Manual of Surgery Volume I Part 8

This may be used as a type with which to compare the ulcers seen at the bedside, so that we may determine how far, and in what particulars, these differ from the type; and that we may in addition recognise the conditions that have to be counteracted before the characters of the typical healing sore are a.s.sumed.

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 quant.i.ty of pus.

The discharge is profuse, thin, acrid, and offensive, and consists of pus, broken-down blood-clot, and sloughs. The edges are inflamed, irregular, and ragged, showing no sign of growing epithelium--on the contrary, the sore may be actually increasing in area by the breaking-down of the tissues at its margins. The surrounding parts are hot, red, swollen, and dematous; and there is pain and tenderness both in the sore itself and in the parts around.

#Cla.s.sification of Ulcers.#--The nomenclature of ulcers is much involved and gives rise to great confusion, chiefly for the reason that no one basis of cla.s.sification has been adopted. Thus some ulcers are named according to the causes at work in producing or maintaining them--for example, the traumatic, the septic, and the varicose ulcer; some from the const.i.tutional element present, as the gouty and the diabetic ulcer; and others according to the condition in which they happen to be when seen by the surgeon, such as the weak, the inflamed, and the callous ulcer.

So long as we retain these names it will be impossible to find a single basis for cla.s.sification; and yet many of the terms are so descriptive and so generally understood that it is undesirable to abolish them. We must therefore remain content with a clinical arrangement of ulcers,--it cannot be called a cla.s.sification,--considering any given ulcer from two points of view: first its _cause_, and second its _present condition_.

This method of studying ulcers has the practical advantage that it furnishes us with the main indications for treatment as well as for diagnosis: the cause must be removed, and the condition so modified as to convert the ulcer into an aseptic healing sore.

A. #Arrangement of Ulcers according to their Cause.#--Although any given ulcer may be due to a combination of causes, it is convenient to describe the following groups:

_Ulcers due to Traumatism._--Traumatism in the form of a _crush_ or _bruise_ is a frequent cause of ulcer formation, acting either by directly destroying the skin, or by so diminishing its vitality that it is rendered a suitable soil for bacteria. If these gain access, in the course of a few days the damaged area of skin becomes of a greyish colour, blebs form on it, and it undergoes necrosis, leaving an unhealthy raw surface when the slough separates.

_Heat_ and _prolonged exposure to the Rontgen rays_ or _to radium emanations_ act in a similar way.

The _pressure_ of improperly padded splints or other appliances may so far interfere with the circulation of the part pressed upon, that the skin sloughs, leaving an open sore. This is most liable to occur in patients who suffer from some nerve lesion--such as anterior poliomyelitis, or injury of the spinal cord or nerve-trunks.

Splint-pressure sores are usually situated over bony prominences, such as the malleoli, the condyles of the femur or humerus, the head of the fibula, the dorsum of the foot, or the base of the fifth metatarsal bone. On removing the splint, the skin of the part pressed upon is found to be of a red or pink colour, with a pale grey patch in the centre, which eventually sloughs and leaves an ulcer. Certain forms of _bed-sore_ are also due to prolonged pressure.

Pressure sores are also known to have been produced artificially by malingerers and hysterical subjects.

[Ill.u.s.tration: FIG. 14.--Leg Ulcers a.s.sociated with Varicose Veins and Pigmentation of the Skin.]

_Ulcers due to Imperfect Circulation._--Imperfect circulation is an important causative factor in ulceration, especially when it is the _venous return_ that is defective. This is best ill.u.s.trated in the so-called _leg ulcer_, which occurs most frequently on the front and medial aspect of the lower third of the leg. At this point the anastomosis between the superficial and deep veins of the leg is less free than elsewhere, so that the extra stress thrown upon the surface veins interferes with the nutrition of the skin (Hilton). 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. In a considerable number of cases, but by no means in all, this form of ulcer is a.s.sociated with the presence of varicose veins, and in such cases it is spoken of as the _varicose ulcer_ (Fig. 14).

