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 phlebitis. | syphilis. |
| Situation: | ||
| where the injury occurred. | usually in lower third of leg. | usually upper third of leg, posterior aspect. |
| Base: | ||
| shallow, inflamed, often grayish yellow. | bluish, pigmented, granulations, sluggish, usually superficial. | dirty, sloughing, deep, often greenish in color. |
| Edges: | ||
| not elevated or thickened. | undermined or thickened space, very irregular. | punched out thin and undermined shape, round or serpiginous. |
| Surrounding area: | ||
| red and inflamed. | pigmented, varicose veins, often edema and eczema. | dusky red, scars of old syphilitic ulcers. |
| Healing: | ||
| rapid under antiseptic treatment. | support of veins, operate and remove veins. | mercury and iodides necessary, 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: