The Ulcer trophic syphilitic traumatic treatment
The

Ulcer

The ulcer (ulcus) is a granulating defect of the skin or mucous membrane, which persistently does not show a tendency to healing.

Morphologically, ulcers are very diverse. According to the shape, depth, state of the edges, etc., some typical types of ulcers are distinguished: round (ulcus rotundum), slit, or cracked (see), ulcus callosum, ulcus sinuosum. Ulcers in the form of a narrow and deep purulent motion are called a granulating fistula (see).

Etiology . The formation of ulcers is characteristic of a number of heterogeneous nosological forms, both infectious (syphilis, leishmaniasis, anthrax, etc.), and not infectious (peptic ulcer of the stomach and duodenum, varicose veins of the lower limb). At the same time, there are ulcers that do not serve as a manifestation of any of these diseases.

The causes of ulceration in all cases are generally the same as necrosis, in particular gangrene (see). Therefore, ulcers for etiologic signs are classified in the same way as gangrene, distinguishing primarily ulcers caused by locally acting factors, and ulcers caused by a violation of the general state of the body. A more detailed classification distinguishes traumatic ulcers (mechanical, thermal, chemical, radiation), infectious, circulatory (with ischemia, venous stasis, lymphostasis), neurotrophic, blastomatous. Common disorders that cause the formation of ulcers can be: diabetes, avitaminosis (scurvy), anemia, alimentary dystrophy, traumatic exhaustion, radiation sickness, a recently transferred or not-ending severe general infection and other conditions in which the resistance and reparative abilities of the organism . Often, a combination of one locally acting factor with another or with common disorders plays a role, for example, an ulcer from pressure in a severe exhausted patient (see Bedshear).

The

Pathogenesis . In the pathogenesis of an ulcer, an inflammatory or necrotic process initially takes place, which causes the death of tissues and the formation of a defect in the cover - significant or in the form of erosion (see). In other cases, the defect is formed due to damage - injury, burn, etc. The transformation of this defect into the ulcer occurs under the influence of the listed etiological factors, if they do not act intensively, otherwise the rapidly progressing gangrene develops, and no granulating defect develops at all . With less vigorous but prolonged action of these factors, the reparative ability of the affected tissues is partially preserved, along with their death and decay, regeneration also takes place: the defect granulates, but does not heal, turning into a more or less stable ulcer. Necrotic process can sometimes prevail over reparative; in these cases, the ulcer increases, extending to the surrounding cover (erosive ulcer - ulcus phagedenicum). Sometimes erosion occurs only in one direction, and on the other side of the ulcer heals; then they speak of a creeping ulcer (ulcus serpiginosum). The ulcer can increase and deep down to the destruction of the entire thickness of the affected part of the body or the wall of the affected organ, such a ulcer is called perforating (ulcus perforans). The ulcerative process can pass to another organ adjacent to the affected person, which is soldered to it (penetrating ulcer - ulcus penetrans). In case of weakening, and then the termination of the etiological factor, gradual healing of the ulcer occurs. However, with a prolonged course of the ulcerative process, the causative cause may join or even replace its new etiologic moment. So, around the ulcer, massive scars that block blood supply are often formed, and then ischemic is added to the infectious or mechanical factor. Even more important are the disturbances of innervation, which are partly due to blocking scars, but mainly in connection with the development of ascending neuritis and with changes in the central nervous system caused by constant pathological impulses from the area of ​​the ulcer. Therefore, any long-term ulcer, which did not initially have a neurotrophic character, eventually acquires it. The most important is the danger of turning an ulcer into a blastomatous, i.e., its malignant degeneration, especially possible with radiation ulcers.

Clinical picture, diagnosis and treatment of ulcers . The clinical course and symptoms of ulcers are determined both by its origin and, to a greater extent, by its localization. This is especially true for ulcers of internal organs (stomach and duodenum). The diagnosis of an ulcer visible to the eye is not difficult. However, the treatment of an ulcer can be successful only if it is conducted taking into account the cause that caused the ulcerative process and is aimed at its elimination. Therefore, it should be carried out in a differentiated way, depending on which group of the resulted ethnological classification the given ulcer belongs to. In some cases, this issue is not difficult to solve on the basis of clinical data.

Mechanical ulcers are formed if the granulating defect is systematically subjected to friction, pressure, or stretching. They are often found in the mouth (pressing dental prosthesis, biting or scratching the tooth) and, if not started, then heal quickly after the elimination of traumatic moments.

