Ulceration

“ When a portion of animal tissue dies in consequence of an infection or injury, the death of that tissue taking place by gradual breaking down or disintegration, the process is termed ulceration and the result an ulcer. When the ulcer is spreading the place is painful and the surrounding parts are flushed with extra blood, but under appropriate treatment the destructive process ceases and the ulcer gradually heals. The bright surface of the ulcer becomes glazed over, and those changes take place in it which occur in an open wound. ”

“ In that due to disease, the ulcers formed are, as a rule, small and circumscribed; in those from poison, there is diffused inflammatory redness over other parts of the stomach, and even in the intestines; and the poison, as in the case of arsenic, may be found adhering to the sides of the ulcer. Ulceration is more frequently the result of disease than of the action of poisons. Perforation of the stomach or intestines may be due to ulceration or to corrosion. The condition of the mouth and gullet will help the diagnosis. ”

“ Such an ulcer has an elevated border, sharply cut edges, an indurated base, and exudes a scanty serous discharge; its surface is at first occupied by yellow necrosed tissue, but in time this is replaced by smooth, pale-pink granulation tissue; finally, epithelium may spread over the surface, and the ulcer heals. As a rule, the patient suffers little discomfort, and may even be ignorant of the existence of the lesion, unless, as a result of exposure to mechanical or septic irritation, ulceration ensues, and the sore becomes painful and tender, and yields a purulent discharge. ”

“ The ulceration becomes more rapid, the discharge is bloody and peculiarly offensive; all the symptoms increase in violence, and may proceed for fifteen or twenty days, or terminate in four or five, either in convalescence or death. ”

“ What serves to distinguish Ulcers from Wounds, is the Dryness and Hardness of the Sides or Borders of Ulcers, and the Quality of the Humour discharged from them; which, instead of being ripe consistent Matter, is a Liquid more thin, less white, sometimes yielding a disagreable Scent, and so very sharp, that if it touch the adjoining Skin, it produces Redness, Inflammation, or Pustules there; sometimes a serpiginous, or Ring-worm like Eruption, and even a further Ulceration. ”

“ Although commencing in this membrane, the ulceration is not confined to it, but gradually extends in depth, until it frequently involves all the component structures of the nose—cartilage and bone, as well as fibrous tissues. As the ulceration extends up among the small bones, the discharge generally becomes profuse and often excessively fetid, requires the frequent use of the handkerchief, and renders the poor sufferer disagreeable to both himself and those with whom he associates. ”

“ The higher the ulcer the less marked is the diarrhoea. The lower its situation the greater is the frequency of the stools and the more liable are they to be accompanied by tenesmus and to contain blood and pus. Toward the last, ulceration is accompanied by rapid emaciation, fever, sweats, a feeble circulation, a dry tongue, great thirst, and oedema of the feet and ankles. Death takes place by gradual exhaustion, more rarely from perforation and peritonitis or from intestinal hemorrhage.46 ”

“ In the first stages of the disease, they are seldom, if ever, enlarged; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer,—an attempt by nature towards a cure, but too often an ineffectual one. ”

“ But in the more severe forms ulceration of the mucous membrane takes place. Commencing in and around the solitary glands of the large intestine in the form of exudations, these ulcers, small at first, enlarge and run into each other, till a large portion of the bowel may be implicated in the ulcerative process. ”

“ The disease being more usually slow than rapid in its progress, weeks may be consumed before ulceration occurs, and merely a discoloration of the skin is seen in spots seldom exceeding the size of a sixpenny or fourpenny piece. ”

“ Men necessarily undergoing much pain and universal soreness from ulceration and inflammation (φλογώσεως) suffered not less in body than in mind by the severe affliction, for a continuous ulcer was observable from head to foot. ”

“ The ulcers are not usually deep, but it may happen that they penetrate as far as the bone, and lead to necrosis. But usually necrosis of the bones is preceded by periostitis, and when the pus makes its way out, an ulceration leading down to necrotic bone is formed. ”

“ Soreness of the throat is present in some, but not in all of these examples of dysphagia, being most marked in the inflammatory condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria. Ulceration of the throat should always be carefully looked for, and if present investigated to ascertain whether it is simple, diphtheritic, or syphilitic. We must be careful not to mistake a mere local accumulation of mucus, or aphthous vesicle, or the curd-like formation of thrush or muguet, either for ulceration or pseudo-membranous deposit. ”

“ Such extensive destruction sometimes takes place that no normal mucous membrane seems to be left. Perforating ulcers are occasionally seen in the large intestine or ileum. Perforation occurred in two of Woodward's ninety-nine cases. Healing ulcers14 are found by the side of others which are growing. Healed follicular ulcers are known by a puckered, stellated appearance15 of the mucous membrane, which is pigmented and of a slate-gray or marbled-brown color16 if the process has been long completed. Larger dense cicatrices, pigmented also, mark the site of more extensive ulcerations. ”

