Ulcer

ULCER. Medically, a breach of either an external or an internal surface, occurring in the course of disease and accom panied by loss of tissue. Common examples are cutaneous, vari cose, corneal, typhoid, dysenteric, gastric and duodenal, tubercu lous, syphilitic and cancerous ulcers. An ulcer has a depressed floor or base, and often the edges are raised somewhat above the general level of the surrounding surface. In all the instances given above, except the cancerous ulcer, the pathological process at work is inflammation, acting often on a tissue the vitality of which has been lowered, so that the destruction is disproportionately great compared with the agent that brings it about. This lowered vitality may result from constitutional diseases, e.g., diabetes or renal or cardiac disease, or may depend upon local causes, e.g., the poorness of cutaneous blood supply over such a bony surface as the shin, the embolic closure of an artery and death of the portion of tissue it supplies, as in some cases of gastric ulcer. The examples of acute bed sores in disease of the lower parts of the spinal cord, and of perforating ulcer of the toe in locomotor ataxy, indicate further, that in some instances interference with the conduction of afferent impulses from the part is fundamental in ulcer f or mation.

In a typical ulcer the floor differs in character according as the lesion is healing or not. If healing, the floor consists of granula tion tissue (see INFLAMMATION AND ITS SEQUELS), covered by a thin layer of sero-purulent fluid, and the edges, when the skin is concerned, show a thin blue line of advancing epithelium whereby the ulcer is finally covered. If recently formed or spreading, the floor usually consists of dead or dying tissue, with smaller or greater exudation of sero-purulent or purulent fluid. In some forms of ulceration, especially those that are chronic, e.g., tuber culous or syphilitic, the floor of the ulcer presents special features (e.g., the presence of giant cells or caseation), and the causal organism may be present in the tissues or exudation. The can cerous ulcer is really an example of molecular necrosis, and the floor consists of dying or dead cancerous tissue, with superposed putrefactive changes. In dyspepsia, small local abrasions on the

tongue or mouth or gastric mucous membrane may occur from the breaking down of papules, perhaps containing serous fluid. Popularly these are often termed "ulcers," but they only involve superficial layers of the epithelium, and hardly deserve the name. In its usual significance an ulcer involves tissue deeper than the epidermis, or in the case of internal surfaces, the entire mucous membrane.

Treatment.

The treatment of ulceration is conditioned by the underlying cause. In all cases rest is necessary; an ulcer over the knuckle may persist for weeks if the hand be used, but heal within a day or two if the joint be fixed upon a splint. But apart from this, it is clear that treatment of any underlying disease will help healing of the ulcer at least as much as local medication. In the case of cancerous ulcers, healing does not occur apart from a successful radiation treatment, but the patient's discomfort may be relieved very greatly by keeping the ulcer bacteriologically clean, and thus preventing the putrefaction that otherwise always occurs. Naturally, this is easier in some situations than others. Sometimes a cutaneous ulcer becomes "indolent" or "callous," and remains unchanged in appearance for weeks. Often such an ulcer may be brought into a healthy healing condition by use of some stimulating lotion, or rubbing with a crystal of copper sulphate; the superficial destruction of tissue is thereby increased, it is true, but the induced inflammation is accompanied by stimulative processes beneath and around the ulcer, which more than compen sate for the added inflammation. Healing of an ulcer, when it occurs, is always by the local formation of fibrous (scar) tissue ; in the case of the skin, the newly-formed fibrous tissue is ulti mately covered by squamous epithelium, in the case of mucous membranes the secreting epithelial system is not re-formed.