The presence of varicose veins is frequently a.s.sociated with a diffuse brownish or bluish pigmentation of the skin of the lower third of the leg, or with an obstinate form of dermat.i.tis (_varicose eczema_), and the scratching or rubbing of the part is liable to cause a breach of the surface and permit of infection which leads to ulceration. Varicose ulcers may also originate from the bursting of a small peri-phlebitic abscess.

Varicose veins in immediate relation to the base of a large chronic ulcer usually become thrombosed, and in time are reduced to fibrous cords, and therefore in such cases haemorrhage is not a common complication. In smaller and more superficial ulcers, however, the destructive process is liable to implicate the wall of the vessel before the occurrence of thrombosis, and to lead to profuse and it may be dangerous bleeding.

These ulcers are at first small and superficial, but from want of care, from continued standing or walking, or from injudicious treatment, they gradually become larger and deeper. They are not infrequently multiple, and this, together with their depth, may lead to their being mistaken for ulcers due to syphilis. The base of the ulcer is covered with imperfectly formed, soft, dematous granulations, which give off a thin sero-purulent discharge. The edges are slightly inflamed, and show no evidence of healing. The parts around are usually pigmented and slightly dematous, and as a rule there is little pain. This variety of ulcer is particularly p.r.o.ne to pa.s.s into the condition known as callous.

In _anaemic_ patients, especially young girls, ulcers are occasionally met with which have many of the clinical characters of those a.s.sociated with imperfect venous return. They are slow to heal, and tend to pa.s.s into the condition known as weak.

_Ulcers due to Interference with Nerve-Supply._--Any interference with the nerve-supply of the superficial tissues predisposes to ulceration.

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.

The _acute bed-sore_ is a rapidly progressing form of ulceration, often amounting to gangrene, of portions of skin exposed to pressure when their trophic nerve-supply has been interfered with.

[Ill.u.s.tration: FIG. 15.--Perforating Ulcers of Sole of Foot.

(From Photograph lent by Sir Montagu Cotterill.)]

The _perforating ulcer of the foot_ is a peculiar type of sore which occurs in a.s.sociation with the different forms of peripheral neuritis, and with various lesions of the brain and spinal cord, such as general paralysis, locomotor ataxia, or syringo-myelia (Fig. 15). It also occurs in patients suffering from glycosuria, and is usually a.s.sociated with arterio-sclerosis--local or general. Perforating ulcer is met with most frequently under the head of the metatarsal bone of the great toe. A callosity forms and suppuration occurs under it, the pus escaping through a small hole in the centre. The process slowly and gradually spreads deeper and deeper, till eventually the bone or joint is reached, and becomes implicated in the destructive process--hence the term "perforating ulcer." The flexor tendons are sometimes destroyed, the toe being dorsiflexed by the unopposed extensors. The depth of the track being so disproportionate to its superficial area, the condition closely simulates a tuberculous sinus, for which it is liable to be mistaken.

The raw surface is absolutely insensitive, so that the probe can be freely employed without the patient even being aware of it or suffering the least discomfort--a significant fact in diagnosis. The cavity is filled with effete and decomposing epidermis, which has a most offensive odour. The chronic and intractable character of the ulcer is due to interference with the trophic nerve-supply of the parts, and to the fact that the epithelium of the skin grows in and lines the track leading down to the deepest part of the ulcer and so prevents closure. While they are commonest on the sole of the foot and other parts subjected to pressure, perforating ulcers are met with on the sides and dorsum of the foot and toes, on the hands, and on other parts where no pressure has been exerted.

The _tuberculous ulcer_, so often seen in the neck, in the vicinity of joints, or over the ribs and sternum, usually results from the bursting through the skin of a tuberculous abscess. The base is soft, pale, and covered with feeble granulations and grey shreddy sloughs. The edges are of a dull blue or purple colour, and gradually thin out towards their free margins, and in addition are characteristically undermined, so that a probe can be pa.s.sed for some distance between the floor of the ulcer and the thinned-out edges. Thin, devitalised 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 grey shreds of tuberculous debris, escapes.

