Alexis Thomson

“ The best clinical example of an inflamed ulcer is the venereal soft sore. The base of the ulcer becomes red and angry-looking, the granulations disappear, and a copious discharge of thin yellow pus, mixed with blood, escapes. Sloughs of granulation tissue or of connective tissue may form. The edges become red, ragged, and everted, and the ulcer increases in size by spreading into the inflamed and oedematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance. ”

“ As soon as the ulcer assumes the characters of a healing sore, it should be covered with skin-grafts, which furnish a much better cicatrix than that which forms when the ulcer is allowed to heal without such aid. ”

“ When an _imperfect nerve supply_ is the main factor underlying ulcer formation, prophylaxis is the chief consideration. In patients suffering from spinal injuries or diseases, cerebral paralysis, or affections of the peripheral nerves, all sources of irritation, such as ill-fitting splints, tight bandages, moist applications, and hot bottles, should be avoided. Any part liable to pressure, from the position of the patient or otherwise, must be carefully protected by pads of wool, air-cushions, or water-bags, and must be kept absolutely dry. ”

“ After the ulcer has healed, the patient should wear in his boot a thick felt sole with a hole cut out opposite the situation of the cicatrix. When a joint has been opened into, the difficulty of thoroughly getting rid of all unhealthy and infected granulations is so great that amputation may be advisable, but it is to be remembered that ulceration may recur in the stump if pressure is put upon it. ”

“ To avoid pressure on the sole of the foot, the patient must be confined to bed. As the main local obstacle to healing is the down-growth of epithelium along the sides of the ulcer, this must be removed by the knife or sharp spoon. ”

“ The ulcer that forms in relation to callosities on the sole of the foot is treated by paring away all the thickened skin, after softening it with soda fomentations, removing the unhealthy granulations, and applying stimulating dressings. ”

“ For purposes of contrast we may indicate the characters of an open sore in which bacterial infection with pathogenic bacteria has taken place. The layer of coagulated blood and lymph becomes liquefied and is thrown off, and instead of granulations being formed, the tissues exposed on the floor of the ulcer are destroyed by the bacterial toxins, with the formation of minute sloughs and a quantity of pus. ”

“ In addition, the offensive odour of many ulcers renders the patient a source of annoyance and discomfort to others. The primary object of treatment in any ulcer is to bring it into the condition of a healing sore. When this has been effected, nature will do the rest, provided extraneous sources of irritation are excluded. ”

“ They grow until they reach the level of the surrounding skin, and so fill the gap with a fine velvety mass of granulation tissue. At the edges, the young epithelium may be seen spreading in over the granulations as a fine bluish-white pellicle, which gradually covers the sore, becoming paler in colour as it thickens, and eventually forming the smooth, non-vascular covering of the cicatrix. ”

“ The prolonged hyperaemia of the tissues in relation to a callous ulcer of the leg often leads to changes in the underlying bones. The periosteum is abnormally thick and vascular, the superficial layers of the bone become injected and porous, and the bones, as a whole, are thickened. ”

“ The importance of imperfect venous return in the causation of such ulcers is evidenced by the fact that as soon as the condition of the circulation is improved by confining the patient to bed and elevating the limb, the ulcer begins to heal, even although all methods of local treatment have hitherto proved ineffectual. ”

“ If the ulcer is of limited extent and situated on an exposed part of the body, the most satisfactory method is complete removal, by means of the knife, scissors, or sharp spoon, of the ulcerated surface and of all the infected area around it, so as to leave a healthy surface from which granulations may spring up. ”

“ For example, _trophic_ ulcers are liable to occur in injuries or diseases of the spinal cord, in cerebral paralysis, in limbs weakened by poliomyelitis, in ascending or peripheral neuritis, or after injuries of nerve-trunks. ”

“ These measures will often prevent a grossly injured portion of skin dying, and will ensure asepticity should it do so. In the event of the skin giving way, the same form of dressing should be continued till the slough has separated and a healthy granulating surface is formed. ”

“ A dressing of gauze moistened with eusol or of boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and 10 minims of compound tincture of lavender, to an ounce of water) , and covered with a layer of gutta-percha tissue, is also useful. ”