The perforating ulcer of the foot calls for special treatment. 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 base also should be excised, and any bone which may have become involved should be gouged away, so as to leave a healthy and vascular surface. The cavity thus formed is stuffed with bismuth or iodoform gauze and encouraged to heal from the bottom. As the parts are insensitive an anæsthetic is not required. 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. The treatment of any nervous disease or glycosuria which may coexist is, of course, indicated.
Exposure of the plantar nerves by an incision behind the medial malleolus, and subjecting them to forcible stretching, has been employed by Chipault and others in the treatment of perforating ulcers of the foot.
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.
Treatment of Ulcers due to Constitutional Causes.—When ulcers are associated with such diseases as tuberculosis, syphilis, diabetes, Bright's disease, scurvy, or gout, these must receive appropriate treatment.
The local treatment of the tuberculous ulcer calls for special mention. 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. Should the raw surface left be likely to result in an unsightly scar or in cicatricial contraction, skin-grafting should be employed.
For extensive ulcers on the limbs, the chest wall, or on other covered parts, or when operative treatment is contra-indicated, the use of tuberculin and exposure to the Röntgen rays have proved beneficial. The induction of passive hyperæmia, by Bier's or by Klapp's apparatus, should also be used, either alone or supplementary to other measures.
No ulcerative process responds so readily to medicinal treatment as the syphilitic ulcer does to the intra-venous administration of arsenical preparations of the “606” or “914” groups or to full doses of iodide of potassium and mercury, and the local application of black wash. When the ulceration has lasted for a long time, however, and is widespread and deep, the duration of treatment is materially shortened by a thorough scraping with the sharp spoon.
Treatment in relation to the Condition of the Ulcer.—Ulcers in a weak condition.—If the weak condition of the ulcer is due to anæmia or kidney disease, these affections must first be treated. Locally, the imperfect granulations should be scraped away, and some stimulating agent applied to the raw surface to promote the growth of healthy granulations. For this purpose the sore may be covered with gauze smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding parts being protected from the irritant action of the scarlet-red by a layer of vaseline. 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.
When the condition has resulted from the prolonged use of moist dressings, these must be stopped, the redundant granulations clipped away with scissors, the surface rubbed with silver nitrate or sulphate of copper (blue-stone), and dry dressings applied.
When the ulcer has assumed the characters of a healing sore, skin-grafts may be applied to hasten cicatrisation.