The principles and practice of modern surgery

The term ulcer pertains to surfaces, and should be defined as a surface which is or ought to be granulating, i. e., healing.

While an ulcer may be the result of ulceration, it is not necessarily so, the term ulceration being one of very loose significance and applied to many different processes. The idea underlying ulceration is infection, and, when limited to its proper significance, the term should never be used for a process in which infection and consequent breaking down of tissue do not virtually comprise the whole process. Therefore, it is to be distinguished from certain disappearances of tissue alluded to under the head of Atrophy or Interstitial Absorption. It is not correct to say that the sternum ulcerates away, making room for a growing aortic aneurysm, the question of infection here not being raised. These distinctions should be accurately maintained and constantly borne in mind.

ULCERS.

The causes of ulcers may be—

• A. Traumatic;
• B. Local; or,
• C. Constitutional.

A. Traumatic.

—This includes all surfaces which are granulating and healing more or less rapidly, or are displaying a disposition toward healing, and which may have been produced by wounds, burns, frostbites, etc. These include also ulcers due to pressure, as from splints, bandages, orthopedic apparatus, or from external friction. Ulcers which form around foreign bodies may also be included under this head, their essential cause being traumatic. It should include also destruction of the surface by various chemical agencies, such as strong caustics, and the consequences of intense heat or cold, including burns and frostbites.

B. Local.

—1. Among local causes may be mentioned local infections, with tissue death in consequence, such as occur in tuberculous, cancerous, leprous, syphilitic, and other specific manifestations where surfaces are involved.

2. Tumors, either benign or malignant, whose blood supply is cut off and whose surface is thereby predisposed to infection.

3. Perverted surface nutrition, for example, in connection with varicose veins of the extremities, where, aside from any perverted trophoneurotic influence, there is stagnation of blood, saturation of tissues with serum, and final leakage of the same, even to the surface. Varicose veins of the leg which lie near or underlie ulcerating surfaces become thrombosed and obliterated, so that such ulcers rarely bleed. On the other hand, a passive hyperemia here leads to edema, perversion of nutrition, failure to repair trifling surface injury, and a surface is left which of itself rarely, if ever, heals.

4. So-called pressure sores or bed-sores, which in some cases may be regarded as having a traumatic origin, but which, nevertheless, would not occur from purely traumatic influences without predisposing tissue changes. The bed-sore is probably the best illustration of this. Simple ulcer is known as bed-sore, while a sloughing ulcer of this kind is frequently alluded to as decubitus. Such ulcers are usually found over those regions of the body made most prominent by bony projections, upon which undue pressure is made when debilitated patients have lain for a long time in bed.

5. Ulcer is the frequent result of numerous skin diseases, into whose etiology as yet bacteria have not been introduced—e. g., pemphigus, eczema, etc.

6. Ulcer is the occasional result of embolic or other disturbance of the principal artery of the part, by which nutrition is cut off and tissue death results.

7. Bites of insects or other parasites or of noxious animals frequently lead to ulceration.

8. Certain more specific forms of ulcer are described by some writers, apparently with more or less reason, among them being chancroid, perforating ulcer of the foot, etc. (Chancroid is described in Chapter X.) Trophic ulcers of the fingers or hand are also seen, particularly after injury to or division of nerve trunks in the arm or forearm. Perforating ulcer of the foot is a circumscribed circular ulcer with thickened edges, often nearly concealed by overhanging skin. It may be found in any part of the sole of the foot, but is most common near the first joint of the great toe. The borders of the ulcer are usually anesthetic. It is frequently seen in diabetics. By some it is associated with trophic nerve disturbance; by others it is regarded as having a specific etiology of its own. The probability, however, is that it is simply a subvariety of pressure sore.

9. Since the introduction of the Röntgen or x-rays into surgical therapeutics a new local cause of painful and intractable ulcers should be enumerated. A too prolonged or injudicious exposure of a part to this peculiar influence induces first a dermatitis, which is not always immediate, but may be tardy in appearance, and which may be followed by desquamation or exfoliation that may proceed to absolute surface destruction and sloughing. These lesions are popularly spoken of as x-ray burns. The superficial ulcers thus produced may be extensive and are nearly always excessively sensitive and painful. The very structure of the surface vessels is affected and they undergo a species of sclerosis. A strong preparation of radium has been known to produce a similar effect.

