﻿NOTES ON CHRONIC ULCEUS. 559 



inflammation is shown in the sections. They are not characteristic of 

 syphilis nor of tuberculosis. The bacteria and spirochaetse found in 

 the smears probably were all secondary invaders, for the most part 

 saprophytic. Their absence in sections points to this conclusion. If 

 we concede that the four cases have the same etiology, we may say that 

 they are due to a chronic, but curable, nontuberculous disease causing 

 hypertrophy and ulceration, and that the disease is probably infectious. 

 The diagnosis of syphilis is almost forced upon us. Blastomycotic 

 infection and tertiary lesions of yaws are far less probable than syphilis. 

 Elephantiasis does not require serious consideration as a possible diag- 

 nosis. Whether we do or do not concede that these cases have the same 

 etiology, it must be recognized that they have many differences. The 

 contracture and loss of toes in the third case and contracture in the 

 fourth are not easily explained by assuming that syphilis alone is present. 

 They may have resulted from long antecedent phagedenic ulcers which 

 preceded the hypertrophic process. The present condition of the skin 

 renders it difficult to judge of this by observation. Nerve leprosy 

 seems less probable as an explanation in view of the careful consideration 

 it was given and the negative verdict. Congenital defects and trauma 

 are possible, but not probable, etiologic factors. 



Table I of the Catbalogan cases shows (1) a strikingly large number 

 of lesions on the legs, (2) multiplicity of lesions, (3) a marked resem- 

 blance in the distribution of lesions, and (4) a considerable number of 

 deformities. Clinically, the resemblance between individual lesions 

 in different cases and between individual cases themselves is very strik- 

 ing. This points to a common etiology. 



Leprosy, tuberculosis, and syphilis require careful consideration in 

 the diagnosis of this group. Against leprosy we have the facts that 

 there were no signs such as loss of eyebrows, there were no nodules, 

 spots, nor anaesthesia, and also six or more smears taken from inside 

 the nose, the lobes of the ears and from the lesions in every case were 

 negative. Were the bone lesions tuberculous, sinuses or typical tuber- 

 cular lesions of the skin would have been present in some of the cases. 

 Nothing of this sort was found and no tubercle bacilli were seen in the 

 smears made for leprosy. 



The following lesions : Destruction of soft palate, dactylitis, destruc- 

 tion of the phalanges, depressions in the bone of the forehead, and 

 "elephantoid" swellings of the legs, with gumma-like idcerations indicate 

 the presence of syphilis. The microscopic evidence is negative. Syphilis, 

 then, is a probable diagnosis, but syphilis, uncomplicated, rarely produces 

 ulcerations deep enough to cripple limbs or amputate toes. According to 

 Scheube, tropical ulcerating phagedena does this very thing. It com- 

 monly invades unprotected lesions in the Tropics. Therefore, the diag- 

 nosis of syphilis complicated by phagedena might be made. 



