ULCERS
=Definition.= An ulcer is a lesion of a cutaneous or mucous surface,
caused by a molecular disintegration of the superficial parts, usually
attended by more or less suppuration. A wound, or superficial loss of
tissue due to traumatism, is not primarily an ulcer, but may become
such if the healing process is arrested or the wound becomes infected
with pyogenic microorganisms.
The following ulcers frequently come under the observation of the
podiatrist:
=Simple Ulcer=, a local non-constitutional lesion attended with no
marked pain or inflammation.
=Indolent or Callous Ulcer=, a chronic lesion, with hard, elevated
edges and few or no granulations and showing no tendency to heal.
=Varicose Ulcer=, localized destruction of the skin over a varicose
vein, usually of the leg, due to mechanical pressure, to nutritive
disturbances, or to bacterial action.
=Perforating Ulcer of the Foot=, malum perforans pedis, a round, deep,
trophic lesion of the sole of the foot, following disease or injury (in
any part of its course from the centre to the periphery) of the nerve
supplying the parts.
=Syphilitic Ulcer=, due to syphilis in late secondary or in tertiary
stages.
Before describing the characteristics of the various forms of lesions
just mentioned, together with their differential diagnosis, treatment,
etc., it is deemed advantageous to briefly discuss the general etiology
and pathology of all ulcers.
=Etiology.= One or several factors may be concerned in the etiology of
ulcers, which are grouped under: (a) predisposing causes; (b) exciting
causes. The first group includes local as well as general causes.
=Predisposing Causes.= Age can hardly be considered as a very important
factor, except that old age is accompanied by retrogressive tissue
changes, hardening of the arteries, impaired circulation, etc., and one
would therefore expect the statistics to show a greater proportion of
ulcers during the later years of life.
As regards sex, ulcer is more common among men than women in the ratio
of about three to one. Alcoholism, syphilis, and traumatism may in
some measure explain why ulcers are more common in men than women.
Occupation seems to have little to do with the etiology beyond the fact
that it may predispose to various forms of infection, and it is due to
this element that we have the most important factors in the causation
of ulceration. Varicose ulcer is always associated with varicose veins
in the lower extremity, and these may be described as veins whose
valves are incompetent. The most obvious cause of the breaking down
of the valves is hard work, that is the lifting or carrying of heavy
loads, as in the case of laborers, freight handlers, and longshoremen.
The great strain occasioned by work of this kind lays a heavy load
upon the veins of the legs. Whether the valves become useless through
stretching of the vein walls, or are directly broken, is immaterial.
The occupations which involve standing for long periods without moving
the legs are, in a lesser degree, a source of valvular incompetence,
and this is not from excessive back pressure but from stasis due to
lack of muscular movement. Among women, the venous engorgement of the
legs, so often seen in pregnancy, may, after the birth of several
children, result in varicosity.
Many of the constitutional diseases such as gout, anemia, diabetes,
syphilis, and tuberculosis, which lower the vitality of the tissues,
and other conditions, such as valvular disease of the heart, general
obesity, and arterial hardening which prevent proper circulation,
predispose to the formation of ulcers when there is in addition some
exciting cause.
Embolism, which cuts off the nutrition of the part, may also act as a
local cause. Certain vasomotor disturbances, such as occur in frost
bite and in Raynaud’s disease, may produce small areas of localized
gangrene which subsequently become the seat of an ulcer.
Interference with the return of venous blood from a part predisposes to
ulceration. Where phlebitis and periphlebitis occur, especially in the
smaller venous radicles, small abscesses often form, the adjacent skin
becomes involved, and an ulcer results; or the rupture of the diseased
wall of one of the small veins may become infected, and ulcer develops.
Perforating ulcer of the foot is a frequent complication of tabes
dorsalis. Myelitis, and other pathologic conditions of the nervous
system may also, either through trophic changes or by reason of
impaired sensation, bear a distinct relationship to ulcerative
processes.
=Exciting Causes.= Traumatism is one of the most frequent causes of
ulcer formation. Its degree may, of course, vary greatly, and whether
it will produce an ulcer depends upon one or more of the predisposing
causes already mentioned. Infection by any of the staphylococcus or
streptococcus group of organisms as well as by the tubercle bacillus
will produce ulcers; malignant ulceration also occurs.