C. Constitutional.

—1. Ulcers are frequently met with in certain constitutional conditions which are characterized by tendency to local manifestation at points of least resistance. Among these may be mentioned scurvy.

2. There are ulcers of apparently distinctive trophoneurotic origin, of which that mentioned above as B, 8—perforating ulcer of the foot—may possibly be one. These accompany certain nervous disorders of central origin, prominent among which are locomotor ataxia and tabetic disease of all forms.

3. Ulcers are produced sometimes as the result of specific or selective action of certain drugs, among them mercury and phosphorus being the most prominent. These manifestations are usually perceived in the mouth, and may be regarded as infections at points of least resistance. Nevertheless, they are commonly associated with the tendency of these drugs.

4. There are many constitutional conditions in which vitality is so lowered that a special liability to ulcer—i. e., infection and production of ulcer at many points—is noted. It is well, however, to mention that the common diseases in which this tendency is most often noted are typhoid, diphtheria, diabetes, and syphilis.

With this summary of the common causes of ulcer it is again stated that ulcers may be due to direct consequence of traumatic loss of substance or to the process of ulceration—i. e., as a consequence of previous infection, or as permitted by trophoneurotic disturbance and ischemia. Ulceration is a process of molecular death, in which cells die successively and more slowly, as distinguished from gangrene, in which there is simultaneous death of large aggregations of cells, by which a slough or its equivalent is produced.

Ulcers are referred to as healthy when the process of granulation is proceeding with average rapidity; indolent, when the reverse prevails; sloughing, when there is actual visible tissue death in connection with the ulcerative process; phagedenic, when the gangrenous tendency is well marked and the process exceedingly rapid; irritable or erethistic, when the surface is exquisitely sensitive; hemorrhagic, when bleeding easily; fungous or fungoid, when the granulations have risen above the surface and are increasing at too rapid a rate. There is a peculiar form of ulcer, seen mostly upon the face, to which the name rodent ulcer (also lupus exedens) has been given. This is now known to be a slowly growing form of epithelioma, and is described in Chapter XXV.

The best examples of the indolent ulcer are seen in connection with varicose veins of the extremities; of the phagedenic ulcer, in certain cases of chancroid; of the irritable ulcer, in ulceration of the cornea, when the pain and photophobia are intense; or in fissured ulcer of the anus, where the pain and sphincter spasm are sometimes agonizing.

Ulcers are described according to their shape as regular or irregular; as fissured, when they extend more or less deeply and abruptly into the surface involved; as fistulous when they have a tubular arrangement; as rodent, when they spare nothing in their course.

The borders of ulcers are described as healthy, indurated, tumid, edematous, undermined, livid, inflamed, etc., these adjectives explaining themselves.

The surfaces of ulcers are described as healthy when they have normal color and appearance, inflamed, excavated, covered with sloughs, callous, etc. The callous ulcer is one which exhibits little change from month to month; its surface is dirty, and its secretion thin and mucopurulent. It is usually sunk considerably below the surrounding level, while its border is firm and nodular. The best examples of this form are those accompanying varicose veins.

In size or area ulcers may vary from the slightest local destruction of tissue to an area covering an entire limb or a large part of the trunk. In depth they vary within lesser limits; while an external ulcer may connect with some deep lesion by means of a tubular passage or sinus. It thus appears that the term ulcer may be applied to the result of a natural effort to repair loss of substance without introducing the element of disease, or that it may be the consequence of local infection with local tissue disaster.

