The entire limb, after a thorough shaving, cleansing and drying, is slightly elevated to remove any swelling, and a series of coats of Unna's incited Zinc Gelatin Paste is applied with a large brush so as to envelop the leg from the foot to the knee in an even continuous sheet of gelatin, which acts as a second layer of true skin, giving a uniform and elastic support to the limb. The formula for the paste is pure sheet Gelatin, 4 parts soaked for twelve hours in 16 parts of water, and then dissolved by applying heat and adding 6 parts of Oxide of Zinc rubbed with 12 of Glycerin. The paste keeps well, and before being used should be melted on a water-bath.
Where varicosities are present the layer of gelatin is strengthened by previously applying a gauze bandage, which is then painted freely over with the warmed paste.
Jamieson and Low have introduced a modification of this plan which is suitable for the treatment of varicose ulcers and simple varicosities unaccompanied by ulceration. After cleansing the limb with soap and water, and drying with Ether, the varicose veins are painted with Ichthyol Collodion (so per cent.), and the ulcer covered by a thick laver of Airol and cotton-wool, and the entire limb brushed with warmed Zinc jelly, on the top of which a double-headed starched muslin bandage wrung out of water is evenly applied. The jelly is made by adding so parts of pulverised Gelatin to 4o of water, heated on a water-bath till Jissolved, when so of Zinc Oxide mixed with 4o parts of Glycerin are stirred in.
The only objection to the gelatin methods is the necessity of frequent change of the envelope if the ulcer is discharging freely; this may to a certain extent be obviated by cutting out a small aperture in the dressing opposite to the site of the sore, which can he occasionally cleansed and treated by weak Boric Acid Ointment before a new coating be applied.
The old-fashioned method of strapping with adhesive plaster should be abandoned for the elastic or gelatin bandage.
We shall next consider the treatment of the simple healing ulcer when it has been subjected to certain local or constitutional causes, engrafting upon it conditions recognisable as inflamed, irritable, weak, etc.
The Inflamed Ulcer occurs when, from local irritation of a mechanical nature, as friction or the use of an irritating lotion, or the invasion of the granulating surface by microbes, the ordinary signs of inflammation supervene in the ulcer, especially about its margins. The treatment
must in all cases include rest with marked elevation of the entire limb, and the instant removal of all dressings which do not permit of free exit to the discharge. Any form of cool evaporating lotion should be applied without being covered in by a bandage or oiled silk, and this may be sv freely employed as to cause abstraction of local heat. Sometimes one large cold Starch and Boric or Bread and Water poultice is useful to cleanse the sore before applying Spirit or Carbolic Acid lotion. Occasion ally a few small incisions with a tenotomy knife near to the margin of the ulcer will act like leeching; bleeding from the cuts should be encouraged by warm Boric compresses, and a full dose of a saline purgative may be advantageously administered. After the subsidence of the pain, heat, redness, and swelling the ulcer is to be dealt with as if a simple healing sore by the methods already described.
The Irritable or Painful Ulcer is allied to the preceding condition, but the pain may be present without any signs of local inflammation, and it may be almost of neuralgic intensity. Rest in bed with elevation of the limb and the removal of all pressure by bandages or strapping and a smart purge should be administered. A pill of 5 grs. Calomel with to 1min. of Croton Oil often acts most satisfactorily upon the pain, and in some cases seems to have a specific action.
Narcotics arc as a rule objectionable, but Aspirin, Antipyrine and Bromides may be tried. The best local sedative will be a i in 3o Carbolic lotion applied on lint under oiled silk. It has been advised to search carefully for evidence of any exposed twig of a cutaneous nerve, and divide this with a fine knife, but a better plan is to cocainise the ulcerated surface by painting it with a 5 to ro per cent. of hydrochloride of cocaine solution, after which the solid Nitrate of Silver or a r in 8 solution should be freely applied to the entire surface. Strong Carbolic Acid may be used in the same way, and after cauterisation the sore should be treated by an evaporating lotion till the resulting inflammation has subsided, when the usual treatment of the simple sore may be instituted. It is sometimes necessary to pass a tenotomy knife beneath the base of the ulcer in such a way as to completely divide all sensory nerve fibres on their way to the ulcerated surface.