REMARKS ON ULCERS 



2191 



Undetermined Subchronic and Chronic Ulcers. 



Knowledge of this group of ulcers is scanty, but the investiga- 

 tions of Strong, Stitt, Rho, Wherry, and Clegg, and others have 

 thrown some light on this subject. Our experience tallies with 

 that of Stitt, and we therefore consider that such ulcers may be 

 roughly divided into three groups: — 



1. Septic Ulcers — Ulcerations following on Neglected Wounds. 



2. Painless Chronic Ulcers. 



3. Diphtheroid Ulcers. 



Septic Ulcers — Ulcerations following on Neglected Wounds. — 



These are of pyogenic origin and often very large dimensions. 

 They are generally of roundish or irregular shape, and may be very 

 deep. The secretion is abundant, purulent, and contains the various 

 staphylococci. If the pus is removed, and a scraping taken from 

 the fundus, the preparation will show numerous polymorphonuclear 

 leucocytes and various cocci. These ulcers do not show tendency 

 to spontaneous cure, but heal quickly under an antiseptic treatment. 

 We generally treat them with hydrargyrum perchloride (i in 2,000). 

 The opsonic treatment also gives good results. 



Nichols has called attention to discharging sores in the Philippine Islands, 

 called 'puente,' which are produced by the natives applying some lime to the 

 skin, and afterwards betel powder, with the object of counter-irritation. 



Painless Chronic Ulcers. — A small red scaly, slightly itching spot 

 appears, generally on the legs, and gradually enlarges for about 

 four to eight weeks, when the affected area begins to exude a serum 

 which quickly dries into crusts. Under the crust ulceration slowly 

 takes place. At first the ulcers are shallow, and may have under- 

 mined edges; later they are often punched out, and may become 

 indurated. There is no pain, except slight pain on pressure, and 

 the general health is not affected. Healing takes place under the 

 crust, and lasts between two and twelve months. A pale cicatrix, 

 with hyperpigmented margins, is left. 



As noted by Stitt, scrapings from the fungus show a prevalence 

 of mononuclear cells, polymorphonuclears being practically absent. 

 No pyogenic organisms are found. 



Treatment. — The treatment is difficult. Cauterization does very 

 little. In some cases the application of bismuth subnitrate, xero- 

 f orm, novoform, dermatol, and firm bandaging is useful. In others 

 a protargol ointment (5 to 10 per cent.), or a nitrate of silver 

 (J per cent.) balsam of Peru (i per cent.) ointment is of advantage. 

 Allantoin preparations may also be used. When the ulcers are 

 very large and atonic, skin transplantation may be necessary. 



Diphtheroid Ulcers. — An angry red, painful spot, often surrounded 

 by vesicles, appears on the legs. Within a few hours — twelve to 

 forty-eight — -the affected area is turned into a dark greyish or 

 blackish membrane. If this membrane be removed, an ulcer will 