The character of the material discharged from an ulcer will vary according to the category in which it belongs. The healthy, healing, or granulating surface, often spoken of as ulcer, discharges a material in gross appearance much resembling pus from an acute abscess; in consistency, color, and other appearances it is the same. Nevertheless, its origin is essentially distinct. This material represents simply the waste of reparative material, sent up to the surface for the purpose of hurrying the process. Its fluid, like that of pus, comes from the serum of the blood; its corpuscular elements, like those of pus, are leukocytes or wandering tissue cells, which have been furnished in great numbers—in fact, in excess. As it comes to the surface—or as, rather, it is rejected from the surface, being superfluous in amount—it is likely to become contaminated with bacteria by contact infection, and consequently may be seen under the microscope to contain various microörganisms. This contamination, however, has been final, accidental, and irrelevant. This material is not pus; has no infectious properties, except those which may accidentally be conveyed to it; represents no warfare of cells, only excess of supply or overdemand; and should be spoken of as pyoid or puruloid material, and never confused with pus. In amount it will vary according to the activity of the reparative endeavor, and somewhat according to the amount of irritation of the surface by dressings which may be applied. If a granulating surface is absolutely protected from possibility of contact infection, it will never contain microörganisms; while this pyoid, if allowed to remain too long, especially when infection is permitted, may decompose and become irritating, and is a material to be gently dislodged by a spray or an irrigating stream with each dressing, which dressing should be made once in twenty-four to sixty hours.

PROCESSES OF REPAIR.

An ulcer having been defined as a surface which is or ought to be granulating, it becomes necessary to define the granulation process and to show how healing is thereby achieved. Granulation tissue is a name applied to a new and temporary tissue of embryonic type, which acts as a scaffolding or temporary structure, permitting the construction of more permanent tissue. It is produced entirely by the activity of cells, which are the mononuclear and polynuclear leukocytes and the wandering cells already mentioned. They are frequently known as embryonal cells when performing this function; sometimes as formative cells. They have a distinct nucleus, which stains readily, and, having this resemblance to epithelial cells, they are often referred to as epithelioid cells—sometimes as fibroblasts, because they may later assume the dignity of connective-tissue cells. They assume a multitude of shapes. Between these cells as they are drawn toward the point at which they are most needed, perhaps by chemotactic activity, there is an intercellular substance which later becomes fibrillated. As these fibers develop the remaining cells become entangled between them, and in this way a new connective tissue is formed of cells of originally mesoblastic origin. Of such tissue the solid part of granulation tissue is built. This tissue is essentially different from the epithelium which it is expected will subsequently cover it. If a normal granulating surface is scanned with a magnifying glass of small magnifying power, it will be seen to consist of numerous minute projections, each of which is known as a granulation, consisting of the tissue above described, formed as a minute eminence around a budding capillary bloodvessel, from which a projection has arisen upon the exposed surface. This capillary bud is the result of karyokinetic activity on the part of the endothelium—namely, the hypoblastic cells of which it is essentially composed. In each of these cells, under certain circumstances, the karyokinetic threads already mentioned develop and become loosely coiled, while the chromatin in the nucleus increases in amount and the nucleolus disappears. The chromatin threads become thicker, arrange themselves equatorially around the poles of the nucleus, and gradually turn so as to point toward it, while a new membrane forms around each separate coil, and two nuclei are thus made out of one. While this is taking place within the nucleus the cell protoplasm undergoes active rotary motion, is finally segmented, and by the time the nucleus is divided is nearly ready for complete division of the cell. While nuclear division is usually bipolar, it may be multipolar; if a rearrangement of the protoplasm is delayed, the result becomes a multinuclear cell, known as a giant cell.

The consequence of this endothelial activity is new cell formation and the construction of a projection from the capillary which soon attains the dignity of its parent vessel, and, as connective-tissue cells form around it, soon becomes a granulation by itself, each granulation being marked by a capillary loop of its own. Healing by granulation or the granulation process, no matter how set up or caused, is essentially the formation of hundreds or thousands of these tiny structures, a new one being formed on top of those which precede it, while those first formed and deeper down undergo condensation and metamorphosis of tissues, by which they are converted into something higher in the tissue scale. Under ideal conditions true granulation building proceeds pari passu with epithelial reproduction around the margin of the granulating surface, so that by the time granulation tissue has completely filled the defect, no matter how caused, epithelial covering has been completely constructed and the healing process thus completed. These two processes, however, do not necessarily keep pace with each other. Should surface repair take place relatively early, we may have a depressed scar; while, on the other hand, should it not proceed rapidly enough, or, to state it in another way, should the granulating process be too rapid, we have such excess of granulations as shall rise considerably above the surrounding level, and may, under certain circumstances, become so exuberant that nutritive material cannot be formed rapidly enough, and those granulations farthest away from the centre of supply may die. Such exuberant granulation is often spoken of as fungoid, and constitutes that great bugbear in the eyes of the laity which is termed by them proud flesh. It has no further significance than that the supply has exceeded the demand and that the granulating process has been overdone. Such luxuriant granulations may be cut away with scissors or knife, may be burned away with caustic agents or the actual cautery, or may be disposed of in any other manner without harm and only with benefit; in fact, it is often necessary to suppress this exuberant tendency by caustics and pressure, in order that the desired epithelial covering may be properly formed.