=Pathology.= The pathology will vary according to the conditions
causing the ulcer, although in the non-specific forms of ulcer
the phenomena of congestion, exudative and necrotic inflammation,
together with reparative inflammation or granulation, will only be
in evidence. In the development of an ulcer the degenerative process
predominates; in the healing stage, the reparative. When the ulcer
develops from without, as when infection enters the skin through an
abrasion, congestion first occurs. This is rapidly followed by the
emigration of leucocytes, by a diapedesis of red blood cells which
rapidly disintegrate, and by an exudation of serum and fibrin. At
the same time there is a proliferation of the epithelial cells and
also a proliferation of the connective tissue cells of the corium. The
tissue next becomes softened by the exudate between the cells. Then,
as a result of the pressure of the exuded serum, of the crowding by
the leucocytes, and of the cutting off of the blood supply, and also
in some measure through the effects of the toxins furnished by the
bacteria, there occurs necrosis of the cells, which are thrown off
from the surface with the products of exudation, until there is formed
an ulcer with its base consisting of spheroidal and a few epithelioid
cells developed from the connective tissue cells by proliferation.
When an ulcer in its complete stage of development is examined,
the surface is found to be covered with a layer formed by the
overproduction of new round cells, together with the exudate of fibrin,
serum, and the cellular elements of the blood. When the discharge from
the ulcer is profuse, this may be constantly washed away. When the
ulcer is sluggish, it may be in a condition of coagulation necrosis. In
this latter condition a croupous material covers the base of the ulcer,
and below this is a more or less distinct layer, largely composed of
cellular elements, with very little cellular substance, the cells being
spheroidal and epithelioid in character and mingled with polynuclear
leucocytes. As we go deeper, the amount of intercellular substance
increases, and a number of transparent fibres and fusiform cells are
found. In this layer of granulation tissue are also the newly formed
blood vessels, the most superficial branches being vertical to the
surface, and developing by a process of budding from the endothelial
cells of the capillaries deeper down. This layer is paler in color than
the layer made up of the cellular elements, but may contain pigment
from the disintegration of the red blood cells. It gradually merges
into a layer of cicatricial connective tissue which lies beneath the
ulcer.
A section of a chronic ulcer would show an enlargement and
prolongation of the papillæ, with a marked proliferation of
the epithelial cells covering them. This is most pronounced in
the condition known as callous ulcer, where the edges may, by
proliferation, be considerably raised about the level of the
surrounding skin, and often overhang the base of an ulcer. Under proper
treatment the reparative process proceeds faster than the degeneration
of the cells and the ulcer begins to heal by granulation. Small sprouts
or buds of protoplasm protrude from the capillaries below or in the
base of the ulcer, developing from the cells in their walls. These
are hollowed out by the blood pressure and form new blood vessels
which anastomose with others. Nuclei form in the protoplasm and thus
endothelial cells develop. At the same time small spheroidal cells,
developing from the connective tissue cells, become grouped around
the blood vessels. These are closely crowded together at first, being
separated by only a small amount of fluid intercellular substance. Some
of the round cells then become larger and fusiform or branched. The
larger cells are known as epithelioid cells. Some of the fusiform and
branched cells, called fibroblasts, develop the new delicate fibrillar
intercellular substance, while others form the connective tissue cells.
Gradually the fibrous intercellular substance increases in amount,
while the cells become fewer and flattened, and cicatricial tissue
is formed. The contraction of this cicatricial tissue constitutes an
important element in the healing of an ulcer.
During the process of granulation, more of the round cells are produced
than are necessary. These die and are thrown off in the discharge.
Healthy granulations should be small, even, and of a reddish pink
color. Where the growth of the blood vessels proceeds more rapidly than
the development of the cells and the formation of connective tissue,
there is produced a soft, pale, flabby condition known as exuberant
granulations, or proud flesh. On the other hand, both the cells and the
blood vessels may develop very slowly, forming indolent or sluggish
granulations. In order that the ulcer may heal it must eventually
become covered with epithelium, and this can develop only from the
epithelium at the edges of the ulcer. Under favorable conditions,
when the granulations reach the level of the surrounding skin, the
epithelium begins to spread in a thin bluish white line from the edges
out over the surface, until the latter is entirely covered, when the
ulcer is healed.
=Simple Ulcers.= By far the greatest number of ulcers coming under the
observation and within the province of the podiatrist are of the simple
variety. Heavy calloused areas which are neglected are apt to become so
irritant as to cause the softer tissues underneath to break down and
ulcerate, and a similar condition very often occurs in connection with
helomata, particularly heloma molle.
Constitutional diseases, either trophic or specific, may be
predisposing causes of these conditions but the exciting cause is
surely traumatism.
