Ulcers

Ulcers (Lat. ulcus, 'a sore spot'). Ulceration is 'that part or effect of an inflammatory process in which the materials of inflamed tissues, liquefied or degenerate, are cast off, in solution or very minute particles, from free surfaces, or, more rarely, are absorbed from the substance of the body' (Paget on 'Ulcers,' in Holmes's System of Surgery). Generally speaking, however, the name of ulcer is not applied to any inflammatory result, unless the substance of a tissue deeper than the epithelial is exposed; and when the cast-off particles are only epithelial the result is termed desquamation, abrasion, or excoriation, although the process may be essentially the same. Ulceration is closely allied to gangrene, the two processes differing in degree rather than in kind. 'When the degenerate or dead substance,' says Sir J. Paget, 'is cast off in one or more portions visible to the naked eye, the process is usually called gangrene; when the portions are not so visible, or are quite dissolved, it is called ulceration.' The degenerate tissues are always suspended or dissolved in a liquid, termed the 'discharge,' or 'ichor,' which varies in appearance and properties according to the cause and characters of the ulcerative process. 'From some ulcers—e.g. the primary syphilitic—it is contagious; from many it appears corrosive, exciting by its acidity inflammatory changes in the tissues with which it is in contact.'

Ulcers may occur on any surface of the body—e.g. the eye, mouth, stomach, intestines, &c.: here attention will be restricted to ulcers on the skin. They may be classified according either to their obvious characters or to their cause. It is most convenient in the first instance to adopt the former arrangement.

A common, simple, or healthy ulcer is such as is left after the separation of an accidental slough in a healthy person, and is merely a healthy granulating surface, tending to cicatrization. Its edges slerve gently down to the base, and are scarcely harder than the adjacent healthy skin. Their surface near the border is of a purplish blue tint where the young epidermis modifies the colour of the healing granulations; and within this the granulations have a deeper hue than those at the centre, being most vascular where the cuticle is being chiefly developed. The discharge from such an ulcer is healthy or 'laudable' pus. Inflamed ulcers differ less than most kinds from the above described common or healthy ulcers. Their most common seat is on the lower half of the leg or shin. The surface is red, and bleeds easily; the discharge is thin and watery; the edges irregular or shreddy; and the surrounding skin shows a red tinge, and is the seat of a hot and aching sensation. This ulcer most commonly occurs in the infirm and old, the ill-fed and overworked. Hence constitutional treatment, good diet, and complete rest (with elevation of the limb) are here necessary. Sloughing ulcers, in the mildest form, are characterised by an aggravation of the symptoms observed in inflamed ulcers; while the surface becomes gray and is cast off in shreds, and the ulcerative process extends rapidly. They are generally associated with a debilitated state of the system. Phagedena (Gr., from phagein, 'to eat or corrode') designates a severer variety of sloughing ulcer in which there is much infiltration, and at the same time rapid destruction of the affected part, with severe constitutional symptoms. The sore presents an irregular outline, and a gray or yellowish surface; it gives off a profuse bloody or ichorish discharge, and is extremely painful. When occurring in isolated cases it usually attacks persons whose constitutions are not merely debilitated but vitiated by scrofula, by the syphilitic virus, by the abuse of mercury, by intemperance, &c. A link between this virulent form of ulceration and gangrene, though more closely allied to the latter, is the terrible disease known in civil practice as sloughing phagedæna, and in military and naval practice as hospital gangrene. This disorder requires for its development the influence of some of those undefined causes which regulate the outbreak of epidemics, and is peculiarly characterised by its contagious and infectious nature. It is usually engendered by the overcrowding of sick and wounded men, and some idea of its virulence may be formed from the fact that on the return of the French fleet from the Crimean war, no less than sixty deaths from it occurred in one ship in the course of thirty-eight hours. Weak ulcers are those in which the granulations are prominent, pale, and soft. They are generally met with in scrofulous cases. Exuberant or fungous ulcers have also prominent granulations (popularly called 'proud flesh'), but they are firm and bright red like those of a healthy ulcer. They are most often seen in the healing of severe burns. The chronic, indolent, or callous ulcer, beyond all doubt, gives more trouble to the poor-law medical officer and the workhouse surgeon than any other half-dozen surgical affections. It is usually seated in the lower half of the leg, and is most commonly of an oval form, with its long axis parallel to that of the leg. 'Its base lies deep, and is flat, pale, or tawny and dusky, with very minute or no visible granulations. The margin is usually abrupt, or unequally shelving, or more often thickened, smooth, and rounded. Both the margin and all the surrounding integuments, often for many inches round, are thickened, hardened, "callous," as with a kind of very firm œdema.'—Paget, op. cit., p. 147. Many volumes have been written on the proper means of treating this form of ulcer. The distinguished surgeon from whose Memoir we have so largely quoted especially recommends opium, regulated pressure, and blistering. A grain of opium night and morning is usually sufficient. The pressure is applied with straps of adhesive or lead plaster on linen, or with an elastic bandage. The object of blistering is not only to stimulate the ulcer, but to soften its callous edges by causing absorption of part of the exudation with which they are infiltrated, and desquamation of the cuticle which covers them. The expediency of healing old ulcers of this kind has often been called in question, inasmuch as serious diseases are said to have followed the healing of such ulcers. In the great majority of cases, however, no nutoward results are met with.

The recognition of the causes of an ulcer are, however, of even more importance than the characters it presents; for that determines the methods to be employed in order to cure it. It may result from chemical or mechanical injury; from defective circulation, particularly the existence of Varicose Veins (q.v.); and in each of these cases the local cause must be attended to. But it may originate or be kept from healing by a constitutional cause, syphilis, struma, scurvy, or gout; and if so constitutional treatment is of prime importance. Ulceration is also a frequent incident in the progress of malignant, particularly cancerous, tumours. But there is one form of disease, now proved to be cancerous, in which the tumour formation is so slight, and the ulceration so prominent, that it has generally been known under the name of rodent ulcer. It generally occurs in the upper part of the face. As in other cancers, free removal is the only treatment which gives hope of cure.

In the local treatment of ulcers generally, as of other breaches of surface, the most scrupulous cleanliness is of prime importance; and here, no less than in other departments of surgery, the use of the Antiseptic Method (q.v.) has proved of the greatest value as a means of attaining this end. The particular form of antiseptic most suitable depends on the condition of the sore: in healing ulcers boracic ointment, or if the ulcer be too dry a wet boracic-dressing, usually does well; in inflamed and sloughing ulcers much stronger applications are required. Prominent granulations are generally best treated by the occasional application of solid nitrate of silver.—Ulcer of the stomach is treated at STOMACH.