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The same applies to the ulcer of the limb stump caused by a poorly fitted prosthesis. It is more difficult to treat ulcers caused by stretching, which can not be completely ruled out; such are cracks in the anus, often requiring surgery, lip cracks, nipples, etc. In the practice of military surgery, mechanical ulcers occur mainly on the lower limb, most often after injuries to the popliteal fossa or the calf muscle and Achilles tendon. They are supported by stretching during walking, and their etiology usually appears easily, since the movements in the joint noticeably change the shape of the ulcer, and the contraction of the muscle causes a displacement of the soldered bottom of the ulcer. With the ambiguity of these signs, the mechanical nature of ulcers is established ex juvantibus; strict bed rest and immobilization with a gypsum tire quickly and favorably affect the condition of the ulcer, and the resumption of walking immediately nullifies the effect.

Treatment is only prompt. Apply excision of ulcers and scars, closure of the defect with sutures (late secondary suture) or displaced local skin flap. If the scars in the circumference are small, you can confine yourself to thorough scraping of the granulations and transplant a free flap of skin to the bottom of the defect; which often takes root. Attempts to transplant the epidermis for granulation are doomed to failure.

Thermal ulcers in the form of cracks arise almost exclusively with shivering of hands. With careful protection from repeated cooling quickly heals spontaneously or under the influence of conservative treatment (warm baths, ointment dressings with weak antiseptics, for example Vishnevsky ointment).

Chemical ulcers occur as an occupational disease on the hands of the pickers (in the fishing industry, in bacon production). Often, the purulent infection is manifested by swelling and a sharp redness around ulcers, usually multiple. In these cases, it is necessary to release from work for several days, ointment antiseptic dressings. Unpolluted ulcers quickly heal if the hands are protected from brine action by rubber gloves. The latter also serve as a means of prevention. It is much more difficult to treat chemical ulcers caused by the corrosive action of digestive juices, especially pancreatic juices, with external pancreatic fistula and high intestinal fistulas. All measures to protect the skin from maceration and digestion are often infertile, and the ulcer heals only after the fistula has been eliminated. The best means of preparing ulcerated skin before surgery for such a fistula is the constant drying of the unsealed fistula hole, performed by the patient himself with the help of gauze balls.

As a rarity, a chemical ulcer can be encountered, which the patient consciously supports with applications of caustic soda, ashes (hysteria, self-mutilation, etc.).

Radiation sores - see Skin, radiation injuries.

Infectious ulcers of a specific etiology - see Actinomycosis, Leishmaniasis, Soft chancre, Anthrax, Syphilis, Tuberculosis.

Nonspecific infections - purulent, anaerobic, putrefactive - cause the formation of ulcers almost exclusively on the places of the former wounds and mainly in the form of fistulas, supported by deep foci of infection - an extensive purulent cavity, osteomyelitis, foreign body, etc. Treatment consists in surgery for this outbreak .

Much less often the wound can turn into an ulcer under the influence of aggravating agents on the granulations themselves - staphylococcus or streptococcus, and especially diphtheria bacillus. In the past war, this microbe was repeatedly detected in stubbornly healing wounds in the absence of any characteristic manifestations of wound diphtheria (see Wounds, Wounds). The nature of these infectious ulcers is recognized by bacteriological examination, and especially by the elimination method - by the absence of signs characteristic of ulcers of a different origin. It must always be taken into account that the persistent presence of a large number of pathogenic microbes on the granulations may not be the cause, but the consequence of the existing disorders of healing. Treatment consists in local and general use of antibiotics and ultraviolet irradiation. Lip cracks, supported by a fungal infection (yeast fungus), are successfully treated with nystatin ointment.

Circulatory ulcers, ischemic - see Reynaud's disease, Endarteritis obliterans; stagnant - see Varicose veins; lymphostatic - see Elephant.

A special form is a circulatory ulcer caused by strictly local ischemia of granulations caused by blocking blood supply to the scars. Such ulcers occur at the site of wounds with extensive cover defect, especially if the bottom of the wound is formed by tissue, poor vessels (for example, the wide fascia of the thigh that has not been dissected during surgical treatment of the wound). Symptoms: extensive massive scars in a circle, granulations poorly developed, flat, without normal granularity or tuberous, swollen, but always pale, almost bleeding when damaged. Treatment: while the ulcer is not triggered (i.e., when the cessation of epithelialization from the edges and the deterioration of the state of granulations have just been determined), the epidermal transplant can result in Yanovich, Chainsky or Davis (see Skin plasty). If the possibility of engraftment is already doubtful, and the ulcer is very large, it is necessary first to make a test, transplanting for granulation 10-15 small grafts placed evenly over the surface of the defect; In case of engraftment of at least half of them, the entire defect can be closed. In case of failure and in clearly launched slipshakes - extensive excision of ulcers and scarring and transplantation of the skin flap on the peduncle or a stalk flap according to Filatov. As a rule, do not use local skin flaps: their scaling and moving can increase the scarcity of blood supply.

