﻿NOTES OX CHRONIC ULCERS. 557 



FOUliTH TYPE OF 0LCERATION. 



Case IV. — Native, 7 coachman, age 33. Patient denied having had any skin 

 lesion until three years ago when he was scratched by harness. An nicer de- 

 veloped at the site of the scratch and gradually increased in size'. The patient 

 appeared healthy and showed none of the ordinary signs of syphilis. The lesion 

 was roughly circular, 17 to 20 centimeters in diameter and occupied most of 

 the posterior surface of the right buttock. It extended a short distance across 

 the median line to the left buttock. The skin around the lesion appeared normal. 

 The margin of the lesion was elevated aiid composed of a dense, inelastic tissue 

 covered with pink, scaling epidermis, which was adherent and immovable. The 

 same sort of tissue covered the greater part of the lesion. The ulcers near the 

 margin were small, deep, pit-like and of uniform size. Their edges were firm, 

 inverted and slightly undermined. They contained sero-purulent exudate and 

 there was a yellowish slough at the base of each. In the central part of the 

 lesion the ulcers were deeper, larger and serpiginous as if formed by confluence 

 of smaller ones. 



A smear showed polymorphonuclear leucocytes in fair numbers, a few large 

 basophilic cells, and an occasional, small lymphocyte and eosinophile. A few 

 diplococei were observed but no other organisms. A section taken from the edge 

 of an ulcer, stained with hematoxylin and eosin, showed thickening of the 

 Malpighian and papillary layers of the epidermis and vacuolation of some of 

 the cells of the upper stratum htcidum. The normal pigment in one place was 

 wanting. The reticular stratum appeared oedematous and showed a marked in- 

 crease of connective tissue cells. The lymph spaces were wide and contained 

 polymorphonuclear leucocytes and plasma cells. There was no small round-cell 

 infiltration about the veins and no endarteritis. The epidermis at one end of 

 the section was undermined by ulceration. At this point traces only of the 

 structure of the corium remained. There was much fibrinous exudate. Other 

 sections stained by the Gram-Weigert method and for tubercle bacilli show many 

 diplococei and a few bacilli in the horny layer but none in the deeper tissues. 

 No tubercle bacilli were found and a section stained with silver showed no 

 spirochete. 



The patient was put on small doses of potassium iodide and the lesion was 

 cleaned and covered with a wet bichloride dressing. It appeared much better 

 after two days and at the end of six weeks the remnants of ulceration were covered 

 with a few small scabs. The skin over the site of the lesion was still pink, but 

 the subcutaneous induration had disappeared and the skin was soft. 



Case V. — Native, 8 age 55. History unreliable. The patient states that he 

 was kicked by a horse seven months ago on the left leg, and that a chronic ulcer 

 developed from the wound. The right leg became ulcerated at about the same 

 time. The patient was poorly nourished. There were no scars in the throat nor 

 any typical mucous patches. The inguinal glands were somewhat enlarged and 

 hard, but the other glands were not. On the front of the left lower leg was a 

 large, serpiginous, pocketed ulcer. The pockets contained moist, grayish slough 

 and necrotic granulation tissue. The margin was indurated and bands of firm, 

 inelastic tissue covered with adherent skin intersected the ulcer. The left leg 

 presented a few pigmented sears around the ankle. The ulcer was cleaned and 



7 St. Luke's No. 14612. First seen March 22, 1907. 

 9 St. Luke's No. 14584. First seen March 20, 1907. 

 62668 6 



