Ulcer

ulcer (ulcus). A lesion of a cutaneous or mucous surface usually attended by suppuration.

 For Scrofulous Ulcerations

Mix one drachm of ioduret of zinc and one ounce of lard together.

Use  twice a day to the ulcerations. 


An Ulcer  may be defined as the loss of substance due to necrosis of a superficial structure, and the causes of ulcers may be divided into (1) predisposing and (2) exciting. In the former, age, sex, occupation and social condition have to be considered. The exciting causes are traumatism and infection.

The chief varieties of ulcers seen on the leg and foot are as follows: indolent or callous; varicose; tubercular; syphilitic; epitheliomatous; diabetic; perforating and blastomycotic

In indolent or callous ulcer, the cause may be divided into general and local. Among the former may be mentioned typhoid fever, chronic nephritis, anemia, poor hygiene, improper food, overwork, and lack of sleep. Local causes: old scar tissue, extremes of heat or cold, irritation of the tissues, injury, the presence of a foreign body such as dead bone, splinter, etc.

Symptoms. The most common location of these callous ulcers is on the inner side of the lower third of the leg. They show a great variety in size, shape, appearance and base, edges and surrounding area, and in accordance with these differences, many different names are applied to them. The size varies from a small ulcer less than one centimeter in diameter, sometimes found with varicose veins, to the large ulcerations which surround the leg and are called annular  ulcers. The shape may be round, very irregular, or funnel shaped. The base may be much or slightly depressed, or the granulations may be at a higher level than the surrounding edges. When the granulations are large, irregular, and bleed easily, they are spoken of as exuberant ; when pale, soft and flabby, as weak  or edematous ; when small and slowly growing, as indolent.

A peculiarly painful form of chronic ulcer is found over the internal malleolus, and most frequently in women of middle age; it is often associated with menstrual disorders and is known as a congested  or irritable  ulcer. It begins as a small area of congestion over the internal malleolus, which gradually increases in size and becomes dark and more dusky in the centre, due to the deposit of blood pigment caused by chronic congestion. The skin next becomes hard, dry, scaly and pigmented, while the subcutaneous tissues lose their elasticity, becoming inflexible, hard and adherent to the deeper structures. Then, as a result of slight traumatism or even without injury, the centre of the area breaks down and an ulcer develops. It may be circular or irregular in shape and may be quite deep or superficial. The edges are sharply cut, and both base and edges are bound down to the deeper tissues. The intense pain of the ulcers is supposed to be due to pressure upon the terminal nerve filaments in the dense sclerotic tissue. This form of ulcer is very often difficult to cure and shows a tendency to return after healing.

Treatment. This naturally depends upon the time the ulcer is seen and the conditions present. If there is considerable inflammation, accompanied by marked cellulitis and pain, the milder wet dressings, such as boric acid or Thiersch are indicated. Rest, of course, is the most important factor. The patient must be prohibited from walking, and if necessary, the movements of the neighboring joints must be prevented by the application of suitable splints. After the acute inflammatory symptoms have subsided the granulations must be stimulated, (see Chapter XIX).

Varicose Ulcer. To chronic ulcers of the leg associated with varicose veins, especially of the smaller venous radicles, the name varicose ulcer has been given.

Symptoms. The usual development of this variety of ulcer is as follows: persons who suffer from varices of the leg usually complain for some time before the external manifestation of the disease, of a deep aching pain in the limb, with a sense of weight, fullness, and fatigue. In a more advanced state of the disease, the ankles swell after a day's hard work, and the feet are constantly cold; an embarrassed state of the circulation is denoted by these symptoms and the deep seated veins begin to swell. After a time, which varies with the idiosyncrasy and occupation of the patient, small soft, blue tumors are seen at different points of the leg, most of them disappearing on pressure, but returning when this pressure is removed or when the patient stands up. Each little tumor is caused by a vein dilated at the point at which it is joined by the intramuscular branch. Around many of these tumors a number of minor vessels of a dark purple color are clustered, these being the small superficial veins which enter the dilating vein and in which the varicose ulcer is often of a brownish blue color, due to a deposit of pigment. Frequently a leg, which is the seat of varicose veins, or which is edematous from other causes, is attacked by acute eczema. The recognition of varicose ulcers is usually easy but the mere presence of enlarged veins, it should be noted, is not pathognomonic, because they may often exist along with ulcers of other origins, tuberculous, syphilitic, etc.

