[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.