“ 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, [Pg 68] 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. ”

“ And whatever ulcer gets swelled along with inflammation and does not subside as the other parts subside which became inflamed and swelled at the same time, there is a danger that such an ulcer may not unite. When from a fall, or in any other way, a part has been torn or bruised, and the parts surrounding the ulcer have become swelled, and, having suppurated, matter flows from the swelling by the ulcer, if in such cases a cataplasm be required, it should not be applied to the sore itself, but to the surrounding parts, so that the pus may have free exit, and the indurated parts may be softened. ”

“ 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. ”

“ But when the parts are softened as the inflammation ceases, then the parts which are separated are to be brought toward one another, binding on sponges and applying them, beginning from the sound parts and advancing to the ulcer by degrees. But plenty of leaves are to be bound above the sponge. When the parts are prevented from coming together by a piece of flesh full of humors, it is to be removed. When the ulcer is deep seated in the flesh, it is swelled up, both from the bandaging and the compression. ”

“ The chronic and intractable character of the ulcer is due to interference with the trophic nerve-supply of the parts, and to the fact that the epithelium of the skin grows in and lines the track leading down to the deepest part of the ulcer and so prevents closure. While they are commonest on the sole of the foot and other parts subjected to pressure, perforating ulcers are met with on the sides and dorsum of the foot and toes, on the hands, and on other parts where no pressure has been exerted. ”

“ A wise physician, with any regard to his own reputation, should abandon a patient laid up with an ulcer which appears to have been dusted over with a sort of pulverised crust, or who has been suffering from one accompanied by loss of flesh and strength, cough, difficult respiration and aversion to food. An ulcer, which occurring at any of the vital parts of the body secretes a copious quantity of pus and blood, and refuses to be healed even after a course of proper and persistent medical treatment, is sure to have a fatal termination. ”

“ From what has been said you can see that in general the prognosis of ulcer of the stomach is good, that with proper avoidance of all irritation, the ulcer has a tendency to heal of itself. This tendency has been observed even in large ulcers, where death was perhaps the result of some intercurrent disease. ”

“ The mucous membrane becomes softened, and one or more superficial abrasions appear on the surface of the diseased patch, which extend and unite into one large ulcer, and this ulcer proceeds to various depths through the coats of the bowel, and even to completed perforation, but Rindfleisch and other recent German writers do not allude to this process.
The fourth stage, or that of cicatrization, usually commences with the beginning of the fourth week. The swelling of the edges of the ulcers gradually diminishes, and they become adherent to the tissues beneath. ”

“ Sometimes the patients have ulcers in their noses and mouths, not unlike those which are one of the malignant consequences of the venereal disease. The small swellings or eruptions, when squeezed, very often yield blood; in other respects the patient is generally in good health, saving the pain the ulcers give him, and the still greater uneasiness of mind which he suffers from the spoiling of the smoothness of his skin; for all the nations in Africa within the tropics are wonderfully affected at the smallest eruption or roughness of the skin. ”

“ 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. ”

“ In process of time the part ulcerates, a discharge of fetid ichorous matter issues from it; sometimes it bleeds freely, and there is a burning pain in the part. The ulcer becomes of considerable size, and assumes a frightful aspect. The patient becomes dejected in his spirits, his countenance is sallow and woe worn, his appetite fails, his days and nights are full of sorrow and pain, the disease still progresses, till, finally, death comes to the aid of the unhappy sufferer, and closes the scene of anguish and misery. ”

“ In cases of peptic ulcer, you will find that the pain is in direct relation to the amount and quality of food taken; that the patient has little or no pain when the stomach is at rest; that coarse foods as well as acids cause or aggravate the pain, and that indifferent foods, such as milk, do not bring it about, though they may sometimes cause a sense of fullness or oppression. Some patients with ulcer will tell you that the position of their body has an influence on their pain. ”

“ When the ulcer is spreading, the discharge is fetid, black, attended with great pains, and other symptoms of inflammation; irritation is produced by relaxing medicines, and relief by the opposite class. When the ulcer is clean, the fluid is small in quantity, consistent, without smell, thick, white, with an agreeable sensation. When the ulcer is inflamed, we must use those things recommended for inflammations. When it is foul, we must inject the juice of ptisan with honey, or basilicon ointment with the oil called Susinum ”

“ An ulcer is a circumscribed area of necrosis occurring on the skin or mucous membrane and covered with granulation tissue. It is a process of destruction, and when this process is going on faster than regeneration can take place, we have a gnawing, or eating, ulcer. When such an ulcer increases rapidly in size it is termed a phagedenic ulcer. A fungoid ulcer is one in which the bottom of the ulcer projects beyond the edge of the skin. These ulcers secrete milky or bloody-white liquid called ichor. ”

“ 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. ”