The surface of varicose ulcers usually presents imperfect and unhealthy granulations, secreting a more or less thin and offensive pus, and the granulations are sometimes covered with membranous exudation. The edges and base are thickened and callous, and enlarged veins, capillary or otherwise, are present near the circumference and often amount to genuine blood tissue which tunnels the infiltrated tissues. In examining such an ulcer one gets the impression of a great pigmented scar, the centre of which has broken down.

Lymphangitis and venous thrombosis are not of infrequent occurrence in connection with varicose ulcers, while embolism and even pyemia are sometimes in evidence. Among the most frequent complications is cellulitis, andthis may sometimes be so severe as to necessitate operation. Erysipelas may also occur in cases of varicose ulcer, and hemorrhage is a common and serious complication and has at times been fatal.

Differential Diagnosis

CALLOUS VARICOSE SYPHILITIC
History :
injury varicose veins or phlebitis.syphilis.
Situation :
where the injury occurred.usually in lower third of leg.usually upper third of leg, posterior aspect.
Base :
shallow, inflamed, often grayish yellow.bluish, pigmented, granulations, sluggish, usually superficial.dirty, sloughing, deep, often greenish in color.
Edges :
not elevated or thickened.undermined or thickened space, very irregular.punched out thin and undermined shape, round or serpiginous.
Surrounding area :
red and inflamed.pigmented, varicose veins, often edema and eczema.dusky red, scars of old syphilitic ulcers.
Healing :
rapid under antiseptic treatment.support of veins, operate and remove veins.mercury and iodides necessary, or neosalvarsan.

Treatment. The treatment of varicose ulcers must be based on antiseptic cleanliness, and the improvement ofnutrition by improvement of the circulation of the blood and lymph. Then again the treatment will vary according to the time when the ulcer is first seen by the surgeon. In aggravated ulcers, especially those accompanied by crusts, foul smelling discharges and various inflammatory conditions, the leg should be washed once or twice daily with soap and water, cleansed with a piece of sterile gauze, and shaved when necessary. Warm applications should be employed such as Wright's solution, boric acid; Thiersch and the stronger antiseptics are uncalled for, as they often induce eczema. Under such treatment, in most cases, the swelling and irritation will subside and the ulcer will become clean and more healthy in appearance, especially if the patient be confined to bed with elevation of the limb. Rest always seems to the patient a useless waste of time, but in reality time is thus saved. It is by far the most important point in the treatment of ulcers of the leg in which poor circulation is a factor, but the plan must be carried out consistently in order to obtain the best results. The condition does not admit of occasionally walking about the house or of sitting in a chair. However, when circumstances do not permit of the recumbent position, the veins can be supported in various ways. Bandages of plain rubber, or rubber cloth, or cloth woven and rendered elastic by the character of mesh, or elastic stockings, or flannel, gauze, or muslin bandages, can be used. It is preferable to use flannel bandage (see Therapeutic measures) for the reasons mentioned. The best means of obtaining the support, however, is by the use of Unna's Paste. The technic and application of this method of treatment has also been described (Therapeutic measures).

Operations upon varicose veins are frequently called for in aggravated cases, provided the general condition of the patient permits. Briefly, these many consist in multiple ligations, in ligation of the internal saphenous alone, in extirpations of large or small sections of varices, in circumcision of the skin above the ulcer, or of the ulcer itself, tying all the veins and reuniting the cuticle. However, it must not be forgotten that in the presence of an ulcer, infection of an operative wound is likely to occur.