Neurotrophic ulcers (trophic ulcers) develop in areas with impaired innervation, with diseases and injuries of the spinal cord, large peripheral nerve. Such are the perforating foot ulcer (malum perforans pedis) with sciatic nerve damage (Figure 3), the ulcer in place of decubitus with lesions of the spinal cord, etc. These ulcers have a primary neurotrophic origin, are formed on a site that has been necrotic - "spontaneous" or caused an insignificant external cause. The ulcerative-necrotic process usually progresses rapidly. So, perforating foot ulcer, beginning with necrosis of the skin area on the sole in the area of ​​the metatarsal heads, deepens to the rear of the foot, where it also destroys the skin, forming a through hole. The nature of these ulcers is easily recognized by anamnesis and the presence of other signs of a sharp violation of innervation - gross sensory and motor disorders. Sometimes these disorders themselves play an important role in ulcer formation; loss of sensitivity does not allow the patient to avoid dangerous external influences (corneal injuries - with the defeat of the first branch of the trigeminal nerve, repeated burns - with syringomyelia), and the paresis can create a vicious position of the limb that promotes her permanent trauma. The ulcer at the ends of the toes with their paralytic flexural contracture can have a purely mechanical, and not a neurotrophic origin. Treatment of primary neurotrophic ulcers can be successful if possible to restore impaired innervation by operative (neurolisis, nerve seam, decompression of the spinal cord, etc.) or conservative measures. If this task is not feasible, the ulcer does not respond to treatment and can lead to amputation if it is localized to the extremities and caused by damage to the nerve trunks. With a break in the spinal cord, which did not lead to the death of the patient, vegetative innervation can recover over the years; then the ulcer from the pressure sores heal spontaneously. Treatment in these cases is reduced to protecting the ulcer from infection (topical application of sulfonamides, antibiotics, weak antiseptics).

Less symptomatic of an ulcer, which acquired a neurotrophic character secondary because of its great prescription, is less demonstrative. Most often, varicose ulcers of the shin (Figures 1 and 2), then ischemic ulcers, supported by blocking scars, and radiation ulcers (Figure 4), less often all others. The ulcer does not lose its initial signs, and its changed nature is indicated only by vegetative disorders in the circumference: hyperhidrosis or excessive dryness of the skin, its atrophy, hypertrichosis, or poor and brittle hair compared to the symmetrical area. Only sometimes there are some changes in sensitivity around the ulcer. All these signs must be sought with any circulatory, mechanical or other ulcer existing more than 3-4 months. It should also be borne in mind that with wounds (especially gunshot wounds), the prolonged course of the wound caused by its severe infection or general weakening of the body can lead to secondary trophic disturbances before the features of the wound defect will qualify it as an ulcer. In this case, secondary neurotrophic disorders are often the only reason for the subsequent transformation of the wound into an ulcer, so that there are no signs in the symptomatology of the wound indicating another origin.

Treatment should eliminate the supporting ulcer pathological impulses - centripetal and centrifugal. For this purpose, long-term oily-balsamic dressings are recommended (see) in the form of a warming compress, ionophoresis with novocaine, short or circular blockade, spirituonokine blockade (see Novocain blockade), neuromotomy of the corresponding cutaneous nerves according to Molotkov (all without guarantee of success). Failure is inevitable if these methods are used in ulcers, supported, in addition to secondary trophic disorders, by the etiological factor that initially caused the ulcer process: infection (foreign body, osteomyelitis), ischemia (massive scars), etc. Elimination of this factor (eg, excision ischemic ulcers and blocking scars with plastic replacement of the defect) with continuing neurotrophic disorders will also be fruitless: the flap will not survive or ulcerate. Success in such cases can be calculated with the combination of plastic surgery with blockades or neurotomy, but it is not always effective.

Thus, even with accurate knowledge of the complex etiology of these ulcers, their treatment remains a very difficult task. The more important is their prevention, which is to achieve the healing of the mechanical, circulatory or other ulcer before it causes secondary changes in the nervous trophism. Therefore, one should never delay with surgical intervention for an existing ulcer, or with accelerating healing operations with extensive granulating wounds.

