+FISTULAE; FISSURES; SINUSES; ABSCESSES; FURUNCLES; ULCERS+
A +Fistula+ (pl. fistulae) is an abnormal communication between the
surface and an internal part of the body, or between two natural
cavities or canals. The first form is seen in a rectal fistula, the
second in vesicovaginal fistula. Fistulae may result from a congenital
defect and can arise from sloughing, traumatism and suppuration.
Fistulae are named from their situation and communication.
A +Fissure+ is a crack and in podiatry, has special reference to a
condition found in the toeweb.
A +Sinus+ is a tortuous track opening usually upon a free surface and
leading down into the cavity of an imperfectly healed abscess. A sinus
may be an unhealed portion of a wound. Many sinuses may be due to pus,
burrowing subcutaneously. A sinus fails to heal because of the
presence of some irritant fluid (as saliva, urine) or, because of the
existence of some foreign body, as dead bone, a bit of wood, a bullet,
a septic ligature, or because of rigidity of the sinus wall, which
rigidity will not permit collapse. The walls of a tubercular sinus are
lined with a material identical with the pyogenic membrane of a cold
abscess. Sinuses may be maintained by want of rest (muscular
movements) and by general ill-health.
+Treatment.+ In treating a fistula, remove any foreign body; lay the
channel open, curet, touch with pure carbolic acid, and pack with
iodoform gauze. In obstinate cases, entirely extirpate the fibrous
walls; sew the deeper parts of the wound with buried catgut sutures,
and approximate the skin surfaces with interrupted sutures of silkworm
gut. Fresh air is necessary; nutritious food and tonics must be
ordered.
+Acute Abscesses.+ An abscess may be defined as a circumscribed cavity
of new formation, containing pus. An essential part of this definition
is the assertion that the pus is in a cavity of new formation; is an
abnormal cavity; hence pus in a natural cavity (pleural or synovial)
constitutes a purulent effusion, and not an abscess, unless it is
encysted in these localities by walls formed of inflammatory tissue.
An acute abscess is due to the deposition and multiplication of
pyogenic bacteria in the tissues or in inflammatory exudates.
When abscesses form in an internal organ or in some structure which is
not loose like connective tissue, for instance, in a lymphatic gland,
a mass of pyogenic bacteria floating in the blood or lymph, lodges,
and these bacteria, by means of irritant products, cause coagulation
necrosis of the adjacent tissue and inflammatory exudation around it.
The area of coagulation necrosis becomes filled with white blood
cells, and the dry necrosed part is liquefied by the cocci.
Suppuration in dense structures causes considerable masses of tissue
to die and to be cast off, and these masses float in the pus.
An abscess heals by the collapse of its walls, and the formation of an
abundance of granulation tissue; in many cases granulations of one
wall join those of the other side, the entire mass of granulations
being converted into fibrous tissue, and this tissue contracting,
heals by third intention. If the walls do not collapse, the abscess
heals by second intention.
+Symptoms.+ The symptoms of an acute abscess may be divided into (1)
local, (2) constitutional. Locally there is intensification of
inflammatory signs; swelling enormously increases; the discoloration
becomes dusky; the pain becomes throbbing, and the sense of tension
increases; the cutaneous surface is seen to be polished and edematous,
and after a time, pointing is observed and fluctuation can be
detected. The constitutional symptoms are usually limited to chills
and fever, depending upon the severity of the infection.
+Treatment+ is free incision and drainage. The wound should be opened
early, if possible even before pointing or fluctuation, to prevent
destruction, subfascial burrowing, and general contamination; drainage
is continued until the discharge becomes scanty, thin and
seropurulent.
+Chronic Abscess+ is a term referring only to time. Usually a tubercular
abscess is designated as a chronic, cold, or scrofulous abscess. It is
an area of disease produced by the action of the tubercular bacilli
and is circumscribed by a distinct membrane. The symptoms present no
inflammatory signs. Constitutional symptoms are trivial or absent
unless secondary infection occurs. The treatment of these cold
abscesses depends upon their location.
+A Furuncle or Boil+ is an acute and circumscribed inflammation of the
deep layer of the skin and the subcutaneous cellular tissue, following
on bacterial infection of the hair follicle through a slight wound (by
scratching, shaving), with the staphylococcus pyogenes aureus.
