Surgery, with Special Reference to Podiatry Part 9

where the injury usually in lower usually upper occurred. third of leg. third of leg, posterior aspect.

_Base_:

shallow, bluish, pigmented dirty, sloughing, inflamed, often granulations, deep, often grayish yellow. sluggish, greenish in color.

usually superficial.

_Edges_:

not elevated or undermined or punched out thin thickened. thickened s.p.a.ce, and undermined very irregular. shape, round or serpiginous.

_Surrounding area_:

red and inflamed. pigmented, varicose dusky red, scars veins, often of old syphilitic edema and eczema. ulcers.

_Healing_:

rapid under support of veins, mercury and antiseptic operate and remove iodides necessary, treatment. veins. salvarsan or neosalvarsan.

+Treatment.+ The treatment of varicose ulcers must be based on antiseptic cleanliness, and the improvement of nutrition 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 circ.u.mstances do not permit of the rec.u.mbent 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 circ.u.mcision 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 a.s.sumes 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 b.l.o.o.d.y, 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 Wa.s.serman 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 Wa.s.serman 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 pa.s.sed 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 a.s.sumes 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 a.s.sertion, attention is called to certain interst.i.tial 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 a.s.sociated 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 a.s.sociated with diabetes. When talipes or hammertoe exists, the ulcer is apt to occur wherever pressure is p.r.o.nounced, 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 quant.i.ty 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 rec.u.mbent 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 sc.r.a.ped 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 ma.s.sage, 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 100F. to 300F., depending upon the patient's ability to tolerate heat.

The pa.s.sive, venous or obstructive form of hyperemia is absolutely contraindicated in this cla.s.s 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 cla.s.s of ulcers have been obtained by stretching the posterior tibial nerve, together with sc.r.a.ping 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. Pota.s.sium 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 dermat.i.tis 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 circ.u.mstance 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.