Part 8

Mixtures of Thus, elemi, turpentine, canadine balsam, &c. with wax, or oil, have no advantage over the common ung. resinosum.

An ointment composed of these resinous substances is much recommended in the Acta Med. Berolin. Tom. VII. p. 58.

The bile, either by itself, or diluted, or mixed with yolk of eggs, does not seem to be of much service.

Lemon juice, or the mineral acids, particularly the nitrous, diluted so as to be of equal strength with the juice, are frequently of service. Port wine is also an useful lotion.

These acids coagulate the pus, and thus afford an artificial covering, or film, which remains in close contact with the granulations, and thus, by producing the natural circumstance of contact and covering, the effects of which have been already mentioned, as well as by creating a more vigorous action by their specific action, they frequently bring those sores into a healthy state.

Infusion of Cayenne pepper, in vinegar, added to water, in such a quantity as to smart, forms also a very useful application.

Of all these remedies, the ointments composed of the nitro-metallic salts, particularly the mercurial, are most generally useful: And the cure seems to be accelerated, by applying cloths dipped in weak solution of metallic salts, or weak acids, during the intervals of dressing. Whenever these applications fail, they must be dropped: And those which fail first, and soonest, seem to be the watery, or fluid applications; and, next to these, the simple resinous ointments.

These remedies generally produce their effect first at the margins. When this takes place, we must diminish the strength of the application at that part, in proportion to the activity of the action, which is marked by the redness and pointedness of the granulation, and the cicatrizing state. The circumference, and the rest of the surface, must, in this case, be dressed with different strips of linen, spread with different ointments. Soft linen, spread with simple cerate, or dry lint, which is preferable, should be applied to the cicatrix, and cicatrizing granulations, whilst a stimulating substance is applying to the rest of the surface.

When the surface is obstinately diseased, or the action very torpid and imperfect, caustic has been applied; but, although I have often used it, and even applied cloths dipped in solutions of metallic salts, so strong as to form an universal eschar, or slough, yet no benefit whatever was derived; for we do not thus change the nature of the action, but only remove a layer of the surface, and leave that below in possession of the same mode of action with the former. Caustic is more useful, when applied to callus edges; but even these are more effectually removed, by remedies which act more permanently, and gradually, particularly by pressure. The ancients used to extirpate these with the knife, but few will consent to its use. It is indeed more speedy and effectual than the caustic; but, unless the action be afterwards properly supported, it will be of no permanent service.

The hard and thickened state of the surrounding integuments, in old ulcers, is best moderated by pressure; but this must be long continued.

Varicose veins, were, by the ancients, considered as canals running into the sore, and furnishing the discharge; but, when we consider that these varices frequently occur without any ulceration, or discharge, the opinion must be abandoned. In such cases as occur alongst with ulceration, it will be more natural to consider the affection of the vein as a disease dependent originally on the ulcer, and induced by it, in the same way as the structure and functions of other neighbouring parts are changed and impaired by the continuance of a tedious and diseased ulcerative action. This state of the vein being once induced in any part of it, and even in a slight degree, two consequences follow: First, from the power or property of the vein being impaired, the blood is not duly propelled, but circulates slowly, and cannot overcome readily the weight of the blood above, which presses more powerfully, in consequence of the valves being rendered imperfect by the distension of the vessel. The disease, therefore, gradually increases; for, every day, the power of acting properly diminishes, at the same time that the mechanical necessity for acting, or the resistance of the column of blood increases. On account of the dilatation of the vessels, and the morbid or abortive effect to propel what they are unable to do, pain is produced, in the course of the varix, whenever the legs are kept in a dependent posture, or exercise is used. This pain is confounded with the uneasiness arising from the ulcer; and, therefore, these ulcers are said to be painful, and to be attended with pain in the course of the veins.

The second consequence is, that, as the veins which are more immediately connected with the ulcerated part, are diseased, and do not perform their part in the circulation properly, the functions of the part must be still more injured, and the varix, which originally perhaps was produced by the ulcer, comes in its turn to act on the sore, and prevent its healing; for the vein not acting properly, and conveying the blood fully, the action at the capillaries must be injured, and the artery and vein cannot act healthily. If this be the case, the power of forming granulations must be impeded, and these never can be deposited in the necessary degree of perfection.

Two modes of cure have been proposed, the one palliative, and the other radical. The first is effected by means of rollers, or bandages, which prevent the vein from being distended, and, therefore, enable it the better to carry on its circulatory function. In this way, we prevent, to a certain degree, the hurtful operation of the vein upon the ulcer, and are often enabled to heal it up. But, as we do not thus restore the vein to its natural powers, unless in young people, who continue the support or pressure for years, we can obtain no permanent cure of the varix; and very frequently the parts again ulcerate; because, whenever the pressure or support is withdrawn, and the patient walks about, then the function of the part becomes affected, the organic particles are not deposited in the same state of perfection, and the action which is induced by exercise causes the destruction of these granulations; or even the very circumstance of their being formed imperfectly is sufficient to produce their destruction, and the opening of the part; for all parts which have been formerly ulcerated are most ready to assume this action again, and the organic particles of that part are less perfect, and less able to bear action.