_Bazin's Disease._--This term is applied to an affection of the skin and subcutaneous tissue which bears certain resemblances to tuberculosis. It is met with almost exclusively between the knee and the ankle, and it usually affects both legs. It is commonest in girls of delicate const.i.tution, in whose family history there is evidence of a tuberculous taint. The patient often presents other lesions of a tuberculous character, notably enlarged cervical glands, and phlyctenular ophthalmia. The tubercle bacillus has rarely been found, but we have always observed characteristic epithelioid cells and giant cells in sections made from the edge or floor of the ulcer.

[Ill.u.s.tration: FIG. 16.--Bazin's Disease in a girl aet. 16.]

The condition begins by the formation in the skin and subcutaneous tissue of dusky or livid nodules of induration, which soften and ulcerate, forming small open sores with ragged and undermined edges, not unlike those resulting from the breaking down of superficial syphilitic gummata (Fig. 16). Fresh crops of nodules appear in the neighbourhood of the ulcers, and in turn break down. While in the nodular stage the affection is sometimes painful, but with the formation of the ulcer the pain subsides.

The disease runs a chronic course, and may slowly extend over a wide area in spite of the usual methods of treatment. After lasting for some months, or even years, however, it may eventually undergo spontaneous cure. The most satisfactory treatment is to excise the affected tissues and fill the gap with skin-grafts.

[Ill.u.s.tration: FIG. 17.--Syphilitic Ulcers in region of Knee, showing punched-out appearance and raised indurated edges.]

The _syphilitic ulcer_ is usually formed by the breaking down of a cutaneous or subcutaneous gumma in the tertiary stage of syphilis. When the gummatous tissue is first exposed by the destruction of the skin or mucous membrane covering it, it appears as a tough greyish slough, compared to "wash leather," which slowly separates and leaves a more or less circular, deep, punched-out gap which shows a few feeble unhealthy granulations and small sloughs on its floor. The edges are raised and indurated; and the discharge is thick, glairy, and peculiarly offensive.

The parts around the ulcer are congested and of a dark brown colour.

There are usually several such ulcers together, and as they tend to heal at one part while they spread at another, the affected area a.s.sumes a sinuous or serpiginous outline. Syphilitic ulcers may be met with in any part of the body, but are most frequent in the upper part of the leg (Fig. 17), especially around the knee-joint in women, and over the ribs and sternum. On healing, they usually leave a depressed and adherent cicatrix.

The _s...o...b..tic ulcer_ occurs in patients suffering from scurvy, and is characterised by its prominent granulations, which show a marked tendency to bleed, with the formation of clots, which dry and form a spongy crust on the surface.

In _gouty_ patients small ulcers which are exceedingly irritable and painful are liable to occur.

_Ulcers a.s.sociated with Malignant Disease._--Cancer and sarcoma when situated in the subcutaneous tissue may destroy the overlying skin so that the substance of the tumour is exposed. The fungating ma.s.ses thus produced are sometimes spoken of as malignant ulcers, but as they are essentially different in their nature from all other forms of ulcers, and call for totally different treatment, it is best to consider them along with the tumours with which they are a.s.sociated. Rodent ulcer, which is one form of cancer of the skin, will be discussed with new growths of the skin.

B. #Arrangement of Ulcers according to their Condition.#--Having arrived at an opinion as to the cause of a given ulcer, and placed it in one or other of the preceding groups, the next question to ask is, In what condition do I find this ulcer at the present moment?

Any ulcer is in one of three states--healing, stationary, or spreading; although it is not uncommon to find healing going on at one part while the destructive process is extending at another.