Simple ulcerations are most generally found upon the plantar surfaces
of the feet, under the heads of the first or fifth metatarsal bones. As
has been previously mentioned, however, the interdigital surfaces are
also prone to these conditions. In this latter location the amount of
perspiration excreted in the locality undoubtedly has much to do with
the lowering of the vitality of the skin covering the part, and renders
it susceptible to disintegrative processes.
=Treatment.= All the overlying callous must be immediately removed
so that the parts may be properly cleansed and so that drainage may
be maintained. This may be done with a sharp sterile scalpel, but
sufficient care should be exercised so that no hemorrhage is caused.
After the hardened tissue has been cut away, all necrosed tissue
adhering to the floor and edges of the ulcer should be removed. A spray
of alcohol, 60%, may then be employed to obtain thorough asepsis and
after the parts are thoroughly dried, a dressing is applied in keeping
with the conditions present.
=Wet Dressing.= If infection is present, or if the parts be
considerably inflamed, due simply to the traumatic irritation, a
wet dressing of mercury bichloride, ¹⁄₄₀₀₀, liq. aluminum acetate,
or alcohol and boric acid, equal parts, should be employed for a
sufficient time to reduce all infective or other inflammatory symptoms.
Bichloride of mercury should not be used for a prolonged period of time
in these cases, for its corrosive action will prevent new granulations
and thus retard healing. The aluminum acetate and alcohol, boric acid
combination may be used without fear of toxic irritation. If simple
inflammation is present in the parts, Goulard’s extract may be employed
to reduce the acute symptoms, but care must be exercised and the parts
watched so that no lead dermatitis shall develop from the drug.
It is unwise under any condition to prolong the use of wet dressings
beyond a time when they are thought to be necessary. The constant
moisture is not conducive to prolific or to healthy granulation and
for this reason these applications are best discontinued as soon as
possible.
=Boroglycerine=, a combination of boric acid and glycerine, applied to
a simple ulceration, particularly one of the indolent type, is found to
stimulate granulation and thus aid materially in the healing process.
It is applied on sterile gauze and allowed to remain unchanged for from
twenty-four to forty-eight hours.
=Dry Dressings.= Dry dressings, either of plain aseptic gauze or
of dusting powders, are found effective in the treatment of simple
ulcerations. The choice of the dusting agent is, of course, dependent
upon the conditions present, but it should combine astringent and
antiseptic properties.
=Thymol Iodide=, while not astringent, is a general favorite for most
simple ulcerations. Contrary to the action of most powders, this
combination of iodine and thymol induces a discharge rather than
prevents it. This is due to the action of its constituent thymol and
is desirable in dry ulcerations where more or less coagulation is
present. This powder, known best by its trade name, aristol, has an
energetic, antiseptic action due to the liberation of iodine and is
used practically to the exclusion of all other iodine powders. It
is principally used as an iodoform substitute, having none of the
disagreeable odor of this drug.
=Bismuth Subgallate=, a combination of gallic acid and bismuth, is an
efficient powder for use in these conditions. Its action is markedly
astringent and it can be depended upon for antiseptic action as well.
=Bismuth Subnitrate= is also an astringent and antiseptic powder which
may be substituted for the other bismuth salt in these conditions. The
molecules of this powder are very fine and there is a tendency for it
to cake so that when used, the dressing should be changed at regular
and short intervals; the parts should be thoroughly cleansed of the
dried powder from previous application before the new dressing is
applied.
=Zinc Powders=, such as the oxide and the stearate, are also applicable
in cases of simple ulcer. Zinc oxide may be combined with various other
powders and numerous such combinations are now in the market. Zinc
stearate is used alone and can be depended upon for a mild astringent
action, although not comparable with either bismuth subgallate or
subnitrate.
=Ointment Dressings.= The use of ointments is contra-indicated in the
presence of a discharging surface and for this reason drugs in fatty or
oily bases are not generally used in all stages of ulcer regeneration.
Several ointments may be used, however, either for antiseptic or
stimulative action after the acute discharge, if present, has subsided
or if no great amount or exudation is present.
=Ung. Hydrargyri Ammoniati=, white precipitate of mercury, will be
found useful where antiseptic action is desired.
=Ung. Acidi Borici=, an antiseptic ointment, is also used in this
connection.
=Ung. Acidi Tannici=, twenty parts of tannic acid, twenty parts
glycerine, sixty parts cerate, is an astringent ointment efficient in
these cases.
=Ung. Eucalypti= is used as an antiseptic and stimulant application for
indolent ulcers.