Syphilitic Ulcers  may result from pustules or they may begin as tertiary sores. They occur frequently where the integument is thin or where the part is kept moist by the natural secretions. The deep ulcers of tertiary syphilis develop from gummata. These are variously sized deposits largely made up of large spheroidal cells and a few giant cells. They are poorly supplied with blood vessels and undergo coagulation necrosis, but do not tend to suppurate until infected. Sooner or later the overlying skin becomes involved, either with or without a pyogenic infection, and the gumma sloughs out leaving the typical syphilitic ulcer. A protozoa microbe (Schaudinn's and Hoffmann's organism) is now the recognized cause of syphilis. It is called the spirochaeta pallida  or treponema pallidum.

Symptoms. When a syphilitic ulcer develops it usually assumes one of two types, superficial or deep. The former may appear comparatively early in the disease. It usually varies in size from a quarter to a half dollar piece, has a circular outline, sharply cut, indurated edges, and a dirty greenish base. The deep ulcers result from the breaking down of gummata. They are, at the beginning, surrounded by a reddened area of inflammation, the small ones being crater like, with punched out edges, the larger ones having overhanging, thin, soft, inflamed edges. The base is indurated, of a dusty red color and dirty or sloughing in appearance, the slough being often of a greenish color. The discharge is thin, frequently bloody, and contains debris from the broken down gumma. The surrounding skin is indurated, of a dusky red color and dirty or sloughing in for some time, they loose their characteristic appearance and take on the form of simple chronic ulcers. The scar remaining is characteristic. It is thin, of a dead white color, pigmented here and there, and when pinched it wrinkles like tissue paper. Thin form of syphilitic ulcer is found most frequently on the upper third of the leg. When ulcers are accompanied by enlarged veins, it is extremely difficult at times to make a differential diagnosis between a luetic ulcer and one of a varicose type. The chief differential points are as follows:

Location :

    Varicose ulcers, the lower third of the leg.

    Syphilitic ulcers, the middle and upper third of the leg.

Appearance :

    Varicose, irregular, not undermined, granulations reddish.

    Syphilitic, typical punched out edges, sharp, and undermined, greyish discharge, thin and watery.

Number :

    Varicose usually single.

    Syphilitic, multiple, having a tendency to coalesce and form one large ulcer.

A very important point to remember is that a syphilitic ulcer, once healed, usually remains so. At times it is extremely difficult, even in view of the different points already mentioned, to make a distinct diagnosis between a varicose and a syphilitic ulcer; then the Wasserman reaction should be resorted to, but too much stress should not be placed upon its findings. It may happen that a patient having a suspected luetic ulcer is given mercurial treatment with the result that the reaction is negative, but this should not exclude the possibility of syphilis existing. A positive Wasserman in a case of chronic ulcer with enlarged veins which refuses to heal, warrants a diagnosis of a syphilitic lesion. In a great many cases the Noguchi luetin skin reaction is of great aid in establishing a diagnosis.

Treatment. The treatment is both local and general. As regards local treatment, if the ulcer secretes freely, either the black wash or a solution of bichloride, varying from 1 to 5000 to 1 to 10000 should be employed. Where there is very little discharge, calomel powder is indicated. In addition, it is understood that a firm compression bandage be applied (especially in those cases complicated with enlarged veins) beginning at the base of the toes and carried up to the knee.

The general treatment consists of the intravenous injection of salvarsan or neosalvarsan (10 grains), or the intramuscular injection of bichloride of mercury, one quarter of a grain, or 10 minims of a 10 per cent. suspension of salicylate of mercury. In addition, mercurial rubs and the administration of iodides and mercury internally are advised.

