Ulcer.

- RUDDOCK.E.H,

DEFINITION.-- An Ulcer is an open wound or sore, which differs from a healing sore in that there are present in the ulcer certain conditions tending to prevent it undergoing the natural process of repair.

The process of ulceration is defined as the molecular or cellular death of tissue taking place on a free surface-skin or mucous membrane. It is essentially the same in nature as the process of suppuration; in the latter, however, the purulent discharge collects in a closed cavity forming an abscess whereas in the case of an ulcer the pus escapes at once on the surface.

Of the factors which prevent an ulcer from becoming a healing sore, one of the most important is the presence of pathogenic bacteria, which by their action not only prevent healing, but so irritate and destroy the tissues as to lead to an actual increase in the size of the sore. Interference with the nutrition of apart by oedema or chronic venous congestion may impede healing, as may also induration of the area surrounding an ulcer, by preventing the contraction which is such an important factor in repair. Defective innervation, the vitiated state of the tissues in the certain constitutional conditions (diabetes, syphilis, Bright's disease, etc.) ,and mechanical causes, such as unsuitable dressings, or ill-fitting appliances act as impediments to repair.

The discharge from an ulcer is profuse, thin, acrid, and offensive, and consists of pus, broken-down blood-clot and sloughs. The edges are inflamed, irregular,and ragged, showing no sign of growing epithelium-- on the contrary., the sore may be actually increasing in area, by the breaking-down of the tissue, at its margins. The surroundings parts are hot, red,swollen, and oedematous; there is pain and tenderness both in the sore itself and in the parts around.

CAUSES.-- Crush or bruise,heat and exposure to the Roentgen rays, pressure of improperly padded splints, or other appliances, imperfect circulation, tuberculosis, syphilis, malignant disease, etc.

TREATMENT.-- The treatment of ulcers is a matter of great practical importance. An ulcer is not only an immediate cause of suffering to the patient, crippling and in capacitating him for his work, but is a distinct and constant menace to his health; the prolonged discharge reduces his strength, and among other complications it is not uncommon for ulcers of long standing to become in elderly persons the seat of cancer. In addition, the offensive odour of many ulcers renders the patient a source of annoyance and discomfort to others.

The primary object of treatment in any ulcer is to bring into the condition of a healing sore. When this has been effected, nature will do the rest, provided extraneous sources of irritation are excluded.

Steps must be taken to facilitate the return of the venous blood from the ulcerated part, and to ensure that a sufficient supply of fresh healthy blood reaches it. The importance of imperfect venous return in causing or maintaining ulcers, is evidenced by the fact that as soon as the condition of the circulation in a lower limb is improved by confining the patient to bed with the ulcer thereon elevated above the level of the heart, the ulcer begins to heal, even though all methods of local treatment have hitherto proved ineffectual. The septic element must be eliminated by disinfecting the ulcer and its surroundings, and any other source of irritation must be removed.

If the patient's health is below par, good nourishing food, tonics and general hygienic treatment are indicated.

MANAGEMENT OF A HEALING SORE.-- One of the best dressings for a healing sore is a layer of Lister's perforated oiled-silk protective, which is made to cover the raw surface and the skin for about quarter of an inch beyond the margins of the sore. Over this three or four thickness of sterilised gauze, wrung out of boracic (or calendula) lotion, or boiled water are applied and covered by a pad of absorbent wool. As far as possible the part should be kept at rest, and the position adjusted to favour the circulation in the affected area, as for example elevating the limb on which the ulcer is. The dressing may be renewed every two or three days, and care must be taken to avoid any rough handling of the sore. Any discharge that lied on the surface should be removed by a gentle stream of calendula lotion, rather than by wiping. The area round the sore should be cleansed before the fresh dressing is applied.

In some cases healing goes on more rapidly under a dressing of ointment,such as Calendula, Hamamelis, or weak Boracic acid. Very chronic ulcers sometimes respond to a dressing with Serum of even Liebig's Extract.

Unless absolute rest with the elevation of the foot can be enforced in cases of ulcers on the legs, bandages are more or less necessary to support the tissues. they should be of some elastic material and be applied after the limb has been elevated for ten minutes.

The frequency with which the dressings should be changed depends on the amount of the discharge. If it is considerable they should be changed once or twice daily; otherwise a few times a week may suffice.

TREATMENT.-- Strictly constitutional treatment is generally necessary. This may be illustrated by the fact that the appearance presented by a sore often furnishes an excellent test to a patient's health; a weak of indolent Ulcer rapidly assumes a healthy aspect on any improvement of the constitutional powers of the patient; on the other hand, a healthy sore immediately becomes indolent, or sloughs, when any extreme depressing cause comes into operation.

Belladonna.-- Painful Ulcer, with surroundings redness.

Silicea.-- Simple Ulcer; and in chronic cases.

Kali Bich.-- Ulcer on the leg, deep, with hard base and overhanging edges. This remedy may also be used externally (gr.n j. aq. z3vj).



Hydrastis Canadensis.-- Unhealthy Ulcers; Ulcerations of mucous surfaces -- the mouth, throat, nose, eyes, etc. It should be administered internally, and applied locally as a gargle or wash, as the case may require.



Arsenicum.-- Inflamed ulcers with burning pain, raw surface, or presenting a livid appearance, and easily discharging blood or thin foetid matter, and often with general indifferent health. This remedy is specially valuable in indolent Ulcers of the legs, and should also be used in the form of a lotion.

Rhus, ext. and int.; Polygonum and Ammon.-Mur. have cured superficial Ulcers and sores on the lower extremities.

Hep.-S., Calc.-C., or Sulph.--For constitutional Ulcers, and to improve the health. Also Ferr., Mur. (as a paint).