LCERATION AND ULCERS

Definitions--Clinical examination of an ulcer--The healing
sore.--Classification of ulcers--A. According to cause:
_Traumatism_, _Imperfect circulation_, _Imperfect nerve-supply_,
_Constitutional causes_--B. According to condition: _Healing_,
_Stationary_, _Spreading_.--Treatment.

The process of _ulceration_ may be defined as the molecular or cellular
death of tissue taking place on a free surface. It is essentially of the
same nature as the process of suppuration, only that the purulent
discharge, instead of collecting in a closed cavity and forming an
abscess, at once escapes on the surface.

An _ulcer_ is an open wound or sore in which there are present certain
conditions tending to prevent it undergoing the natural process of
repair. Of these, 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 a part by oedema
or chronic venous congestion may impede healing; as may also induration
of the surrounding area, by preventing the contraction which is such an
important factor in repair. Defective innervation, such as occurs in
injuries and diseases of the spinal cord, also plays an important part
in delaying repair. In certain constitutional conditions, too--for
example, Bright's disease, diabetes, or syphilis--the vitiated state of
the tissues is an impediment to repair. Mechanical causes, such as
unsuitable dressings or ill-fitting appliances, may also act in the same
direction.

#Clinical Examination of an Ulcer.#--In examining any ulcer, we
observe--(1) Its _base_ or _floor_, noting the presence or absence of
granulations, their disposition, size, colour, vascularity, and whether
they are depressed or elevated in relation to the surrounding parts. (2)
The _discharge_ as to quantity, consistence, colour, composition, and
odour. (3) The _edges_, noting particularly whether or not the marginal
epithelium is attempting to grow over the surface; also their shape,
regularity, thickness, and whether undermined or overlapping, everted or
depressed. (4) The _surrounding tissues_, as to whether they are
congested, oedematous, inflamed, indurated, or otherwise. (5) Whether or
not there is _pain_ or tenderness in the raw surface or its
surroundings. (6) The _part of the body_ on which it occurs,