A Tuberculous Ulcer  usually results from the bursting through the skin of a tuberculous abscess. The base is, soft, pale and covered with feeble granulations, and gray shreddy sloughs. The edges are of a dull blue or purple color and gradually thin out toward their free margins, and in addition, are characteristically undermined, so that a probe can be passed for some distance between the floor of the ulcer and the thinned out borders. At times the edges are solid and puckered, being scarlike in character. Thin, devitalized tags of skin often stretch from side to side of the ulcer. The outline is irregular, small perforations often occur through the skin and a thin watery discharge containing shreds of tuberculous debris escapes. The ulcer is usually superficial and very little pain is present. At times it is crusted over, the crust being thin and of a brown or black color. Again it may be progressing at one point and healing at another. It is slow in advancing but often proves very destructive. The scars left by its healing are firm and corrugated, but are apt to break down.

Treatment. The local treatment calls for special mention. If the ulcer is of limited extent, the most satisfactory method is complete removal by means of the knife, scissors, or sharp spoon, of the ulcerated surface and of all of the infected area around it, so as to leave a healthy surface from which granulations may spring. If the raw surface left is likely to result in cicatricial contraction, skin grafting should be employed.

The general treatment should consist of tonics, plenty of fresh air, and a good nutritious diet. Bowels must be regulated.

Perforating Ulcer of the Foot  occurs in connection with lowered resisting powers of the tissues, due usually to some lesion of the nerves or vessels. The ulcer is circular in shape, painless, with callous borders, and eats progressively into the deeper tissues and bones, and has little or no tendency to heal.

Etiology. Although formerly looked upon as a specific disease, perforating ulcer is now known to depend upon many local and general conditions of which it is occasionally a more or less accidental manifestation. The various theories as to its immediate causation may be divided into: (1) mechanical, (2) vascular, (3) nervous, (4) mixed.

The Mechanical Theory  regards injury as the sole cause, due in most instances to the pressure or rubbing of a shoe. If this explanation were adequate, however, such ulcers would be extremely common, while in reality they are rare.

The Vascular  theory assumes that arteriosclerosis is always present, and causes ischemic necrosis through arterial and capillary thrombosis.

The Nerve  theory, which is the one most commonly accepted, is that perforating ulcer is always of trophic origin and depends upon a chronic peripheral neuritis. In support of this assertion, attention is called to certain interstitial and parenchymatous alterations frequently demonstrable in the nerves of the affected part. It must not be forgotten, however, that these nerve changes may be due to secondary disturbances in nutrition, depending upon arteriosclerosis as in senile, diabetic, and other forms of gangrene.

According to the Mixed Theory  either vessels or nerves, or both may be at fault. It admits that traumatism is an important factor, although seldom if ever an exclusive cause. Perforating ulcer is observed in connection with various diseases and conditions, the most prominent of which are locomotor ataxia, fractures of the spine, injuries of the cord, diabetes, spina bifida, syringomyelitis and injury and division of the peripheral nerves. Perforating ulcer from lesions of the central nervous system is comparatively rare and it is doubtful if it is ever due to embolism or to ligation of the arteries.

The three most prominent causes, therefore are, (1) affections of the spinal cord (2) injuries of the peripheral nerves and (3) diabetes.

This variety of ulcer is seen more frequently in males than in females, and it is almost exclusively confined to adults, especially between the ages of forty and sixty. Occupations requiring standing or walking are strong predisposing causes, provided a tendency to the disease exists. A poor fitting shoe and deformities of the foot giving rise to excessive pressure or irritation, are of much importance in determining the appearance and location of the ulcer. It rarely appears in children, unless it is associated with spina bifida.

Symptoms. Perforating ulcer has a marked tendency to develop where pressure and irritation are greatest, which is almost always upon the sole of the foot at the junction of the great or little toe with the metatarsus. It may occur, however, upon the heel, the sides of the foot, the plantar surface of any portion of the great toe, or even upon the centre of the sole, these unusual situations being most commonly found associated with diabetes. When talipes or hammertoe exists, the ulcer is apt to occur wherever pressure is pronounced, even upon the dorsum of the foot or the ends of the toes. Usually but one foot is affected, although both feet may be involved, in which case the disease is termed symmetrical.