Epithelium, being an epiblastic structure and capable of no other origin save from its kind, can only be supplied from those regions where it has preëxisted. Consequently, ulcers involving the external surface of the body demand a lively epithelial reproduction in order that they may have a normal covering. Epithelial activity sometimes becomes retarded, and is much slower toward the termination of the healing process than at the beginning. The epithelial covering of a healing ulcer is always marked by a delicate whitish or pinkish film, which proceeds from the periphery as well as from any little island of original epithelial structure left. It is well known that after a certain amount of this repair the process sometimes comes to a complete halt, and the various expedients for stimulating and promoting it, as sponge grafting and the different methods of skin grafting, have been devised solely to atone for such sluggishness or inability.

Ulcers of small size, which are more or less exposed to the air in healthy individuals, while also exposed to possibility of infection, nevertheless seem to escape it, owing to the defensive power of the blood serum and the active cells. Such discharge as naturally comes from them, when not excessive, undergoes evaporation until a point is reached where a dry crust or scab is formed. Under this scab granulation proceeds to a point where the pressure of the scab itself, presumably on the level of the surrounding parts, checks its activity, while at the same time epithelial reproduction goes on until it has been completed. Then the scab, being no longer of use, drops off or is detached by slight friction.

Such is granulation tissue: at first a mere trelliswork of temporary and delicate cell structure, traced in a certain amount of intercellular, homogeneous substance, into which the budding vessels project, the whole mounting, nearer and nearer to the surface, day by day, with variable rapidity, diminishing in this regard as the days go by, so that frequently the granulation process comes to an apparent halt before enough new tissue has been formed. While the superficial granulations preserve the characteristics above noted, those deeper down undergo firmer and more complete organization, and the delicate embryonic structures show the same tendency which they do in the growing embryo, by virtue of what Virchow has called metaplasia, to become converted into something higher and more dignified in the tissue scale. These cells do not specialize themselves to the extent of permitting complete repair of organs of special sense. Thus, while a wound in the cornea or retina may be completely healed, it heals by cicatricial tissue, and not by repair of the special structures involved. On the other hand, tissues of more common connective type—fibrous, bone, cartilage, etc.—are capable of regeneration; and it seems to be a part of the privilege of these new granulations to merge themselves into that kind of tissue necessary for filling the gap. Nevertheless the most common result of granulation is its metablastic conversion into fibrous tissue, which has the special characteristic of contractility without elasticity. As a result the scars contract, in consequence of which disfiguring results are sometimes the almost inevitable consequence of healing of extensive losses of substance. In certain instances it is possible by constant effort to overcome the unpleasant effect of this cicatricial contraction. For example, after extensive burn of the anterior part of the arm, the forearm will be gradually and permanently flexed upon the arm by virtue of contraction of the scar in front of the elbow unless some forcible means is practised for maintaining extension of the limb for at least a part of the time. So with many other injuries and the various mechanical or other expedients required to prevent the untoward result. Nowhere are the after-effects more disfiguring or serious than about the face, where the eyelids are drawn out of shape, the contour of the mouth altered, and where, sometimes, there are other extensive manifestations (Figs. 10 and 11).

