Ulcer

ULCER (ulcus), a defect of the skin or mucous membrane that has arisen as a result of tissue necrosis and proceeds with weakly expressed phenomena of healing. In the case of a traumatic tissue defect, it is considered that a wound turns into an ulcer only if there is a significant delay in the healing process, and especially if along with healing there continues the process of tissue decay. A characteristic feature of an ulcer is its chronic course and its "non-healing" (Landerer). An acute course of tissue decay, as for example in acute infectious necrosis, gives a defect that does not fit under the concept of an ulcer; it can become an ulcer only with a chronic course and the presence of at least imperfect phenomena of healing, in the form for example of granulations. Older authors distinguished ulcers as a special disease. Etiological factors and pathogenesis were given less attention partly due to their unknown nature, while the main determining moments were considered to be morphological signs. With modern views, the concept of an ulcer is closely connected with pathogenesis, therefore ulcers are considered as certain forms of manifestation of one or another pathological process, with the main attention being given to the essence of the process itself, and not to its form of manifestation; thus, the basis of cancerous and tuberculous ulcers are different processes, despite the fact that both of them manifest in the form of an ulcer. From this point of view, it is difficult to give a general classification of ulcers without turning it into a list of processes that can manifest in the form of an ulcer. However, it is still possible to group the various forms of ulcers from an etiological point of view, taking into account that the main cause is often not the direct factor, but those conditions that lead to the prolonged existence of the defect and prevent its healing. Taking this circumstance into account, ulcers can be divided into the following groups: 1) Ulcers caused by mechanical reasons. These include ulcers arising from pressure on tissues both from the outside (like bedsores) and from the inside at the site of protruding bones, for example on stumps after amputations, ulcers arising from friction, from pressure by prostheses, for example on gums, etc. However, in all these forms, the mechanical factor plays the role only of a directly causing cause, while the basis of the ulcerative process lies in disorders of nutrition of the corresponding area of tissue of a different order. 2) Ulcers caused by temperature factors. These include ulcers after burns and ulcers after frostbite. Ulcers after burns usually occur with extensive lesions, when healing of the defect stops either due to general nutritional disorders or due to exhaustion of the regenerative abilities of the covering epithelium. Ulcers after frostbite form on the basis of reduced regenerative ability of the tissue surrounding the defect, especially when vessels and nerves are affected. 3) Ulcers arising after exposure to chemical substances. Here also the stopping of healing sometimes depends on insufficient epithelialization with too extensive defects, but greater importance is attached to those forms where healing is delayed as a whole due to the specific effect of the chemical substance on the tissues. Many examples of chemical damage can be given, but due to a special tendency to turn into ulcers of the sites of damage due to the properties of the substance itself, mustard gas injuries deserve attention. The basis of the ulcers forming here is a sharp decrease in the regenerative abilities of the tissue surrounding the defect. It must be assumed that at the same time there is also damage to the vascular-nervous apparatus. 4) Ulcers remaining after necroses caused by exposure to X-rays, radium rays, ultrashort waves, as well as sometimes arising after prolonged use of ultraviolet and even violet rays. Of course, the nature of the effect of radiant energy depending on these factors is not entirely identical, but all these forms can be brought together from the point of view of a decrease in regenerative processes of the tissues surrounding the defect, i.e., the commonality of conditions causing the ulcerative process. 5) Ulcers on the basis of damage to the vascular system. A classic example of such ulcers are the so-called "varicose ulcers", they usually develop on the leg as a result of chronic nutritional disorders of the tissue in the presence of varicose dilated veins with more or less widespread thrombosis of them. The basis of such an ulcer is necrosis either from a minor, often even unnoticeable injury, or from complete cessation of nutrition of this area; and due to constant stagnation in the venous system and clearly insufficient nutrition and gas exchange of the entire area and even the entire limb, necrosis easily increases and the ulcer formed in its place acquires a persistent and stubborn character. Close in origin are ulcers in arterial thrombosis both on the basis of so-called spontaneous gangrene, and in other forms of obstruction of supplying vessels (embolism, thrombi in infectious diseases, etc.). The nutritional disorder in these forms has the character of starvation, which is what determines the delayed healing and the transition of necrosis into an ulcer. 6) Ulcers as a result of damage by acute purulent processes. The pathogenesis of these ulcers consists not so much in the infection, the causative agents of which are usually pus-forming microbes, as in special unfavorable conditions in the tissues, giving the process a chronic character with weak healing phenomena. These conditions can be general exhaustion after severe diseases, starvation, cachexia in malignant tumors, avitaminosis (scurvy), metabolic disorders (for example diabetes mellitus) etc. And under these conditions, the initial impulse is usually given by

