In the latter case the disease, if not to the mucous membrane of the rectum, and stricture of the anus is frequent^ the result. Characters of the sore and the symptoms which accompany it.?The appearance of the sore is The base is entirely devoid of remarkable. induration and is freely moveable over the -underlying structures. The surface is raised to a height of an eighth or a quarter of an inch above the surrounding skin and consists of a thick layer of granulative tissue of a pale pink colour and of soft gelatinous consistence and has a smooth, somewhat waxy looking surface. The edges, which are below the level of the surface, are smooth and regular in outline and completely devoid of signs either of healing or of ulceration, the epithelium terminating abruptly. The sore is devoid of pain, and there is hardly any discharge from the surface. The surrounding skin is sometimes marked by If the layer of granulative tissue be cicatrices. removed, the base is exposed and is seen to be of a white colour and presents a fibrous appearScattered over its surface a number ance. of short hairs may be seen. The above description represents the ulcer as it is seen in its most chronic stage, a sta^e which may extend over many months or years during which the sore undergoes little, if any, change: this tendency to an almost indefinite prolongation of the disease forms one of its most remarkable features. Occasionally the sore takes on a spreading action and its appearances alter. The floor of the ulcer becomes depressed beneath the level of the surrounding skin and orifice.
arrested, spreads
CHRONIC VENEREAL SORES. By Surqn.-Lt.-Col. J.
Maitland,
m.d., i.m.s.,
Madras.
here described and which in this country, are with frequently remarkable on account of the extremely protracted course which they run, and the stubborn resistance which they offer to ordinary methods of treatment, and also on account of certain peculiarities in their pathology. Although venereal in origin, they are unconnected with syphilis. Cause, mode of origin, and location of the sore.?As already stated these sores are of venereal origin. They almost invariably originate in one of two ways; either as a chancre on the preor as a suppurating bubo of puce or glans penis, the groin secondary to an ulcer of the penis. In one case only have I seen a sore of this nature other than those men011 any part of the body the case that patient had a sore on tioned. In the inner surface of the cheek, as well as one in The
sores
which
are
met
are
the pubic region. Where the ulcer is situated on the penis it usually remains confined to the glans and prepuce, but it may, under certain circumstances, involve the body of the penis and gradually spreading, the whole organ. In may ultimately destroy the orifice of the uresurrounds it most cases to stricture of the rise ultimately thra
giving
aperture.
ot cases a second In a considerable proportion one of the groins, having taken in found is ulcer bubo. From the its origin from a suppurating on to the pubic region groin the sore may spread of the iliac crest or or may creep round the top downwards into the sulcus between the thigh and as well as the the scrotum, involving the latter and ultimately surrounding the anal
perinseum
presents a slightly scooped out appearance. edges become abrupt and clean cut and pour out a considerable quantity of purulent fluid and the ulcer is seen to spread from day to day. The flow may become brownish in colour, and the discharge somewhat offensive, and burning pain may be experienced. This condition of active ulceration is generally limited to certain parts of the sore, the remaining portion retaining its former characters. Occasionally some parts of the sore take on a healing action, but, unless healthy granulation has been established by the treatment, to be presently described, the process is very
The
slow and differs from the normal method very
considerably. A thin layer of greyish epithelium creeps slowl}' and almost insensibly over the
granulative tissue and the latter gradually sinks to the level of the surrounding skin. The vivid lines, red, bluish, and white, which characterise the normal process are not seen. Another important peculiarity in the healing in these sores, is the fact that process, as seen small islands of npw epithelium appear here and there over the surface and assist in covering it with new epidermis. Comparatively little cicatricial contraction results from the healing
May
LIVER ABSCESS AMCEBA
1898.]
?f the sore. The reasons for these peculiarities in the healing process will be more obvious when we come to consider the pathology of the
disease. In
uncomplicated
cases
the
dition of the patient presents
constitutional no
con-
peculiar features.
:
there to
BUCHANAN.