The second is obtained, by obliterating the diseased vein, or interrupting its communication with the trunk above, by which we make the blood take a different course, and be transmitted by healthy veins. If we now cure the sore, we find, that the same effects are produced as if we used permanent pressure; and, therefore, the functions of the part are more properly performed, and the organic particles possess greater power of acting, and sustaining action. The older surgeons proposed to effect the radical cure, by tying the vein at the two extremities of the diseased part, and cutting out the intercepted portion, or by laying it open, and digesting it, as they said. This, however, was, as they confess themselves, very seldom submitted to in ulcers of the legs; and was rather inserted to complete their treatises, than from a belief that the operation ought to be insisted on. Of late, it has been proposed by Mr. Home, to tie only the upper extremity of the diseased portion, by which adhesion takes place at that spot, and the circulation is there stopped. The pressure of the blood above is thus taken off, and the blood from below must circulate, in a greater degree, through vessels which are better able to perform their functions; and, therefore, the actions of the capillary vessels, whether nutrition, absorption, or conversion of the blood from arterial into veinous, must be more naturally performed. After the veins are tied, they gradually become smaller; for the pressure being permanently removed, the diseased veins can more fully propel their blood by lateral branches, at the same time that they receive less blood, more going by other vessels.

This operation is performed by making an incision through the skin which covers the vena saphena below the knee; a ligature is then passed under the vessel, by means of a blunt needle, and the vessel is tied. In two or three days the ligature may be removed, its circle being previously divided with a pair of scissars.

It is a curious circumstance, that although ulcers may have remained in an indolent state for many years, and have become almost habitual, that yet, the cause of the indolence being removed, they recover their powers rapidly, and with very little assistance. Thus, when a varix, which originally was produced by the ulcer, reacts on the sore, and prevents it from healing, we find, that if this cause be removed, the ulcer frequently heals quickly, owing to the sudden removal of a principal cause of indolence, although a similar ulcer, without varices, would not be cured by the same application in the same time; because then all the usual causes of indolence would still remain to be removed, or their effects counteracted; but, in this case, having suddenly removed one great cause, the action rises so much, that it can overcome the rest, although, without this alleviation, the healing process would not be commenced, nor continued. It may be useful to attend to this circumstance in every case of indolent ulcers, whether attended by varices or not; because, if we can remove any particular cause, we do much toward producing a cure. Thus, callus edges, and diseased, or thickened integuments, &c. although originally dependent on the ulcer, yet react on it, and prevent it from healing. If, then, by pressure, or otherwise, we remove these causes, we accelerate the cure.

As an instance of the good effects of tying varices, I shall transcribe the following case from Mr. Home’s Observations: “A man, sixty years of age, had, for many years, gained his livelihood by going on messages, having been rendered unfit for any more laborious employment by a large ulcer on the left leg, just above the inner ankle. The complaint was of twelve years standing: It had been sometimes much better than at others, but had never been well during the whole of that period. In the year 1792, it became so bad as to confine him entirely. It was at this time I first saw him. Upon examining the limb, the veins were extremely large, and varicose; and the trunk of the vena saphena, at the knee, appeared almost the size of the little finger. The size of this vein led me to the idea of taking it up at that part, with a view of relieving the lower branches from the pressure of the blood, which I believed to be the cause why the parts remained weak, and the ulcer could not be healed. I explained my opinions upon this subject to the patient, and told him, that, if he thought it worth while to try it, I was very ready to do it for him. The man’s desire to get well was such as to induce him to embrace the offer of any mode of treatment which afforded the smallest chance of it. The vein was taken up in the way that I have mentioned: He complained of very little pain, no improper degree of inflammation was brought on by this operation, the ligature came away in nine days, and in fourteen the wound was healed.

“The ulcer upon the leg was dressed with dry lint; it put on a better appearance on the second day after the operation; on the fourteenth it had diminished in size one half; and in twenty-eight days was completely healed. He was also freed from a pain in the course of the veins of that leg, to which he had been subject for many years, whenever he used any exercise.

“He returned to his business of carrying messages, and called upon me a year after, perfectly well; his leg having continued sound.”

Issues have been proposed for the cure of this genus of ulcers; but, upon the principles which have been already mentioned, it must be evident, that they can be of little or no service; and, I am sure, that I never saw the smallest influence exerted by them over an ulcer. They are useful, however, after the ulcer is healed, by keeping up a secreting action, diminishing the risk of apoplexy, &c.; but then they ought never to be introduced until the sore be nearly healed, or until we have reason to suppose that the sore will heal, and that they will be required.

The treatment of this genus of ulcers may be comprised in the following aphorisms:

First, When the action of an ulcer becomes too low and imperfect, pressure is the best remedy for restoring it to its proper state, and for accelerating the cure.

Second, Whenever this ceases to produce any farther effect, or the action relapses, and begins to go backward, we must lay aside the pressure for a time, and dress the sore with some of the stimulating applications above mentioned, particularly the nitro-mercurial salts; and these, in their turn, must be laid aside, when they cease to produce a good effect, and the pressure be again had recourse to.

Third, When we use stimulating dressings, we must attend to the effects which they produce on different parts of the sore, and dress these differently, according to their condition. We must likewise proportion the strength of application to the state of the general action. Our remedies ought to smart most when the action is most torpid, and the smarting ought to continue longest; but, when the action has begun to be more perfect and vigorous, the same application will often be too strong.

Fourth, We must, in conjunction with this general plan, attend to particular morbid structures, which may be produced by the particular state of the ulcer, and which may react on it. The chronic thickness and hardness of the integuments, are best removed by pressure, and gentle frictions; but the restoration of the natural structure is very tedious. Callous edges are likewise best removed by pressure. When this fails, caustic must be repeatedly applied. Varicose veins may be palliated by firm bandages, but are, in general, after they have continued long, only to be cured by an operation.

Fifth, When chronic ulcers can be healed, it is useful to form an issue, in order to keep up the accustomed secretory action; but these issues have little effect in advancing the cure.

GENUS III.

Of the overacting Ulcer.