either a minor trauma, a wound is complicated by infection, and then the infected wound turns into an Ulcer. The infection in such an Ulcer does not exhibit special virulence, otherwise the condition would not develop into an Ulcer and the process would develop toward phlegmon with a threat of further generalization. 7) Ulcers in specific infections. Among acute infections that cause ulcers, diphtheritic lesions can be mentioned; however, these forms still have a more acute course. Great importance is attached to ulcers in chronic specific infections, and the form, type, character, and course of the ulcer are often so specific that the infection and even its stage of development can be recognized by the properties of the ulcer. In typical cases, there is no need even for bacteriological or serological research. Such are syphilitic and tuberculous ulcers. These forms are characteristic not only on the skin but also on the mucous membranes of the mouth, tongue, larynx, intestines, etc. Similarly, typhoid and dysenteric ulcers of the intestine can be recognized by their localization as well as by their character. 8) Ulcers on the basis of disintegrating malignant neoplasms, most often carcinomas. For some carcinomas, the ulcerative form is characteristic, the tumor turns into it at fairly early stages of development. Such are skin cancers (ulcus rodens), cancers of the gastric mucosa, rectum, etc. Such ulcers are in direct connection with the tumor and when it is eliminated, for example by means of radiant energy, these ulcers heal. 9) Trophic ulcers, depending on disorders of tissue nutrition from direct damage to the nervous system. These include ulcers in injuries and diseases of the central nervous system, usually the spinal cord, ulcers in injuries and diseases of peripheral nerves; apparently, ulcers of unclear etiology, where the pathogenesis cannot be established, should also be included in this category. An example can be round ulcers of the stomach and duodenum. It was mentioned above that the presence of any ulcer presupposes a disturbance of trophicity, i.e., to some extent the involvement of the nervous system, but this category includes ulcers where the involvement of any other etiological factors, and consequently secondary damage to the nervous system, is excluded. 10) Finally, mention should be made of artificial ulcers that form after the intentional introduction into tissues of some irritating or infected material. Such ulcers in the pre-revolutionary period were observed in conscripts for military service, as well as in soldiers of the tsarist army, and were caused with the aim of evading military service. A large number of methods have been described that self-mutilators used to obtain ulcers; most often it was a matter of injecting mixtures containing kerosene, paraffin, turpentine, urine, feces, etc. Often, initially, phlegmons with more or less extensive necrosis of the coverings were obtained, which then, after the acute period had passed, turned into ulcers. Owners of such ulcers sometimes intentionally traumatized the ulcer surfaces or exposed them again to irritating substances and thereby sought to further prolong healing. Pathological anatomy. From the above list of all processes that give rise to the development of ulcers, it follows that it is impossible to give a general pathological picture for all ulcers. Specific and characteristic for ulcers remain those morphological changes in tissue nutrition, which consist mainly in pictures of disorders of the vascular and nervous systems. From the latter point of view, the data concerning the nervous system, which shed light on some unclear aspects of ulcer development, are particularly interesting. Thus, in ulcerative lesions of the stomach, Stohr with sufficient convinceness proved pathological changes not only in the nerve fibers in the immediate vicinity of the ulcer, but also in the entire area of its location. The connection between the development of ulcerative processes and damage to the nervous system is also pointed out by numerous studies of Speransky and his colleagues (Doinikov), and the changes in nerve fibers extend far to the center, reaching even the spinal cord. The connection between damage to the central nervous system and the ulcerative process is also evident from the works of Burdenko and Mogilnitsky. Very interesting data was presented by Weil, who proved by a series of studies