=Ung. Zinci Oxidi= is a soothing and mildly astringent ointment which
can be used advantageously.
=Ung. Balsam of Peru=, a 3% to 10% ointment of Peruvian balsam in
vaseline or lanolin, is both antiseptic and stimulant.
=Scarlet Red=, an ointment prepared from medicinal scarlet red
(Biebrich), may be used in strengths from 1% to 8% as a stimulant and
healing application.
In the use of all ointments it is advisable to place only a thin film
of the mass over the parts. Avoid the tendency to use a large quantity
of any ointment.
A shield may, at times, be used in connection with the application
of the dry or of the ointment dressing. These appliances, however,
particularly if made from a thick material, tend to arrest the
circulation to the localized area, and, as free blood flow is to be
desired at all times, the shield should be omitted in cases in which an
ointment dressing is being used, unless it is sure that circulation is
not being thereby impeded.
Squares of sterile gauze held in place by adhesive strips or by a
soft cocoon dressing, are practical means of retaining a powder or an
ointment to the part. In choosing the latter form of dressing, never
use a great amount of collodion in binding down the cotton fibre. If
applied too freely, it is absorbed by the cotton and is apt to come in
contact with the ulcerated surface itself. The dressing, if applied
over a discharging area, should be absorbent, and this possibility is
nullified when it is hardened by collodion.
INDOLENT OR CALLOUS ULCER.
This form of ulcer occurs principally on the leg, but occasionally is
found on the foot and ankle. Callous ulcers vary in size from a five
cent piece to the entire circumference of the part attacked.
The surface is usually smooth and glistening and of a dirty yellow
color, with perhaps a few badly formed granulations. The edges are hard
and sharply cut and elevated considerably above the surface, while the
surrounding skin may be inflamed over the margin and is either covered
with sodden cuticle or is congested. The skin surrounding the part
is often deeply pigmented from chronic congestion, the pigmentation
starting in separate papillæ as maculae, which gradually coalesce. The
discharge is purulent or serous and may be so abundant and irritating
as to cause eczema of the skin. The base is adherent to the underlying
tissues and this constitutes one of the main difficulties in healing,
as contraction is thus prevented. If the ulcer is situated above a
bone, such as the tibia, chronic periostitis may result. Such ulcers
are sometimes very painful from pressure on cutaneous nerves, or from a
localized cellulitis associated perhaps with inflammation of veins and
lymphatics. Thrombosis not infrequently occurs in both sets of vessels,
leading to chronic edema of the feet.
=Etiology.= _General Causes_: (a) Various devitalizing fevers and
diseases such as typhoid, scorbutus, diphtheria, chronic nephritis,
etc. (b) Mineral poisoning, such as is produced by phosphorus. (c)
Anemia and debilitating conditions brought on by starvation, improper
food, poor hygiene, overwork, lack of sleep, etc.
_Local Causes_: (a) Old scar tissue, the contraction of which has cut
off the circulation. (b) Continuous pressure, from splints, lying in
bed, etc. (c) Local destruction of the tissues such as is produced by
extremes of heat and cold. (d) Local irritation or injury of tissues
from violence. (e) Various diseases of the skin, for example, pemphigus.
=Symptoms.= These ulcers are most commonly found on the inner side of
the lower third of the leg. They show great variety in size, shape and
appearance, of base, edges, and surrounding area, and in accordance
with these differences, many different names are applied to them. They
may be round, very irregular, or funnel-shaped, as in perforating
ulcer of the foot. When the granulations are large, irregular, and
bleed easily, they are spoken of as exuberant or fungating; when
pale, soft and flabby, as weak or edematous; when small and growing
slowly, as indolent. Sometimes the base is covered with a grayish or
yellowish-white necrotic layer formed of fibrin and necrotic cellular
elements. When this is removed, no granulations appear, but instead it
presents a smooth, shining base resembling mucous membrane. This form
is known as the croupous ulcer. The edges also vary greatly. They may
be irregular or sharply cut, moderately thickened, or very much so,
due to chronic congestion and edema, with enlargement of the papillæ
and proliferation of the epithelial cells. When this is a prominent
feature, the name callous ulcer is applied. The edges may be adherent
to the deeper structures, thus preventing contraction and healing; they
may be rounded, elevated, undermined, or overhanging.
