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The scorbutic 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 associated 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 masses 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 associated. 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 quantity 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 Ĺ“dematous, either from general causes, such as heart or kidney disease, or from local causes, such as varicose veins, the granulations share in the Ĺ“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.
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 associated 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 œdema 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 hyperæmia 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, stalactite-like processes or foliaceous masses, 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.
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 œdematous surrounding tissues. Such ulcers are frequently multiple. Pain is a constant symptom, and is often severe, and there is usually some constitutional disturbance.
The phagedænic 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 hæmorrhage by ulcerating into large blood vessels. All the local and constitutional 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 pyæmia, 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.
Steps must be taken to facilitate the venous return from the ulcerated part, and to ensure that a sufficient supply of fresh, healthy blood reaches it. The septic element must be eliminated by disinfecting the ulcer and its surroundings, and any other sources of irritation must be removed.
If the patient's health is below par, good nourishing food, tonics, and general hygienic treatment are indicated.
Management of a Healing Sore.—Perhaps the best dressing for a healing sore is a layer of Lister's perforated oiled-silk protective, which is made to cover the raw surface and the skin for about a quarter of an inch beyond the margins of the sore. Over this three or four thicknesses of sterilised gauze, wrung out of eusol, creolin, or sterilised water, are applied, and covered by a pad of absorbent wool. As far as possible the part should be kept at rest, and the position should be adjusted so as to favour the circulation in the affected area.
The dressing may be renewed at intervals, and care must be taken to avoid any rough handling of the sore. Any discharge that lies on the surface should be removed by a gentle stream of lotion rather than by wiping. The area round the sore should be cleansed before the fresh dressing is applied.
In some cases, healing goes on more rapidly under a dressing of weak boracic ointment (one-quarter the strength of the pharmacopœial preparation). The growth of epithelium may be stimulated by a 6 to 8 per cent. ointment of scarlet-red.
Dusting powders and poultice dressings are best avoided in the treatment of healing sores.
In extensive ulcers resulting from recent burns, if the granulations are healthy and aseptic, skin-grafts may safely be placed on them directly. If, however, their asepticity cannot be relied upon, it is necessary to scrape away the superficial layer of the granulations, the young fibrous tissue underneath being conserved, as it is sufficiently vascular to nourish the grafts placed on it.
Treatment of Special Varieties of Ulcers.—Before beginning to treat a given ulcer, two questions have to be answered—first, What are the causative conditions present? and second, In what condition do I find the ulcer?—in other words, In what particulars does it differ from a healthy healing sore?
If the cause is a local one, it must be removed; if a constitutional one, means must be taken to counteract it. This done, the condition of the ulcer must be so modified as to bring it into the state of a healing sore, after which it will be managed on the lines already laid down.
Treatment in relation to the Cause of the Ulcer.—Traumatic Group.—The prophylaxis of these ulcers consists in excluding bacteria, by cleansing crushed or bruised parts, and applying sterilised dressings and properly adjusted splints. If there is reason to fear that the disinfection has not been complete, a Bier's constricting bandage should be applied for some hours each day. These measures will often prevent a grossly injured portion of skin dying, and will ensure asepticity should it do so. In the event of the skin giving way, the same form of dressing should be continued till the slough has separated and a healthy granulating surface is formed. The protective dressing appropriate to a healing sore is then substituted. Pressure sores are treated on the same lines.
The treatment of ulcers caused by burns and scalds will be described later.
In ulcers of the leg due to interference with the venous return, the primary indication is to elevate the limb in order to facilitate the flow of the blood in the veins, and so admit of fresh blood reaching the part. The limb may be placed on pillows, or the foot of the bed raised on blocks, so that the ulcer lies on a higher level than the heart. Should varicose veins be present, the question of operative treatment must be considered.
When an imperfect nerve supply is the main factor underlying ulcer formation, prophylaxis is the chief consideration. In patients suffering from spinal injuries or diseases, cerebral paralysis, or affections of the peripheral nerves, all sources of irritation, such as ill-fitting splints, tight
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