As a result of healing of the granulating surface there is what is known as a cicatrix or scar. This is composed of fibrous tissue, probably more or less distorted by virtue of its contractility, and of epithelial covering furnished from the margin of the original ulcer, constituting a thin, glistening membrane, applied closely to the scar tissue beneath, without intervening fat or tissue which permits of the play of the one upon the other. When this epithelial surface is abraded it is repaired with difficulty, and a raw or ulcerating scar is difficult to heal. Manifestation of perverted epithelial outgrowth is frequently provoked at these points by the action of continuous irritation. In consequence there is what is generally recognized as the transformation of a chronic ulcer, or the site of one, into an epithelioma, or possibly, by similar irritation of the connective-tissue elements, into a sarcoma. This is the so-called cancerous degeneration of previous ulcers, and is noted occasionally. The lesion is one which often requires disfiguring, or even mutilating operations in order to get rid of the malignant disease (Fig. 12.) All the scars thus resulting are liable to undergo a fibrous and degenerative change to which is given the name cicatricial keloid. It is marked by increase in size and density, by reddening which denotes increased vascularity, and extension into surrounding previously healthy tissue. By these changes a given scar is made much more prominent and disfiguring. It cannot be prevented by any ordinary treatment, and is often the bête noir of surgeons. (See also under Fibroma, and chapter on Diseases of the Skin.)

The surface of a superficial scar while thus covered with epithelium shows a complete lack of all the other skin elements. No hair grows upon such a surface, because the original hair follicles are destroyed; neither is it moistened by perspiration nor anointed by sebaceous material, because the secretory glands have also disappeared. It is a surface which often needs more or less protection, especially when in exposed situations.

Treatment.

—Here, as in all other instances, the first effort of the surgeon should be to remove the cause. This may be done by local, or may require constitutional measures. If a definite local cause can be established, its removal may be a slight or may entail a more or less serious surgical operation. Aside from this disposal of the exciting agent, treatment should be divided into the general and the local. General treatment is scarcely called for when dealing with healthy ulcers; but in all those instances where the constitutional condition of the patient is below par, or where there is a general poisoning or infection underlying the ulcer itself, prompt and energetic constitutional treatment should be at once instituted. In scurvy, for instance, the diet and hygienic surroundings of the patient should be rectified immediately. In syphilis no lasting nor deep impression can be made on local manifestations without general constitutional treatment. In tuberculosis and the other surgical infections much will be accomplished by internal medication, by proper hygiene, as well as by local applications or operation. The importance of these general measures is likely to be underestimated, and many fail to realize the advantage of combining suitable internal and external therapeutic measures.

Local Treatment.

—First of all may be mentioned the insistence upon repose which induces physiological rest. The ulcer may then show a tendency to heal. This may necessitate wearing a splint or restraining apparatus, or confinement in bed, depending upon the location of the ulcer. Physiological rest will be enforced sometimes by stretching a sphincter in order to temporarily paralyze it in cases of irritable rectal ulcer, where the principal pain is produced by the reflex spasm of its fibers. Again, the eye with irritable ulcer of the cornea is sometimes kept so tightly closed by the same kind of spasm there that it may be necessary to divide the lids, or the orbicularis muscle at the angle of the lids, in order to make access to the part. This is carrying out the principle of physiological rest, because it permits proper exposure and treatment.

The healthy and healing ulcer needs no treatment except protection. Epithelial covering will probably keep pace with filling of the depression by granulations, and all that is necessary to do is to prevent external irritation. Should there be excess of discharge, the simplest absorbent dressing, with enough antiseptic material to prevent putrefaction by contamination with the bacteria of the surrounding air, should be employed. The ulcer which is becoming tardy in its repair may be stimulated by silver nitrate, zinc chloride, or other caustic applications, which act as a spur to the sluggish granulations, destroying those with which it comes in contact, but stimulating those below to do their duty more promptly.

The conventional applications to ulcers fall usually under two categories—the watery solutions and the unguents.

