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.