The discharge from an ulcer is usually slight in amount, serous in
character, and contains very few pus cells. The surrounding area may
be swollen, red, congested, pigmented, edematous, eczematous, or the
ulcer may be surrounded by smaller sores, by vesicles, or by masses
of varicose veins. As a rule, there is an absence of severe pain
accompanying leg ulcers, unless there is an exposure or involvement of
some nerve filaments; but frequently, after the patient has been on his
feet for a long time, there is a dull, aching pain in the part, due to
chronic congestion which causes tension in and about the ulcer.
=Differential Diagnosis.= The diagnosis of a chronic indolent or
callous ulcer can be easily made by the character of the granulations
and by the location of the ulcer itself. The history points usually to
an injury or infection and the situation of the sore is at the site
of the previous injury or infection. The base is shallow, inflamed
and often of a grayish-yellow color, with no thickening or elevation
of its edges. The surrounding area is usually round and inflamed. A
varicose ulcer is differentiated by the history of varicose veins or
phlebitis, by its occurrence at the lower third of the leg and by the
undermined thickened and irregular-shaped edges. A syphilitic ulcer is
diagnosed by the history of lues; by its usual occurrence at the upper
third of the leg; by a dirty sloughing and deep base; by punched out,
thin, dense, firm and undermined red edges; and by scars of a dusky red
color. A tuberculous ulcer, by the history of previous glandular bone
or lung disease; soft, pale, edematous granulations; thin undermined
edges; involvement of glands and other signs of tubercular sinuses,
bone disease, etc. A perforating ulcer, by the history of the case; the
appearance of the ulcer upon the sole of the foot or in the vicinity of
the heel; the presence of a sinus leading to necrosed bone; the pale,
flabby granulations; all these signs should make the diagnosis easy.
[Illustration: CHRONIC ULCER OF THE FOOT
(BEFORE OPERATION)]
=Treatment.= This naturally depends upon the stage at which the
ulcer is seen and the conditions present. If there is considerable
inflammation, accompanied by marked cellulitis and pain, wet dressings
are indicated. Two distinct therapeutic actions may be derived
from the wet compress, depending upon whether or not an impervious
covering is employed. These actions are antiphlogistic and hyperemic,
and these in turn may be either antiseptic or astringent. The wet
dressing, without a covering, is cleansing and heat reducing,
because of evaporation. There should be frequent replenishment of
the solution where there is considerable discharge, or where it is
desirable to reduce inflammation. A wet dressing with an impervious
covering is contra-indicated in the presence of pus, the warmth and
moisture of such a dressing, being congenial to the growth and to
the multiplication of bacteria. For the relief of pain and for the
reduction of inflammation, wet dressings are the most effective form of
treatment because (1) they are aseptic; (2) they permit free drainage;
(3) no new granulations are disturbed in changing the dressing.
A great many different solutions are used and among these are: (1)
sterile water; (2) ordinary saline solution (a teaspoonful of salt
to a pint of water); (3) saturated solution of boric acid (prepared
by dissolving a teaspoonful of boric acid in a pint of water); (4)
Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid
and 90 grains of boric acid in a pint of water); (5) Burow’s solution
(prepared by dissolving 675 grains of alum and 270 grains of lead
acetate in a pint of water); (6) solution of bichloride of mercury
(varying in strength from 1 to 3,000 to 1 to 10,000); (7) lead and
opium wash (U. S. P.); (8) Dakin’s solution (hypochlorite of soda).
After the reduction of the inflammation, the next step is the cleansing
and sterilization of the ulcer. Before healthy granulations can
form, the removal of sloughs and the cleansing of the base must be
accomplished as thoroughly as possible. Many means toward this end may
be effective. A one-half to two per cent. creolin or lysol emulsion
is very useful for those dirty ulcers from which a profuse, foul
discharge escapes. A one per cent. solution of formalin is of great
value for smaller ulcers, especially those due to tuberculous disease.
The destruction and removal of sloughs may be hastened by cauterization
with the solid stick of nitrate of silver. The use of certain ferments,
such as brewer’s yeast, papoid, or protonuclein, may help to clean up
a chronic ulcer. The most frequent means employed for the cleansing
and sterilization of the ulcer, previous to the application of some
stimulating dressing, is washing the part with tincture of green soap
and water. Peroxide of hydrogen can next be used, then sulphuric
ether, and finally ninety-five per cent. alcohol. Where there is an
accompanying eczematous condition, the scales can best be removed with
benzine.
[Illustration: CHRONIC ULCER OF THE FOOT
(AFTER OPERATION)]
Having reduced the inflammation and succeeded in cleansing the ulcer,
the next thing to consider is the means by which granulations may be
stimulated. This may be accomplished by applications in the form of
powders, solutions, ointments and grafts.
