﻿NOTES ON CHRONIC ULCEUS. 555 



greatest diameter. Its outline was made up of curves like the arcs of intersect- 

 ing circles. The margin was clearly defined, a little raised and slightly under- 

 mined. The surface of the granulations was level ; they were boggy and dark 

 bluish-red in color. No slough was visible. Several round, ulcerated papules 

 appeared near the anus. Their interior resembled the surface of the large ulcer. 

 There was an ulcer of moderate size in the groin which appeared to be improving. 

 Dr. Dudley curetted the large ulcer and those near the anus. The granulations 

 were so soft that they could almost have been wiped away. The fascia beneath 

 appeared healthy. A week later the ulcer was covered with healthy granulation 

 tissue, but at the end of the second week the surface was uneven and covered 

 with small patches of grayish slough. The granulations at the edge were slightly 

 exuberant, and those in the other portions appeared as if gnawed away. The 

 color of the granulation was light red. The ulcer of the groin presented the 

 same appearence. There had not been much change in the size of the ulcers. 



Smears from the ulcerated surface showed ordinary pus and a few diplococci, 

 but no other bacteria. Smears from the depths showed neither bacteria nor 

 parasites. After curetting, agar cultures were made from the base in the 

 ordinary way and under anaerobic conditions. They remained sterile. A culture 

 on blood serum showed one colony of staphylococcus and several colonies of a 

 white mould. A section stained with hematoxylin and eosin showed a rounded 

 edge covered with epithelium and undermined by ulceration. The papillary 

 layer of the epithelium was hypertrophied. The fibrous tissue of the corium was 

 much increased and infiltrated with a few small round cells. There was a 

 fibrinous exudate on the surface of the ulceration, having polymorphonuclear 

 leucocytes and plasma cells in its meshes. Other sections were stained with 

 eosin and methylene blue, by silver impregnation, by Gram's method, and for 

 tubercle bacilli, but neither parasites nor bacteria were found in the tissues. 



Like Dr. Strong's second case this nicer began without previous 

 injury, spread slowly in spite of treatment, and did not improve until 

 after curetting. It differed clinically from Strong's case in having 

 a smooth base and no slough, although the lesions may have been 

 modified by the two months' treatment. The discoloration and bog- 

 giness of the surface recalls Scheube's (4) description of phagedenic 

 ulcers. Against the supposition that this ulcer was due to the same 

 organism as the chancroid, we have the fact that the lesions reacted differ- 

 ently to treatment, one healing and the other not. Syphilis is ruled 

 out by the failure to respond to energetic treatment with iodide and 

 mercurials. The appearance and behavior of the ulcer was not as 

 it would have been if produced by tuberculosis. When first seen it 

 differed from the description of ulcerative venereal granuloma (Menso 

 and Manson) (2 and 3) in having a dull, bluish appearance, a smooth 

 surface, a comparatively rapid development, and the absence of a 

 tendency to heal in the center. Dr. Dudley is sure that until he curet- 

 ted the ulcer it had neither been trimmed nor scraped nor cauterized, 

 but only dressed. Its appearance was not that of ulcerative venereal 

 granuloma. In favor of phagedena are the obstinacy of the ulcer, the 

 discoloration of the granulation tissue, and the fact that common 

 causes can be excluded. 



