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[57], 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.
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.