Dusting powders are employed either as antiseptics or as astringents
or for both purposes. Their use in this instance is limited, and they
are employed only where the secretion is scanty. Among the various
powders used are: aristol, dermatol, boric acid, orthoform, calomel,
protonuclein, alum, zinc oxide, etc. Thymol iodide, or aristol, is
a superior antiseptic powder and enjoys the advantage over iodoform
of being inodorous. Iodoform should be used only in tuberculous
conditions; calomel only in syphilitic cases. Dermatol, or bismuth
subgallate, combines the astringent and mildly antiseptic qualities of
bismuth and gallic acid. Boric acid is mildly antiseptic. Zinc oxide
and alum are both astringent. Scarlet red, five per cent., with boric
acid, ninety-five per cent., is indicated when the granulations are
sluggish.
Among the various solutions used are silver nitrate in various
strengths, zinc and copper sulphate, ichthyol, balsam of Peru, and
calamine. Silver nitrate, zinc and copper sulphates are employed for
their astringent action. Balsam of Peru, fifty per cent., with castor
oil, fifty per cent., is used for its stimulating action.
Ointments are used in the treatment of ulcers either to stimulate the
granulations or to soften thick epidermis. Ointments should never be
employed where there is a profuse discharge. Many different kinds of
ointments are used, prominent among them being: balsam of Peru, in a
ten per cent. strength for the stimulation of the granulations; boric
acid and ichthyol, in the same strength; Lassar’s paste (which consists
of salicylic acid, one dram; starch and zinc oxide, each one ounce,
and vaseline to make four ounces). This latter ointment is especially
indicated when there is an eczema present. An ointment which has given
good results is scarlet red, 1% to 5%. Scarlet red (Biebrich) was
originally prepared as a dye for wool and silk, and is so named because
of the fact that it was first manufactured in the town of Biebrich.
Its application to granulating surfaces induces healing, not by the
formation of scar tissue, but in every case by producing a high grade
of normal skin which very soon becomes freely movable on the underlying
tissue. The return of sensation in the healed area takes place from
the periphery inward, instead of upward from the underlying tissue.
Usually the dressing should be left undisturbed for from twenty-four to
forty-eight hours, then reapplied, as indications warrant. In removing
the dressing, if it be adherent to the granulations, peroxide of
hydrogen should be used to loosen it. The skin about the granulating
surface is best cleansed by benzine, as this removes all traces of
scarlet red better than any other solution. The following formulas are
recommended:
Scarlet red (medicinal Biebrich) fifteen grains; ungt. acidi borici, q.
s. ad three ounces (one per cent.).
Scarlet red (medicinal Biebrich), forty-five grains; ungt. zinci oxidi,
q. s. ad three ounces (three per cent.).
Scarlet red (medicinal Biebrich), seventy-five grains; balsam of Peru,
seventy-five minims; petrolati, q. s. ad three ounces (five per cent.).
The first is indicated where scarlet red is desired over a large area
and for a long time; the second, where an astringent action is required
because the granulations are profuse; the third, where the granulations
are sluggish and require stimulation.
VARICOSE ULCER.
=Etiology.= To chronic ulcers of the leg, associated with varicose
veins, especially of the smaller venous radicles, the name varicose
ulcer has been given. The usual development of this variety of ulcer
is as follows: persons who suffer from varices of the leg usually
complain, for some time before the external manifestation of the
disease, of a dull, aching pain in the limb, with a sense of weight,
fullness and fatigue. In a more advanced state of the disease the
ankles swell after a day’s hard work, and the feet are constantly
cold; an embarrassed state of circulation is denoted by these symptoms
and the deep-seated veins begin to swell. After a time, which varies
with the idiosyncrasy and occupation of the patient, small, soft,
blue tumors are seen at different points of the leg, most of them
disappearing on pressure, but returning when it is removed, or when
the patient stands up. Each little tumor is caused by a vein, dilated
at the point at which it is joined by an intramuscular branch. Around
many of these tumors a number of minor vessels of a dark purple color
are clustered; these are the small superficial veins which enter the
dilating vein and in which the passage of the blood is retarded. An
increasing area of veins gradually becomes involved and a number
of irregular, knotty, consolidated tumors are developed, grouping
themselves around the point at which the dilatation first began. The
external and internal saphenous veins are those primarily affected,
but long tracts of tortuous veins may extend up the leg and thigh.