165
the base and to for m structures. Treatment.?The treatment of these sores is beset with difficulties. So far as my experience goes constitutional treatment has no effect whatever upon the disease. Tonics, more especially iron, should be administered where there are evidences of debility and anaemia, and cod-liver oil is also called for where there are signs of This treatment, however, will malnutrition. have no effect unless combined with very vigorous local treatment. The disease being of an infective character the principles of treatment consist in destroying as far as possible the infected tissues. Until this is effected no improvement can be expected. As much as possible of the diseased tissue must be removed by means of a sharp spoon and the destructive process carried still further by the application of escharotics, or the actual cautery. The best agent to employ for the latter purpose is Vienna paste which should be applied in a thin layer over the surface. After four or five hours the part is washed and boric acid poultices are applied until the eschar separates. If these measures have been effectually carried out a healthy granulating surface is left which may be dressed with boric acid ointment. Should the process show any sign of flagging or relapsing, the best dressing to apply is oxide of zinc powder which succeeds when iodoform or any of the well-known antiseptics have failed. In a considerable proportion of cases the sore after an attempt at healing, relapses into its former condition, and the operation has to be
pockets
penetrate beneath in the underlying
In the majority of cafes the general health is but little, if at all, affected, whilst in a few there is considerable anaemia. Many cases eventually become complicated by stricture of the orifice of the urethra or stricture of the anus, and the former may ultimately prove to be the cause of death. Pathology.?That the disease is not connected with syphilis is proved by two facts. In the first place, in a considerable number of cases there is no history of syphilis nor any evidences of that disease to be seen. In the second place, the condition of the sores is never influenced in the slightest degree by the administration either of mercury or iodide of potassium. It is, however, quite possible for a patient to have become infected with syphilis prior to the development of the disease under discussion or at a subsequent period. As the two diseases may have been acquired simultaneously just in the same way that syphilis and the ordinary chancroid may arise from an inoculation of mixed poisons. Bearing these facts in mind it is easy to understand why patients suffering from these sores sometimes manifest signs of syphilis. Such cases of mixed infection are apt to give rise to much confusion in diagnosis, and it is not unusual to hear these sores spoken of as being syphilitic lesions. That they are not so is proved repeated. by the two facts previously cited. Some cases are so inveterate and the process The morbid changes which characterise the cure so of a in protracted that the patient leaves disease may be described as consisting ch ronic infective inflammation involving pri- hospital in despair before the sores have healed. marily the epithelial layer of the skin, but Such cases frequently return to hospital after the lapse of several months, the appearance of occasionally attacking the papillary layer also. As a result of inflammatory action, the diseased the sore having changed but little during the structures become converted into tissue of jelly- interval. like consistence. This granulative tissue may remain unchanged for long periods, but in favourable cases becomes in part absorbed and converted into fibrous partly tissue, the surface being covered with epithelium. In unfavourable cases the tissue liquifies, its cells become converted into pus cells, and destructive ulceration ensues. The disease does not implicate the^ whole of the structures of the skin. Many of the hair follicles escape destruction and in places the deep laj^ers of epithelium remain intact. If the granulative tissue be removed, hairs may be seen here and there protruding through the base of the sore, and when a healthy process of repair has been excited in the sore numerous islands of new epithelium may be seen siudding the surface of the granulations, affording proof that all the epithelium had not been destroyed. The jelly-like tissue, although superficial over a great extent of the sore, may be seen here and
arrested, spreads
CHRONIC VENEREAL SORES. By Surqn.-Lt.-Col. J.
Maitland,
m.d., i.m.s.,
Madras.
here described and which in this country, are with frequently remarkable on account of the extremely protracted course which they run, and the stubborn resistance which they offer to ordinary methods of treatment, and also on account of certain peculiarities in their pathology. Although venereal in origin, they are unconnected with syphilis. Cause, mode of origin, and location of the sore.?As already stated these sores are of venereal origin. They almost invariably originate in one of two ways; either as a chancre on the preor as a suppurating bubo of puce or glans penis, the groin secondary to an ulcer of the penis. In one case only have I seen a sore of this nature other than those men011 any part of the body the case that patient had a sore on tioned. In the inner surface of the cheek, as well as one in The
sores
which
are
met
are
the pubic region. Where the ulcer is situated on the penis it usually remains confined to the glans and prepuce, but it may, under certain circumstances, involve the body of the penis and gradually spreading, the whole organ. In may ultimately destroy the orifice of the uresurrounds it most cases to stricture of the rise ultimately thra
giving
aperture.
