration . . ." (see Figures 1.10 and 1.11). Max Schede in 1877 operated on varicose limbs by multiple ligature or venesections and percutaneous liga-tions. Delbet described in 1884 the reimplantation of the terminal portion of the great saphenous vein just below a healthy femoral valve. In the same year, Madelung proposed a complete excision of the great saphenous vein (see Figure 1.12) through a long incision much like those used today in vein harvest for coronary bypass. On the contrary, the incision was spiral (see Figure 1.13) and the lancet plunged deep to the fascia in the operation proposed by Rindfleish and Friedel in 1908. Saphenous ligation followed by

Modern Surgery of Superficial Veins

Modern Surgery of Superficial Veins

FIGURE 1.11 Velpeau's method (1826).
FIGURE 1.12 Great Saphenous Veins excision according to Madelung (1884).
FIGURE 1.13 A) Rindfleish intervention and B) its sequelae (1908).

sclerotherapy (see Figure 1.14) was proposed by Tavel (1904), whereas Schiassi (1905) injected varicose veins at the time of surgery (see Figure 1.9).

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