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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 œdematous; and there is pain and tenderness both in the sore itself and in the parts around.
Classification of Ulcers.—The nomenclature of ulcers is much involved and gives rise to great confusion, chiefly for the reason that no one basis of classification 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 constitutional 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 classification; 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 classification,—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 Röntgen 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.
Fig. 14.—Leg Ulcers associated 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 illustrated 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 associated 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 associated with a diffuse brownish or bluish pigmentation of the skin of the lower third of the leg, or with an obstinate form of dermatitis (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 hæmorrhage 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, Ĺ“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 Ĺ“dematous, and as a rule there is little pain. This variety of ulcer is particularly prone to pass into the condition known as callous.
In anæmic patients, especially young girls, ulcers are occasionally met with which have many of the clinical characters of those associated with imperfect venous return. They are slow to heal, and tend to pass 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.
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 association 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 associated 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 passed 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 constitution, 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.
Fig. 16.—Bazin's Disease in a girl æt. 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.
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
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