+Symptoms.+ The symptoms of a boil are as follows: a red elevation
appears, which stings and itches; this elevation enlarges and becomes
dusky in color, a pustule forms that ruptures and gives out a very
little discharge which forms a crust; inflammatory infiltration of
adjacent connective tissue advances rapidly, and the boil in about
three days consists of a large red, tender, and painful base, capped
by a pustule and some crusted discharge. In rare instances, at this
stage, absorption occurs, but in most cases the swelling increases,
the discoloration becomes dusky, the skin becomes edematous, the pain
severe, and the centre of the boil becomes raised. About the seventh
day rupture occurs, pus runs out, and a core of necrosed tissue is
found in the centre of a ragged opening. The hair follicle and the
sebaceous gland, which have undergone necrosis, are found in this
core. Healing by granulation will occur; the constitution often shows
reaction during the progress of a boil.
Boils may be either single or multiple, and the development of one
boil after another, or the formation of several boils at once, is
known as _furunculosis_.
+Treatment.+ The treatment consists of crucial incision and the
application of a wet dressing.
+An Ulcer+ may be defined as the loss of substance due to necrosis of a
superficial structure, and the causes of ulcers may be divided into
(1) predisposing and (2) exciting. In the former, age, sex, occupation
and social condition have to be considered. The exciting causes are
traumatism and infection.
The chief varieties of ulcers seen on the leg and foot are as follows:
indolent or callous; varicose; tubercular; syphilitic;
epitheliomatous; diabetic; perforating and blastomycotic.
In indolent or callous ulcer, the cause may be divided into general
and local. Among the former may be mentioned typhoid fever, chronic
nephritis, anemia, poor hygiene, improper food, overwork, and lack of
sleep. Local causes: old scar tissue, extremes of heat or cold,
irritation of the tissues, injury, the presence of a foreign body such
as dead bone, splinter, etc.
+Symptoms.+ The most common location of these callous ulcers is on the
inner side of the lower third of the leg. They show a great variety in
size, shape, appearance and base, edges and surrounding area, and in
accordance with these differences, many different names are applied to
them. The size varies from a small ulcer less than one centimeter in
diameter, sometimes found with varicose veins, to the large
ulcerations which surround the leg and are called _annular_ ulcers.
The shape may be round, very irregular, or funnel shaped. The base may
be much or slightly depressed, or the granulations may be at a higher
level than the surrounding edges. When the granulations are large,
irregular, and bleed easily, they are spoken of as _exuberant_; when
pale, soft and flabby, as _weak_ or _edematous_; when small and slowly
growing, as _indolent_.
A peculiarly painful form of chronic ulcer is found over the internal
malleolus, and most frequently in women of middle age; it is often
associated with menstrual disorders and is known as a _congested_ or
_irritable_ ulcer. It begins as a small area of congestion over the
internal malleolus, which gradually increases in size and becomes dark
and more dusky in the centre, due to the deposit of blood pigment
caused by chronic congestion. The skin next becomes hard, dry, scaly
and pigmented, while the subcutaneous tissues lose their elasticity,
becoming inflexible, hard and adherent to the deeper structures. Then,
as a result of slight traumatism or even without injury, the centre of
the area breaks down and an ulcer develops. It may be circular or
irregular in shape and may be quite deep or superficial. The edges are
sharply cut, and both base and edges are bound down to the deeper
tissues. The intense pain of the ulcers is supposed to be due to
pressure upon the terminal nerve filaments in the dense sclerotic
tissue. This form of ulcer is very often difficult to cure and shows a
tendency to return after healing.
+Treatment.+ This naturally depends upon the time the ulcer is seen and
the conditions present. If there is considerable inflammation,
accompanied by marked cellulitis and pain, the milder wet dressings,
such as boric acid or Thiersch are indicated. Rest, of course, is the
most important factor. The patient must be prohibited from walking,
and if necessary, the movements of the neighboring joints must be
prevented by the application of suitable splints. After the acute
inflammatory symptoms have subsided the granulations must be
stimulated, (see Chapter XIX).
+Varicose Ulcer.+ To chronic ulcers of the leg associated with varicose
veins, especially of the smaller venous radicles, the name varicose
ulcer has been given.
+Symptoms.+ 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
deep 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 the 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 this pressure 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 the intramuscular
branch. Around many of these tumors a number of minor vessels of a
dark purple color are clustered, these being the small superficial
veins which enter the dilating vein and in which the varicose ulcer is
often of a brownish blue color, due to a deposit of pigment.