Ulcers associated with general disorders (diabetes, scurvy and other diseases listed above). With the modern possibilities of recognizing and treating these diseases, they very rarely cause a "spontaneous", without external cause, ulcer formation, but can serve as one of the important causes of ulcer development at the wound or burn site. Of the common infections it is necessary to note syphilis, which, in addition to specific infectious ulcers, can cause and the transformation of the wound into a nonspecific ulcer (by reducing the reparative abilities of the body). In wartime, the most important combination is C-hypovitaminosis with alimentary dystrophy and blood loss; in besieged Leningrad, it sharply disturbed the healing of wounds and led to their transformation into ulcers.

With each ulcer, and even more so when its origin is unclear, the general condition of the patient should be studied in detail (primarily the search for symptoms of hypovitaminosis, the determination of sugar in the urine, a general blood test, serological reactions to syphilis), and the results are taken into account when treatment.

High-calorie, rich in vitamins nutrition is indicated for ulcers that are not associated with violations of the general condition of the patient.

An ulcer is a long-lasting non-healing granulating tissue defect that has occurred as a result of their necrosis, in the absence or weak manifestation of regeneration (healing) processes. Ulcers must be distinguished from erosion (see), in which only the surface layer of tissues perishes, and the deeper layers are not affected.

In the origin of ulcers, many causes play a role. Ulcers due to common diseases accompanied by metabolic disorders include ulcers in scurvy , diabetes, radiation sickness , severe exhaustion, etc. Depending on the nature of the causes that caused ulceration, distinguish ulcers: traumatic, thermal, electrical, chemical, etc. ; infectious - specific (tubercular, syphilitic, actinomycotic, etc.) and nonspecific; ulcers that develop as a result of circulatory and lymph circulation disorders ( endarteritis and atherosclerosis, venous congestion) or innervation (neurotrophic ulcers, trophic ulcers); changes in the walls of blood vessels in atherosclerosis, obliterating endarteritis, etc .; blastomatous process (blastomatous ulcers); local action of penetrating radiation (radiation ulcers, Figure 6).

ulcer
Fig. 6. Trophic ulcer of the hand as a result of the action of x-rays .
Fig. 7. The perforating ulcer of the foot. 1. Varicose ulcer of the lower third of the shin.
Fig. 2. The same ulcer, which took a trophic character.
Fig. 3. Primary trophic ulcer (perforating ulcer of foot).
Fig. 4. Radiation ulcer as a result of the action of X-rays.

In some cases, the ulcer can be caused by a combination of causes. For example, the necrosis of the skin, followed by the formation of ulcers in bedsores (see) is caused, on the one hand, by pressure on the tissue, on the other - by a violation of their viability due to exhaustion of the patient or due to a disorder of their innervation (especially in spinal cord injuries ).

According to the peculiarities of the current, ulcers are distinguished: erosive (gradually increasing in the plane); creeping (from one side of the ulcer is healing, on the other - corroding); perforating (forming a through hole in the wall of a hollow organ or in a part of the body, Figure 7); Penetrivirujushchie (penetrating from the amazed or struck organ in another, the organ soldering with it, for example from a stomach in a liver ).

Ulcers of the covers accessible to inspection (skin, oral cavity, etc.) are recognized without difficulty according to the history (duration) and the type of granulating defect. The difficulty of recognition can only concern the definition of the nature of the ulcer, which is necessary for proper treatment, consisting primarily in eliminating the cause of the ulcer. The most simple recognition and treatment of traumatic ulcers caused by pressure limb prosthesis on the stump, denture - on the gum, tooth edges - on the tongue, etc. In these cases, the ulcer heals as soon as the trauma stops.

Traumatic ulcers are most often formed on the site of wounds or deep burns of the elbow bend, popliteal fossa , in the calf muscle, Achilles tendon - in general in places where the granulating defect undergoes compression and stretching during movements. These ulcers quickly heal when immobilizing the limb, with strict bed rest, but often reopened once the patient starts using the limb. In these cases, the operation is shown - excision of the ulcer and closure of the defect with a skin graft.

Chemical ulcers are found on the hands of the pickers, in the fish and bacon industry; they are usually multiple, small, often complicated by a purulent infection. Prevention - protection of the hands from brine action by rubber gloves ; treatment - ointment dressings with weak antiseptics (sintomitsinovoy emulsion , ointment Vishnevsky). With a significant defeat - the release from work until the full healing of the ulcer, which occurs quickly. Much more persistently, chemical ulcers occur due to the constant ingestion of digestive juices from the external gastric and intestinal fistulas . Especially abrupt skin changes occur with duodenal and high intestinal fistulas. In this case, measures to protect the skin from the digestive action of the detachable are not effective, the ulcer heals only after the operative closure of the fistula. In the area of ​​the fistula of the large intestine, ulcers can only form with poor care (see Anus praeternaturalis).

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