The diagnosis of an ulcer includes the recognition of its condition and its cause. The determination of the former depends upon a careful observation of its features, whilst to recognize the latter necessitates many cases, in addition, an examination of the general condition of the patient, a history of the progress of the sore, the detection of any concomitant affections, and possibly bacteriological and microscopic investigations.<Callout type="important" title="Important">Always document the ulcer's shape and edge carefully.</Callout> The base of an ulcer may exhibit special characteristics such as those which constitute it a sinus or a fistula. The edge of the ulcer may be sloughy and irregular when the process is still advancing, or 'punched-out' when a slough has separated; or rounded and thickened, indicating a chronic stationary ulcer.<Callout type="risk" title="Risk">Infiltrated edges can indicate a secondary condition like granuloma or carcinoma.</Callout> The tissues surrounding the ulcer may be quite healthy, showing the limited character of the lesion, or inflamed or eczematous. The examination of the upper and immediately surrounding tissues may reveal the nature of the underlying tissues imme diately distant from the heart (the tissue being more vascular in proportion to its distance from the heart). When found upon paralysed limbs, the cause is most likely to be some trophic condition.<Callout type="tip" title="Tip">Look for signs of systemic conditions like diabetes or renal disease when ulcers are widespread.</Callout> Certain forms of ulceration are almost limited to definite regions of the body, e.g. lupus to the face and arms, rodent deer to the upper half of the face, varicose ulcers to the lower half of the leg, soft sores to or near the genitals, tuberculous ulcers to the neck or over bones and joints.<Callout type="warning" title="Warning">Avoid misdiagnosis by recognizing that a single ulcer can be syphilitic.</Callout> Ulcers may be classified into three main groups: spreading, healing, or stationary. Spreading ulcers show an entire absence of granulations over the base, which is either uneven and spongy in appearance, or more or less completely covered with sloughs; an uneven, irregular, inflamed, or sloughing edge; and an inflamed or edematous condition of the surrounding skin. Healing ulcers have a base covered with even florid granulations, an epitheliating edge of three concentric zones, an absence of inflammation in the surrounding tissues and of pain, and the discharge of a small amount of turbid serum.<Callout type="important" title="Important">Monitor for signs of infection or poor healing.</Callout> Stationary ulcers have great variations but common features include an absence of healthy granulations, a thickened, rounded, adherent edge, infiltration of the surrounding tissues, thickening and pigmentation of the skin in the neighbourhood, and a thin, watery, but foul discharge. Severe pain and tenderness may be present, especially in chronic ulcers of the anus and legs.<Callout type="gear" title="Gear">Use proper sterilization techniques to prevent infection when treating ulcers.</Callout> The various ulcers that are commonly met with in surgical practice are conveniently classified under the three following headings: 1. Ulcers due to injury or to pyogenic organisms, with or without predisposing circulatory or nervous disturbances; 2. Ulcers due to specific micro-organisms; 3. Malignant ulcers.<Callout type="important" title="Important">Always seek confirmation of syphilitic ulcers through microscopic examination.</Callout> Syphilis ulcers are usually single, acute in their course, with well-marked induration of the base and edge, the ulceration being perhaps not more than a superficial abrasion, and accompanied by moderate enlargement of the neighboring group of lymphatic glands, which are firm but movable under the skin and over each other. Tuberculous ulcers are chronic and superficial, situated in a nodular eruption on the face, arm, or hand, which commenced during childhood or youth, has only very slowly broken down, and has left smooth and shining scars behind.<Callout type="risk" title="Risk">Misdiagnosis of tuberculous ulcers can lead to improper treatment.</Callout> Soft chancre is characterized by multiple ulcers situated on the genitals, or adjacent parts of buttock or thigh having shelving, fissured edges, a soft base covered with greenish sloughs, surrounded by a red areola and exuding a copious purulent secretion, the neighboring glands rapidly becoming inflamed and tending to suppurate. Actinomycosis is an ulcerated surface occurring in a nodular thickening of the skin over the lower jaw or neck, from which sinuses lead inward towards the buccal cavity, with a thin purulent or sanous discharge.<Callout type="tip" title="Tip">Actinomycosis ulcers often have a history of secondary infection.</Callout> Malignant ulcers include rodent ulcer and epithelioma. Rodent ulcer is very chronic, slowly destroying all the tissues present, with a very narrow indurated edge and a smooth shining character, drying up in which it forms; at times it is fungating, at others deeply excavated.<Callout type="important" title="Important">Monitor for signs of progressive destruction when treating rodent ulcers.</Callout> The diagnosis of ulcers of the genital organs is given at p. 622.
Key Takeaways
- Carefully observe the base, edge, and surrounding tissues of an ulcer for signs of its condition and cause.
- Classify ulcers into spreading, healing, or stationary based on their characteristics.
- Recognize specific types of ulcers like syphilitic, tuberculous, and rodent ulcers through their unique features.
Practical Tips
- Always document the ulcer's shape and edge carefully to aid in diagnosis.
- Look for signs of systemic conditions when treating widespread ulcers.
- Use proper sterilization techniques to prevent infection during treatment.
Warnings & Risks
- Avoid misdiagnosis by recognizing that a single ulcer can be syphilitic.
- Misdiagnosis of tuberculous ulcers can lead to improper treatment.
- Monitor for signs of progressive destruction when treating rodent ulcers.
Modern Application
While the techniques described in this chapter are historical, the principles of careful observation and classification remain relevant. Modern medicine has advanced diagnostic tools but still relies on thorough patient history and physical examination. Understanding these foundational concepts can help in recognizing ulcers early and preventing complications.
Frequently Asked Questions
Q: How can I tell if an ulcer is syphilitic?
A single acute ulcer with well-marked induration of the base and edge, possibly no more than a superficial abrasion, accompanied by moderate enlargement of nearby lymphatic glands that are firm but movable under the skin, may indicate a Hunterian chancre. Confirm through microscopic examination for syphilis.
Q: What are the signs of a chronic ulcer?
Chronic ulcers often have an absence of healthy granulations, a thickened and adherent edge, infiltration of surrounding tissues, thickening and pigmentation of the skin in the neighborhood, and a thin, watery but foul discharge. Severe pain and tenderness may be present.
Q: How do I differentiate between syphilitic and tuberculous ulcers?
Syphilitic ulcers are usually single, acute, with well-marked induration of the base and edge, while tuberculous ulcers are chronic and superficial, situated in a nodular eruption on the face, arm, or hand, which commenced during childhood or youth, has only very slowly broken down, and leaves smooth and shining scars behind. A negative Wassermann reaction helps distinguish them.