The skin of the limb is generally found so macerated and tender that it will not be advisable to cover in the night lotion by oiled silk, though this may sometimes be done to advantage. Sheet lead, cut a little larger than the ulcer, may be laid over one or more plies of lint soaked in weak biniodide of mercury or any other lotion, and placed upon the surface of the ulcer, the whole being covered by a pad of lint or gauze, and kept in position by elastic webbing or woven lndia-rubber bandage as just described. Excellent results follow this method where the pure rubber bandage cannot be tolerated.
By laying a piece of protective over the face of the sore after thoroughly disinfecting it with a i in _boo° Corrosive Sublimate solution, Watson, of Boston, modifies this plan. Over the protective he places a piece of sheet tin, the whole covered by a dry Corrosive Sublimate gauze dressing, held in place by an evenly applied bandage from the toes to the knee. The lead foil and woven rubber bandage are better. Where these plans fail blistering may be tried, but the clanger of converting the indolent callous condition into a sloughing ulcer in debilitated subjects must not be forgotten.
Of surgical procedures the best is to take a sharp bistoury and make a series of linear incisions through the thickened or callous margins, radiat ing outwards from the centre of the ulcer, like the spokes of a wheel from the nave. The incisions should penetrate the deep fascia, and extend for an inch or two beyond the margins of the ulcer. Bleeding is easily stopped by pressure.
This method is more successful than mere scraping of the ulcer or paring its margins. The writer thinks it was first practised in the Edinburgh School, and he has seen its great success in many cases in the hands of an old pupil of Syme.
Spaeth describes a modification of this procedure as practised by Harbordt. The entire ulcer is divided lengthwise by a deep incision, extending far into the healthy tissue. Cross incisions are then made through the callous tissue into the healthy at intervals of about i-inch. The incisions must go through not only the skin, but the underlying fascia; the wounds must gape widely. The bleeding, often profuse, must be stopped with tampons, and the whole wound, which it must be owned has rather a slaughter-house look, is done up with Iodaform dressings. When, after eight to fourteen days, the dressing is changed the difference in appearance is very marked. Healthy granulations are springing up in abundance from the gaping incisions, and soon cover the whole surface, reaching the level of the surrounding skin, from which the growth of new epidermis is seen to advance rapidly.
Where the ulcer is extensive, skin-grafting may be needed, but it is useless to attempt the operation till the entire nature of the sore has been first altered by some of the above plans, or, better still, after thorough excision of the entire ulcer by the knife.
Reverdin's method consists in planting within the margins of the ulcer minute grafts of epidermis with the upper layers of the rote mucosum, and these, by growing into the skin of the margins, give a firm cicatrix. The after-treatment consists in covering the surface with protective bandages under a thick pad of sterile gauze, which should not be removed for 4 or 5 days.
By the Thiersch method a broad piece consisting of epidermis only is shaved off the patient's thigh or forearm. This is laid on a piece of gauze, raw surface uppermost, moistened with normal saline solution, and perforated with numerous pricks with a scalpel point. Graft and gauze are then pressed on the freshened ulcer surface and made to adhere thereto. A dressing of gauze dipped in melted Boric ointment is applied over the graft.
Large grafts of the entire thickness of the skin may be laid on the surface of the scraped and sterilised ulcer, and fastened by sutures; some surgeons employ this method as practised by Young, who places the skin graft on the healthy cleansed granulating surface.
The dressing of grafted surfaces affords a problem not yet satisfactorily solved. Thin sheets of perforated celluloid have lately been used with success. They are kept in position by straps of plaster, and therefore do not displace the delicate graft. They allow the secretions to escape, and prevent adhesions of the graft to the epidermal cells of the graft.
Amputation may be the only resort when all methods fail and the ulcer invades a large area of the entire surface of the leg. The Bell Keatley operation is the best procedure. He scrapes the ulcer thoroughly, removes the bones and soft tissues of the dorsum of the foot, and transfers to the site of the ulcer the whole of the sole of the foot, including muscles, plantar vessels and nerves, and excluding loose tendons after removing a small portion of the lower end of the tibia. The result is a good stump, like a Syme, instead of an ordinary amputation at the knee. He also preserves the dorsal foot flap for ankle amputations in cases of complete circular ulcer of the leg by bending it round upon its neck and covering with it the ulcerated surface.