Dangerous and even fatal hemorrhage may ensue from the bursting of a
varix through the skin. The vessels may become filled with clots and
permanently obstructed, and ulceration with thrombosis or phlebitis
may be the sequel. The capillaries become engorged with blood, and
hence the assimilation changes are retarded and sometimes altogether
checked. Gradually the entire circulation of the part is arrested. The
vitality of the superficial structures becomes permanently impaired;
consequently they are unable to resist the effects of slight injuries
and repair fails to take place after a portion has been destroyed, and
an open sore or ulcer is established.
=Symptoms.= The varicose ulcer is usually single, oval, round or
irregular in outline, and is most often seen on the lower third of
the leg near the internal or external malleolus. The edges are thick,
everted, and swollen. The swelling is largely due to edema and is found
to pit on pressure. The floor is generally covered with rather large
granulations which bleed freely when touched. In a varicose ulcer the
destruction of tissue often begins at the margin of a congested area
and advances toward the centre. The size varies from the small ulcers,
less than one-half inch in diameter, formed by the breaking down of an
area of periphlebitis around a small vein, to those several inches in
diameter. Several ulcers may be present on one limb. The granulations,
as a rule, are weak and flabby. The discharge is thin, serous, mixed
with débris, and may be blood-stained. The skin surrounding a varicose
ulcer is often of a brownish blue color, due to a deposit of pigment.
The recognition of varicose ulcers is usually easy; but the mere
presence of enlarged veins, it should be noted, is not pathognomonic,
because they may exist along with ulcers of other origin--the luetic,
trophic, etc. The most frequent complication is phlebitis; cellulitis
is also seen. This latter may sometimes be so severe as to necessitate
operation. Complications such as necrosis of bone, involvement and
ankylosis of the ankle joint, together with atrophy and contracture
of muscles and adhesions of tendons (perhaps giving rise to various
deformities of the feet, such as flat foot or even club-foot) are
extreme and unusual complications.
Where the varicose ulcers have persisted for a long time and refuse
to heal, it is always advisable to apply the Wassermann test in order
to exclude the possibility of syphilis. In doubtful cases it is also
advisable to test by the Noguchi luetin skin reaction.
[Illustration: VARICOSE ULCER]
=Treatment.= In these cases of varicose ulcers it is impossible to
effect a cure until the chronic congestion of the limb is relieved
and the blood supply of the part approaches normal. Often all that is
necessary is a gauze, muslin, rubber or flannel bandage.
A bandage, when applied with moderate, even pressure, has for its
purpose the relief of congestion. In a great many cases rubber has an
irritating effect upon the skin, and that kind of a bandage should
therefore be cautiously used. When the granulations are almost on a
level with the skin, and also where there is considerable thickening
of the edges of the ulcer, the best means of keeping up an even
pressure and causing absorption of the thickened margins, as well as of
hastening epithelial growth, is to apply zinc oxide adhesive plaster
in strips, one-half to one inch in width. These strips should overlap
to the extent of about one-third of their width, should extend about
three-fourths of the way around the limb, and should be evenly and
smoothly applied. They should be started about one inch below the ulcer
and should run from two to three inches above it.
In order to effect a permanent cure, varicose veins must be operated
upon, and a number of operations have been devised, as follows: the
ligation of the internal saphenous, as advised by Trendelenburg; the
multiple percutaneous ligations of Schede; the total extirpation of the
internal saphenous, as recommended by Mayo; the dissection after the
method of Madelung; and the spiral of Rindfleisch.
=Perforating Ulcer of the Foot.= This type of ulcer usually occurs
where pressure and irritation are greatest and is therefore commonly
found on the plantar surface of the foot under the heads of the first
and fifth metatarsal bones, and on the under surface of the great toe.
Occasionally, however, they develop on the dorsal surfaces or ends of
the toes, in cases such as hammer toe.
=Etiology.= There are various theories relative to the causation of
lesions of this nature. One claims injury to be the sole cause; another
attributes it to arteriosclerosis and capillary thrombosis; still
another charges it to chronic peripheral neuritis and alteration in
the nerve terminals. One writer states that traumatism is an important
factor in their development, conceding, however, that various systemic
conditions must necessarily enter into the etiology, among them,
locomotor ataxia and injuries to the spinal cord, diabetes and injuries
to the peripheral nerves. This latter, known as the “mixed theory,”
is the one most generally accredited and is in all probability most
correct.
This type of ulcer is found more frequently in males than in females
and it occurs almost exclusively in adult life (between 40 and 60
years). Occupation is a predisposing factor, and work demanding long
periods of standing or walking unquestionably has much to do with the
development of a perforating ulcer, all other conditions being equal.