Three stages may be recognized in the development of the ulcer: (1) the formation of callosities, (2) superficial ulceration, (3) deep ulceration. Very frequently in tabes and in diabetes, a purulent blister is the first indication of trouble, but usually a marked epithelial thickening, in the form of a corn or a bunion, is the initial symptom. Sooner or later the centre of a callosity breaks down into a bluish, unhealthy, indolent, superficial ulcer, secreting a small quantity of watery pus, and with an offensive odor. The sore is circular as though punched out of the callous tissue, the latter at times so thickened and overhanging that the ulcer is almost concealed beneath it. There is little or no tendency to heal, even under exacting treatment, and if recovery should take place, a speedy relapse is the rule, even with the patient remaining in bed. The indolent and foul ulcer tends to eat deeply into the adjacent tissues, progressively involving bursae, tendons, muscles, joints, and bones. A deep round hole results, which may even perforate the foot. The most striking symptoms are chronicity, stubborn resistance to treatment, and the absence of pain and tenderness.

The fact that perforating ulcer is so often found in connection with lesions of the nervous system accounts for the abnormalities of sensation, motion and reflexes which accompany it. This explains the various trophic disturbances which are very often observed, such as epithelial growth, not only in the vicinity of the ulcer, but occasionally over the entire foot and leg; also eczema, erythema and excessive perspiration. The nails are frequently thickened and distorted and the subcutaneous cellular tissues are so changed as even to suggest elephantiasis. Inflammatory complications, sometimes serious, are not uncommon owing to infection through the ulcer, and an ascending neuritis may even result in myelitis. Gangrene from arteriosclerosis is also frequently seen.

Treatment  in those predisposed to diabetes and tabes, deserves prophylaxis consideration. The shoes must fit accurately and without undue pressure; much walking is to be avoided; when ulceration has begun the recumbent position and cleanliness are of paramount importance. The callous epidermis should be removed so as to render the ulcer as superficial as possible. Dead bone must be scraped away or extracted, if in the form of a sequestrum, and drainage must be perfected by enlarging the opening. Sinuses should be enlarged and any pockets found should be thoroughly opened. It must be emphasized, however, that operative interference should be undertaken with care and discretion in order to avoid necrosis and infection. Periodic curettments and cauterizations with silver nitrate are often of benefit, as are also the employment of dry iodoform gauze as a packing, together with the occasional use of various moist dressings. Both the constant and interrupted currents of electricity have been resorted to with benefit, sometimes locally and sometimes applied to the spinal cord or affected nerves. Measures directed to the improvement of the circulation of the foot, such as massage, stimulating baths, and lotions, are of service.

Bier's Arterial Hyperemia, in the form of baking of the foot by means of a gas or electric apparatus, especially devised for the purpose (Tyrnauer) is of great benefit, more so when there is a neuritis accompanying the ulcer. The baking should be done once a day for from ten to twenty minutes, and the temperature should be gradually increased from 100°F. to 300°F., depending upon the patient's ability to tolerate heat.

The passive, venous or obstructive form of hyperemia is absolutely contraindicated in this class of ulcers. The initial cause of the trouble must receive attention, because upon its successful management depends the cure, much more so than upon the local measures.

Diabetics and syphilitics should receive appropriate treatment. The bad cases, especially where gangrene or serious infection exists, may require amputation, but unless this can be done in sound tissue with adequate innervation, a perforating ulcer may develop upon the area exposed to the pressure of an artificial limb. Resection of joints is usually of little benefit. The most satisfactory operative results in this class of ulcers have been obtained by stretching the posterior tibial nerve, together with scraping the ulcer, or, better, by excising it, followed by immediate suture of the wound. The operation is best done through a curved incision beneath the internal malleolus, the nerve being isolated and vigorously stretched in both directions by means of some blunt instrument inserted beneath it. Sometimes the external or internal plantar nerve alone is treated in this manner.