_The Healing Condition._--The process of healing in an ulcer has already been studied, and we have learned that it takes place by the formation of granulation tissue, which becomes converted into connective tissue, and is covered over by epithelium growing in from the edges.

Those ulcers which are _stationary_--that is, neither healing nor spreading--may be in one of several conditions.

_The Weak Condition._--Any ulcer may get into a weak state from receiving a blood supply which is defective either in quant.i.ty or in quality. The granulations are small and smooth, and of a pale yellow or grey colour, the discharge is small in amount, and consists of thin serum and a few pus cells, and as this dries on the edges it forms scabs which interfere with the growth of epithelium.

Should the part become dematous, either from general causes, such as heart or kidney disease, or from local causes, such as varicose veins, the granulations share in the dema, and there is an abundant serous discharge.

The excessive use of moist dressings leads to a third variety of weak ulcer--namely, one in which the granulations become large, soft, pale, and flabby, projecting beyond the level of the skin and overlapping the edges, which become pale and sodden. The term "proud flesh" is popularly applied to such redundant granulations.

[Ill.u.s.tration: FIG. 18.--Callous Ulcer, showing thickened edges and indurated swelling of surrounding parts.]

_The Callous Condition._--This condition is usually met with in ulcers on the lower third of the leg, and is often a.s.sociated with the presence of varicose veins. It is chiefly met with in hospital practice. The want of healing is mainly due to impeded venous return and to dema and induration of the surrounding skin and cellular tissues (Fig. 18). The induration results from coagulation and partial organisation of the inflammatory effusion, and prevents the necessary contraction of the sore. The base of a callous ulcer lies at some distance below the level of the swollen, thickened, and white edges, and presents a glazed appearance, such granulations as are present being unhealthy and irregular. The discharge is usually watery, and cakes in the dressing.

When from neglect and want of cleanliness the ulcer becomes inflamed, there is considerable pain, and the discharge is purulent and often offensive.

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. In the macerated bone "the surface is covered with irregular, stalact.i.te-like processes or foliaceous ma.s.ses, which, to a certain extent, follow the line of attachment of the interosseous membrane and of the intermuscular septa" (Cathcart) (Fig. 19). When the whole thickness of the soft tissues is destroyed by the ulcerative process, the area of bone that comes to form the base of the ulcer projects as a flat, porous node, which in its turn may be eroded. These changes as seen in the macerated specimen are often mistaken for disease originating in the bone.

[Ill.u.s.tration: FIG. 19.--Tibia and Fibula, showing changes due to chronic ulcer of leg.]

The _irritable condition_ is met with in ulcers which occur, as a rule, just above the external malleolus in women of neurotic temperament. They are small in size and have prominent granulations, and by the aid of a probe points of excessive tenderness may be discovered. These, Hilton believed, correspond to exposed nerve filaments.

_Ulcers which are spreading_ may be met with in one of several conditions.

_The Inflamed Condition._--Any ulcer may become acutely inflamed from the access of fresh organisms, aided by mechanical irritation from trauma, ill-fitting splints or bandages, or want of rest, or from chemical irritants, such as strong antiseptics. 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 dematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some const.i.tutional disturbance.

The _phagedaenic condition_ is the result of an ulcer being infected with specially virulent bacteria. It occurs in syphilitic ulcers, and rapidly leads to a widespread destruction of tissue. It is also met with in the throat in some cases of scarlet fever, and may give rise to fatal haemorrhage by ulcerating into large blood vessels. All the local and const.i.tutional signs of a severe septic infection are present.

#Treatment of Ulcers.#--An ulcer is not only an immediate cause of suffering to the patient, crippling and incapacitating him for his work, but is a distinct and constant menace to his health: the prolonged discharge reduces his strength; the open sore is a possible source of infection by the organisms of suppuration, erysipelas, or other specific diseases; phlebitis, with formation of septic emboli, leading to pyaemia, is liable to occur; and in old persons it is not uncommon for ulcers of long standing to become the seat of cancer. 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.