that definite lesions of sympathetic nerve fibers precede ulcerative processes on the intestinal mucosa in ulcerative colitis, in ulcers developing above the site of intestinal narrowing, and even in tuberculous ulcers. Changes of the same order found in the nerves in tuberculous ulcers of the larynx (Lavrentiev and Filatov). All this, without finally solving the question of the pathogenesis of one or another type of ulcer, with certainty indicates a much greater involvement of the nervous system in the ulcerative process than was recognized until recently. Changes in the vessels in an ulcer consist either of thrombosis in more acute cases or of perivascular development of connective tissue, in an atheromatous process, deposition of mineral salts, etc. Basically, the pathological-anatomical changes correspond to the form of the disease on the basis of which the ulcer develops. Clinic of Ulcers. It is impossible to speak of the clinical course of ulcers in general, since ulcers, being a manifestation of a specific pathological process, run in accordance with the course of the underlying process; thus, ulcers on the basis of scurvy depend on the conditions of vitamin nutrition, ulcers in syphilis and tbc depend on the general conditions of these diseases, trophic ulcers depend on the degree and character of the damage to the nervous system, etc. (see the respective diseases). In ulcers, the edges and floor are distinguished; to characterize an ulcer, it is necessary to characterize both. When determining the form of an ulcer, either ordinary terms are used—round, oval, star-shaped, etc.—or the general appearance of the ulcer is compared with a crater, funnel, saucer, etc. The floor of the ulcer may be raised or depressed compared to the surrounding tissue, it may be covered with coatings, appear greasy, have necrotic areas, or, conversely, may be lined with granulations. The external appearance and properties of the latter also have clinical significance. The edges of the ulcer may be thinned, diaphanous, or pigmented, undermined, thickened, even calloused, traces of disintegration or fresh epithelialization can be seen on them, sometimes both at the same time, then the areas where disintegration is going on and from which the epithelial covering develops are of importance. The predominance of one or another feature sometimes gives grounds for a corresponding characterization of the entire ulcer. Thus, ulcers with calloused edges are defined as callous, one speaks of phagedenic ulcer when there is a clear predominance of disintegration of the edges and spread in all directions, of serpiginous or creeping ulcer when there are signs of healing on one side and disintegration on the other. If the entire surface of the ulcer is covered with superimposed crusts, it is called rupia. As indicated, the clinical signs of an ulcer may strictly correspond to a specific disease, so for example, on the basis of the character and properties of the primary syphilitic ulcer, the diagnosis of this disease can be established. Under the influence of various internal and external factors, the character of the ulcer and its chronic course can change to a great extent. Any changes for the better are first manifested by the cessation of disintegration, cleansing of the ulcer surface, and the development of healthy granulations filling the cavity and subsequent epithelialization. On the contrary, deeper disintegration, absence of healing phenomena, and painful, usually easily injured and easily bleeding granulations are unfavorable signs of the course of the ulcer. The most important clinical complications of ulcers are bleeding and secondary infection. Bleeding occurs when any more or less large vessel is destroyed in the course of the usual tissue destruction in the ulcerative process. Bleeding that is particularly dangerous and difficult to stop occurs with deep and inaccessible ulcers, for example, ulcers of the stomach, intestines, etc. Bleeding can also be significant in varicose ulcers, but stopping them does not present particular difficulty. Secondary infection, joining the ulcerative process, can greatly change the external appearance of the ulcer, complicate recognition, and lead to the necessity of amputation on the extremities or to general purulent or putrefactive infection. The presence of lymphangitis and thrombophlebitis in the surroundings often accompanies the development and spread of infection. Recognition in ulcers consists first of all in determining the etiology of the ulcer, i.e., the basic disease on the basis of which the ulcer arose, such as tbc, cancer, syphilis, scurvy, diabetes, etc. In a number of typical cases, this presents no difficulties, but in atypical forms, especially complicated by secondary infection, the picture can give rise to confusion, especially with certain localizations, for example, ulcers of the tongue, larynx. In such doubtful cases, it is necessary to use bacteriological or serological research. In ulcers of the stomach and intestines, valuable data is provided by X-ray examination. Finally, in doubtful but still accessible ulcers, decisive data can be provided by biopsy.