Frequently a leg, which is the seat of varicose veins, or which is
edematous from other causes, is attacked by acute eczema. 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 often exist along with ulcers of other origins, tuberculous,
syphilitic, etc.
The surface of varicose ulcers usually presents imperfect and
unhealthy granulations, secreting a more or less thin and offensive
pus, and the granulations are sometimes covered with membranous
exudation. The edges and base are thickened and callous, and enlarged
veins, capillary or otherwise, are present near the circumference and
often amount to genuine blood tissue which tunnels the infiltrated
tissues. In examining such an ulcer one gets the impression of a great
pigmented scar, the centre of which has broken down.
Lymphangitis and venous thrombosis are not of infrequent occurrence in
connection with varicose ulcers, while embolism and even pyemia are
sometimes in evidence. Among the most frequent complications is
cellulitis, and this may sometimes be so severe as to necessitate
operation. Erysipelas may also occur in cases of varicose ulcer, and
hemorrhage is a common and serious complication and has at times been
fatal.
+Differential Diagnosis+
CALLOUS VARICOSE SYPHILITIC
_History_:
injury varicose veins or syphilis.
phlebitis.
_Situation_:
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 space, 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 circumstances do not permit of the recumbent
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 circumcision 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 assumes 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 bloody, 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
Wasserman 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 Wasserman 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 passed 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 assumes 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 assertion, attention
is called to certain interstitial 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 associated 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 associated with diabetes. When talipes or hammertoe
exists, the ulcer is apt to occur wherever pressure is pronounced,
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 quantity 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 recumbent 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 scraped 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 massage,
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 100°F. to 300°F., depending upon the
patient’s ability to tolerate heat.
The passive, venous or obstructive form of hyperemia is absolutely
contraindicated in this class 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 class of ulcers have been obtained by stretching the posterior
tibial nerve, together with scraping 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. Potassium 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 dermatitis 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 circumstance 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.
While so few instances of cancer secondary to varicose ulceration are
seen, it rarely appears before the age of forty. It is usually seen
where varicose ulcers as well as the scars they produce are found. The
base of the characteristic ulcer is hard, nodular and irregular, made
up of firm warty granulations, and often covered with sloughs. It
bleeds easily and has a foul discharge. The edges are hard and
everted. The borders and base present a peculiar and striking
thickness and hardness, as though the ulcer were imbedded in
cartilage, while the granulations feel firm and appear red and warty.
The amount of pain, the involvement of neighboring lymphatic glands
and the rate of growth vary. Epitheliomata which have developed from
congenital warts, moles, or nevi are apt to be very malignant. When
epitheliomatous degeneration occurs in a chronic ulcer, it first
begins to get hard about the edges, which become everted and gradually
bound down to the deeper tissues. The granulations about the margins
become large, red, nodular, hard and bleed very readily. This
condition spreads over the entire ulcer, which assumes a sloughing and
foul character. The diagnosis is confirmed by the microscopic
examination of a section cut from the edge of the ulcer.
+Treatment.+ Malignant ulcer can be cured only by the destruction or
removal of the new growth. For its treatment, caustics with or without
curetting, excision or radiotherapy may be employed. The best caustics
are arsenic, chloride of zinc, caustic potash and formalin.
The objections to this method are the extreme pain; the lack of
certainty as to the removal of all of the neoplasm; the fact that the
lymphatics and glands are not dealt with, as well as the fact that
unless the treatment is thorough, the growth is stimulated rather than
retarded. The scar is also apt to be unsightly. Without doubt excision
forms the best method of treatment. The incision should be wide of the
ulcer, and all indurated tissues and any lymphatics or glands that are
involved must be removed.
In some cases it may be necessary even to amputate the leg in order to
effect a cure. The X-rays from the Coolidge tube are to be
recommended, as the cross fire effect of these rays in some cases is
of great benefit. Recently radium has been used in these ulcers of the
leg with good results. The gamma rays are to be preferred as they are
more penetrating and should be applied two or three hours a day for a
number of days. At least from 50 to 200 milligrams of radium bromide
must be used in order to obtain any effect. Recently beta rays have
been found to be as effective as the gamma rays. In order to prevent a
radium burn the rays have to be filtered before they are applied.