Alexis Thomson and Alexander Miles - Manual of Surgery

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

[Illustration: 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 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, oedematous 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
oedematous, and as a rule there is little pain. This variety of ulcer is
particularly prone to pass 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 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.

[Illustration: 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.

[Illustration: 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.

[Illustration: 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 assumes 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 _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 oedematous, either from general causes, such as
heart or kidney disease, or from local causes, such as varicose veins,
the granulations share in the oedema, 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.

[Illustration: 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 oedema 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,
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.

[Illustration: 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 oedematous surrounding tissues. Such ulcers are
frequently multiple. Pain is a constant symptom, and is often severe,
and there is usually some constitutional 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
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 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.

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 pharmacopoeial
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 bandages, moist applications, and hot bottles, should be
avoided. Any part liable to pressure, from the position of the patient
or otherwise, must be carefully protected by pads of wool, air-cushions,
or water-bags, and must be kept absolutely dry. The skin should be
hardened by daily applications of methylated spirit.

Should an ulcer form in spite of these precautions, the mildest
antiseptics must be employed for bathing and dressing it, and as far as
possible all dressings should be dry.

The _perforating ulcer_ of the foot calls for special treatment. To
avoid pressure on the sole of the foot, the patient must be confined to
bed. As the main local obstacle to healing is the down-growth of
epithelium along the sides of the ulcer, this must be removed by the
knife or sharp spoon. The base also should be excised, and any bone
which may have become involved should be gouged away, so as to leave a
healthy and vascular surface. The cavity thus formed is stuffed with
bismuth or iodoform gauze and encouraged to heal from the bottom. As the
parts are insensitive an anaesthetic is not required. After the ulcer has
healed, the patient should wear in his boot a thick felt sole with a
hole cut out opposite the situation of the cicatrix. When a joint has
been opened into, the difficulty of thoroughly getting rid of all
unhealthy and infected granulations is so great that amputation may be
advisable, but it is to be remembered that ulceration may recur in the
stump if pressure is put upon it. The treatment of any nervous disease
or glycosuria which may coexist is, of course, indicated.

Exposure of the plantar nerves by an incision behind the medial
malleolus, and subjecting them to forcible stretching, has been employed
by Chipault and others in the treatment of perforating ulcers of the
foot.

The ulcer that forms in relation to callosities on the sole of the foot
is treated by paring away all the thickened skin, after softening it
with soda fomentations, removing the unhealthy granulations, and
applying stimulating dressings.

_Treatment of Ulcers due to Constitutional Causes._--When ulcers are
associated with such diseases as tuberculosis, syphilis, diabetes,
Bright's disease, scurvy, or gout, these must receive appropriate
treatment.

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

For extensive ulcers on the limbs, the chest wall, or on other covered
parts, or when operative treatment is contra-indicated, the use of
tuberculin and exposure to the Rontgen rays have proved beneficial. The
induction of passive hyperaemia, by Bier's or by Klapp's apparatus,
should also be used, either alone or supplementary to other measures.

No ulcerative process responds so readily to medicinal treatment as the
_syphilitic ulcer_ does to the intra-venous administration of arsenical
preparations of the "606" or "914" groups or to full doses of iodide of
potassium and mercury, and the local application of black wash. When the
ulceration has lasted for a long time, however, and is widespread and
deep, the duration of treatment is materially shortened by a thorough
scraping with the sharp spoon.

#Treatment in relation to the Condition of the Ulcer.#--_Ulcers in a
weak condition._--If the weak condition of the ulcer is due to anaemia
or kidney disease, these affections must first be treated. Locally, the
imperfect granulations should be scraped away, and some stimulating
agent applied to the raw surface to promote the growth of healthy
granulations. For this purpose the sore may be covered with gauze
smeared with a 6 to 8 per cent. ointment of scarlet-red, the surrounding
parts being protected from the irritant action of the scarlet-red by a
layer of vaseline. A dressing of gauze moistened with eusol or of
boracic lint wrung out of red lotion (2 grains of sulphate of zinc, and
10 minims of compound tincture of lavender, to an ounce of water), and
covered with a layer of gutta-percha tissue, is also useful.

When the condition has resulted from the prolonged use of moist
dressings, these must be stopped, the redundant granulations clipped
away with scissors, the surface rubbed with silver nitrate or sulphate
of copper (blue-stone), and dry dressings applied.