[Illustration: POST-OPERATIVE DIABETIC ULCER]
=Characteristics.= The ulcer is usually found to be irregularly
circular in shape, with a tendency to progressive development,
involving the deeper soft tissues, finally attacking the periosteum
and the bone itself, causing necrosis. The superficial edges of the
ulceration are heavily calloused and the lesion shows little or no
tendency to heal. One of the most marked characteristics is the entire
loss of sensation. Many cases have been observed where the patient
feels no pain, even when the lesion is deeply probed.
=Symptoms.= At times, particularly in diabetic patients, a purulent
blister is the initial lesion, but in most instances these lesions
develop under a heavy callous, the centre of which breaks down into
an indolent superficial ulceration, discharging a thin, discolored,
odorous pus, but never in great quantities.
The fact that changes in the peripheral nerve supply usually take place
in the development of perforating ulcer probably accounts for the
absence of pain, as above mentioned, and also explains the progressive
degeneration which takes place, allowing the ulcerative process to
progress into the deeper tissues.
=Treatment.= The systemic disturbances which may be present are
important factors to be considered in the treatment of perforating
ulcer, but local applications may be made and local conditions must
be considered. If the ulcer be upon the plantar surfaces of the foot,
walking and standing, which would bring continued pressure, must be
avoided. Shoes must be well fitted and must not irritate the parts,
and cleanliness must be obtained and maintained. All callous must be
removed from the edges of the ulcer and proper drainage is of great
importance. All necrosed tissue must necessarily be removed and any
burrowing sinuses should be thoroughly opened. Artificial hyperemia,
massage and electricity are found to be of benefit in improving the
general circulation in the foot and leg.
In the local treatment of the ulceration itself, prolonged application
of strong germicidal solutions is to be avoided at all times. Cleansing
with warm normal salt solution is recommended as a non-toxic and
stimulant application.
Dressings may be of plain aseptic or iodoform gauze packed lightly into
the ulcer. These lesions are discouraging to treat, inasmuch as even
after complete healing, relapses usually occur which leave the parts as
bad or worse than the original lesion.
Stimulant applications may be employed locally, with some success in
connection with internal medications for the systemic disturbance
present. Balsam of Peru or scarlet red (1% to 3%) are advocated in this
connection.
The prognosis in cases of perforating ulcer is bad, inasmuch as the
progress of the lesion sooner or later involves sufficient tissue in
the degenerative process to necessitate surgical interference--perhaps
amputation of the foot. As has been previously mentioned, even when
fully healed, relapse almost always occurs.
=The Syphilitic Ulcer.= The syphilitic ulcers do not properly come
within the province of the podiatrist for treatment, but he should be
able to recognize them. They may develop from pustules or begin as
original lesions in the tertiary stages of the disease. Developing in
this latter instance from gummata, they are immediately deep ulcers.
The worst superficial ulcers of syphilis may develop early in the
course of the general disease.
[Illustration: SYPHILITIC ULCER OF THE LEG]
=Symptoms.= These ulcers vary in size from a quarter to a silver dollar
and occur on the upper third of the leg, occasionally on the upper
part of the middle third. During the early stages of the lesion it is
surrounded by an inflamed area of skin at the ulcer and presents an
even, “punched out” edge. Being a new growth, developed in the corium,
the edges are usually more firm and dense than in other forms of
ulcer. The floor of the lesion is of a dusky red or coppery color,
and has a characteristic slough of a greenish color. The discharge is
frequently bloody and is filled with broken-down tissue.
If on account of the presence of enlarged veins, it is difficult to
distinguish a syphilitic from a varicose or other type of ulcer, a
positive Wassermann test will confirm the diagnosis.
Being merely a local manifestation of a general infection, the systemic
disturbance must be treated by a licensed physician. It is generally
found that a lesion of this type, once healed, remains so.
=Treatment.= Treatment for syphilitic ulcers comprehends the use of
mercurials as local applications. Mercury bichloride ¹⁄₁₀₀₀₀ may
be employed with beneficent results in most cases where a profuse
discharge is present. Where there is little or no discharge, calomel
powder dusted into the ulcer will give good results.
As in most cases where a syphilitic lesion has developed locally on the
leg, the patient is or has been under a physician’s care, practically
none of these cases come to the podiatrist for his treatment alone.
Many times, however, he is called in by the physician to do local
dressings under his direction, and it has even happened that the
podiatrist has been the first to recognize the significance of the
local lesion.