Investigations in the laboratory have led to the employment of peptonized preparations, among which are peptonized cod-liver oil and some of the partially or predigested foods, such as bovinine, etc. These appear to have the power of digesting sloughs and of causing a speedy separation or disposal of everything necessary in the endeavor to secure a healthy condition of the ulcerating surface and give most satisfactory results. When sloughs are present it is an advantage to dust over them papoid, caroid, etc., which have the power of catalytic disposition of decomposing material without reference to the action of bacteria. Under their use there seems to be a solution and disposition of these dead products. With a foul ulcer—one from which the discharge is more or less offensive, due usually to decomposition of sloughing masses, not yet separated—the method of continuous immersion in hot water, when it can be performed, is always valuable. But nothing seems to equal brewers’ yeast for this purpose. It may be applied on absorbent cotton (which should be soaked in it) and covered with oiled silk. Its curative property may be ascribed to the nuclein which it contains in a nascent state. It will, when fresh, clean off a sloughing surface better than anything I ever used.

Many ulcers are surrounded with such firm, indurated borders that it seems impossible that any active regenerative process can arise from such source. Hence, incisions have been practised for centuries. These have been made radially from the centre or have been made parallel to the margin of the ulcer, or sometimes the firm, dense tissues have been minced or chopped by a series of cross-cut stabs or incisions; as the result of which renewed activity has arisen, and an impetus given to the healing process. These methods, however, have yielded to that alluded to above. The ulcer in which granulation has come to a standstill is often treated with the sharp spoon or curette. The result of this has been to provoke again a speedy renewal of granulation efforts, and treatment by curetting is standard and often useful. Actual cauterization of the ulcer with a view to such complete destruction of its covering and border as shall lead to their separation by the sloughing process is occasionally practised. This is perhaps best performed with the actual cautery. It lacks, however, the valuable features of the operative method, to be described below. Modern methods have made it plain that it is often an absolute waste of valuable time to resort to the older expedients of stimulation, incising the edges, etc., and that one can accomplish by an operation in perhaps three weeks what ten times that length of time would fail to do by older methods. The most effective method, therefore, in dealing with old and chronic ulcers is to anesthetize the patient, to excise the entire affected area—i. e., the surface which ought to be granulating and the firm border and tissue in its neighborhood—and then to cover the surface either with skin grafts, pared off with a razor according to the Thiersch method, or with a strip of skin whose full thickness is raised, which is taken from surrounding parts by some autoplastic or heteroplastic method. This line of treatment is so far preferable to all others that, except in case of refusal of the patient to submit to it, it is the one which must hereafter commend itself. It may afford opportunity for extensive plastic operations or for the exercise of the best discretion and knowledge of experienced men; yet cases are rare in which it cannot be successfully performed. These methods of skin grafting have so far supplanted the older method of sponge grafting that the latter is now seldom practised. It may possibly have a sphere of usefulness in certain ulcerated cavities, but under all other circumstances it must take a position far below the plastic methods in practical value.

Finally, ulcers of specific type—syphilitic, tuberculous, leprous, glanderous, etc.—need methods in which the first effort should be not so much to arrange for healing as to dispose of infectious material. The knife, the scissors, the sharp spoon come first into use here, the surgeon bearing in mind that almost all this material is more or less infectious, and that inoculation of his own hands is possible as the result of carelessness. After taking away with instruments all the granulation tissue, with its surroundings, which seems to expose to danger, it is well to cauterize the part with the actual cautery, nitric acid, bromine, or zinc chloride.

The markedly hemorrhagic ulcer, whose surface bleeds on the slightest contact or disturbance, is often a cancerous ulcer, though not necessarily so. This ready bleeding is usually the effect of the fragility of the walls of the new-formed bloodvessels. In many instances it is sufficient to scrape until harder or more resisting tissue is encountered. Hemorrhage may be profuse for the moment, but it is easily controlled. Caustics may then be applied or not, according to the judgment of the surgeon.

Another method is to treat such a surface with the actual cautery. Another is to operate, even in the presence of incurable disease, in order to check a tendency to fatal hemorrhage before the disease has expended itself. In a general way, in regard to small, ulcerating, cancerous surfaces, it may be said that if they bleed excessively or are unduly irritable, it is preferable to attack them by operative measures in spite of the impossibility of effecting a cure.

There are other methods of treating ulcers, but they have mainly been abandoned for those mentioned.