Blastomycotic Ulcer. This is not a common condition in the lower extremity. It is found near the lower third of the leg, and begins as a papule or papulo-pustule, soon becoming covered with a crust which, on removal, discloses a papillomatous area. The typical ulcer is elevated, verrucous or fungating, with a soft base which is infiltrated with a seropurulent secretion. The border is dark-red or purple and slopes more or less abruptly through the normal skin, from which it is sharply defined. The quickest and most positive method of differentiation is by means of the tissues. The organisms are fungi, known as the blastomycetes, saccharomyces or yeasts, characterized especially by their mode of multiplication or cell division, called budding.

Treatment. In all cases, thorough cleansing of the ulcer with antiseptic lotions, as previously described, is of great benefit. Complete extirpation of the ulcerative lesions has been successful, but curetting does not always prevent their recurrence. Potassium or sodium iodide in large doses (totaling from 100 to 400 grains per day) and radiotherapy seem to be the most efficacious forum of treatment. Copper sulphate in a 1 per cent. solution as a wash for external use and also in one quarter of a grain doses internally, has in some cases given good results.

Epitheliomatous Ulcer. In none of the more common ulcerative skin lesions would the conditions for the development of cancer seem to be more favorable than in chronic dermatitis with ulceration; the despised and neglected varicose ulcers of the leg. The extreme chronicity of the inflammatory process, often lasting for many years; the age of the patient, which is usually advanced; the almost inconceivable neglect of the lesion in many cases, so that the persistent presence of foul and decomposing secretion and of the products of tissue necrosis is common: the frequent absence of even an attempt at cure; the fact that most of these patients are compelled to be on their feet all day and thus keep up and increase the unfavorable conditions; and, finally the circumstance that in many of them the added history of alcoholism, of renal or cardiac disabilities, or of other chronic affections is also present; all of these factors would lead to the presumption that in this ulcerative lesion, above all others, carcinomatous degeneration would be the most common.

While so few instances of cancer secondary to varicose ulceration are seen, it rarely appears before the age of forty. It is usually seen where varicose ulcers as well as the scars they produce are found. The base of the characteristic ulcer is hard, nodular and irregular, made up of firm warty granulations, and often covered with sloughs. It bleeds easily and has a foul discharge. The edges are hard and everted. The borders and base present a peculiar and striking thickness and hardness, as though the ulcer were imbedded in cartilage, while the granulations feel firm and appear red and warty. The amount of pain, the involvement of neighboring lymphatic glands and the rate of growth vary. Epitheliomata which have developed from congenital warts, moles, or nevi are apt to be very malignant. When epitheliomatous degeneration occurs in a chronic ulcer, it first begins to get hard about the edges, which become everted and gradually bound down to the deeper tissues. The granulations about the margins become large, red, nodular, hard and bleed very readily. This condition spreads over the entire ulcer, which assumes a sloughing and foul character. The diagnosis is confirmed by the microscopic examination of a section cut from the edge of the ulcer.

Treatment. Malignant ulcer can be cured only by the destruction or removal of the new growth. For its treatment, caustics with or without curetting, excision or radiotherapy may be employed. The best caustics are arsenic, chloride of zinc, caustic potash and formalin.

The objections to this method are the extreme pain; the lack of certainty as to the removal of all of the neoplasm; the fact that the lymphatics and glands are not dealt with, as well as the fact that unless the treatment is thorough, the growth is stimulated rather than retarded. The scar is also apt to be unsightly. Without doubt excision forms the best method of treatment. The incision should be wide of the ulcer, and all indurated tissues and any lymphatics or glands that are involved must be removed.

In some cases it may be necessary even to amputate the leg in order to effect a cure. The X-rays from the Coolidge tube are to be recommended, as the cross fire effect of these rays in some cases is of great benefit. Recently radium has been used in these ulcers of the leg with good results. The gamma rays are to be preferred as they are more penetrating and should be applied two or three hours a day for a number of days. At least from 50 to 200 milligrams of radium bromide must be used in order to obtain any effect. Recently beta rays have been found to be as effective as the gamma rays. In order to prevent a radium burn the rays have to be filtered before they are applied.