However, a piece excised for examination must be taken from the edge of the Ulcer, if possible from areas where there is no deep decay, otherwise even microscopic examination may not resolve the question. The prognosis in Ulcer also depends entirely on the underlying disease. In a number of cases, the condition of the Ulcer itself serves as an indicator of the general condition of the body and must be taken into account in the overall assessment of the disease. Treatment of Ulcer is divided into general and local. General treatment is required for all Ulcers based on syphilis, scurvy, diabetes, tbc and similar diseases. Local treatment consists in creating the most favorable conditions for healing and eliminating all factors that hinder it. Ulcers caused by mechanical factors, such as pressure, friction, etc., require the elimination of these factors, even if their role consists only in the direct formation of necrosis. Thus, in cases prone to bedsores, and also in already developed bedsores, measures are necessary to eliminate pressure on the sacrum, shoulder blades, heels and other parts of the body that experience the greatest pressure. This is achieved by rational arrangement of the patient's bed, the use of rings, pillows, water mattresses, etc. Persistent Ulcers at sites of bone protrusions after amputations should be prevented by proper surgical technique, and if they occur, they may require reamputation and subsequent 'training' of the stump. Unsuccessful prostheses must be corrected. Ulcers remaining after extensive burns require plastic surgery measures. Here all methods of skin restoration are appropriate, and in areas experiencing special pressure or mobility (in joint areas), flap plastic surgery with subcutaneous tissue is necessary, while in other areas the methods of free plastic surgery by Thiersch, Krause, Reverdin-Davis, etc. are applicable. Ulcers after chemical injuries and exposure to radiant energy require the most careful care and avoidance of all irritating substances. The main focus of treatment here lies in restoring the regenerative capacity of the surrounding tissue. Ulcers in cases of nutritional disorders due to insufficient arterial blood supply require the development of collateral pathways, and if this fails, they lead to amputations on the extremities. In disorders of venous circulation, measures that help eliminate stagnation (moderate pressure, elevated position, careful care) should first lead to complete cleansing of the Ulcer. Once this goal is achieved, the Ulcer heals easily thereafter and in most cases does not require plastic surgery measures. Simultaneous interventions for varicose veins significantly facilitate the task. It is clear that Ulcers based on malignant neoplasms require their surgical removal, either X-ray and radiotherapy, or a combination of all these methods. Ulcers of the stomach and intestines require either resection of the affected areas or palliative interventions if systematic internal treatment does not achieve the desired result. Ulcers of purely trophic type are the most difficult to treat if their origin does not depend on a clear and removable cause, such as nerve entrapment, the presence of a removable tumor, etc. Here, with varying success, nerve section (Moltokov), novocaine blockade according to Speransky and Vishnevsky, and even simply encircling skin incisions (Danelidze) have been tried. In some cases, especially in calloused Ulcers, the excision of the Ulcer and plastic closure of the defect have also been beneficial. Practice shows that despite all difficulties, careful study of the conditions of Ulcer development and carefully considered and individually conducted measures lead to success even in Ulcers of many years' standing. However, even with complete healing of Ulcers, their tendency to recurrences should always be kept in mind.