ot cases a second In a considerable proportion one of the groins, having taken in found is ulcer bubo. From the its origin from a suppurating on to the pubic region groin the sore may spread of the iliac crest or or may creep round the top downwards into the sulcus between the thigh and as well as the the scrotum, involving the latter and ultimately surrounding the anal
perinseum
presents a slightly scooped out appearance. edges become abrupt and clean cut and pour out a considerable quantity of purulent fluid and the ulcer is seen to spread from day to day. The flow may become brownish in colour, and the discharge somewhat offensive, and burning pain may be experienced. This condition of active ulceration is generally limited to certain parts of the sore, the remaining portion retaining its former characters. Occasionally some parts of the sore take on a healing action, but, unless healthy granulation has been established by the treatment, to be presently described, the process is very
The
slow and differs from the normal method very
considerably. A thin layer of greyish epithelium creeps slowl}' and almost insensibly over the
granulative tissue and the latter gradually sinks to the level of the surrounding skin. The vivid lines, red, bluish, and white, which characterise the normal process are not seen. Another important peculiarity in the healing in these sores, is the fact that process, as seen small islands of npw epithelium appear here and there over the surface and assist in covering it with new epidermis. Comparatively little cicatricial contraction results from the healing
May
LIVER ABSCESS AMCEBA
1898.]
?f the sore. The reasons for these peculiarities in the healing process will be more obvious when we come to consider the pathology of the
disease. In
uncomplicated
cases
the
dition of the patient presents
constitutional no
con-
peculiar features.
:
there to
BUCHANAN.
165
the base and to for m structures. Treatment.?The treatment of these sores is beset with difficulties. So far as my experience goes constitutional treatment has no effect whatever upon the disease. Tonics, more especially iron, should be administered where there are evidences of debility and anaemia, and cod-liver oil is also called for where there are signs of This treatment, however, will malnutrition. have no effect unless combined with very vigorous local treatment. The disease being of an infective character the principles of treatment consist in destroying as far as possible the infected tissues. Until this is effected no improvement can be expected. As much as possible of the diseased tissue must be removed by means of a sharp spoon and the destructive process carried still further by the application of escharotics, or the actual cautery. The best agent to employ for the latter purpose is Vienna paste which should be applied in a thin layer over the surface. After four or five hours the part is washed and boric acid poultices are applied until the eschar separates. If these measures have been effectually carried out a healthy granulating surface is left which may be dressed with boric acid ointment. Should the process show any sign of flagging or relapsing, the best dressing to apply is oxide of zinc powder which succeeds when iodoform or any of the well-known antiseptics have failed. In a considerable proportion of cases the sore after an attempt at healing, relapses into its former condition, and the operation has to be
pockets
penetrate beneath in the underlying
In the majority of cafes the general health is but little, if at all, affected, whilst in a few there is considerable anaemia. Many cases eventually become complicated by stricture of the orifice of the urethra or stricture of the anus, and the former may ultimately prove to be the cause of death. Pathology.?That the disease is not connected with syphilis is proved by two facts. In the first place, in a considerable number of cases there is no history of syphilis nor any evidences of that disease to be seen. In the second place, the condition of the sores is never influenced in the slightest degree by the administration either of mercury or iodide of potassium. It is, however, quite possible for a patient to have become infected with syphilis prior to the development of the disease under discussion or at a subsequent period. As the two diseases may have been acquired simultaneously just in the same way that syphilis and the ordinary chancroid may arise from an inoculation of mixed poisons. Bearing these facts in mind it is easy to understand why patients suffering from these sores sometimes manifest signs of syphilis. Such cases of mixed infection are apt to give rise to much confusion in diagnosis, and it is not unusual to hear these sores spoken of as being syphilitic lesions. That they are not so is proved repeated. by the two facts previously cited. Some cases are so inveterate and the process The morbid changes which characterise the cure so of a in protracted that the patient leaves disease may be described as consisting ch ronic infective inflammation involving pri- hospital in despair before the sores have healed. marily the epithelial layer of the skin, but Such cases frequently return to hospital after the lapse of several months, the appearance of occasionally attacking the papillary layer also. As a result of inflammatory action, the diseased the sore having changed but little during the structures become converted into tissue of jelly- interval. like consistence. This granulative tissue may remain unchanged for long periods, but in favourable cases becomes in part absorbed and converted into fibrous partly tissue, the surface being covered with epithelium. In unfavourable cases the tissue liquifies, its cells become converted into pus cells, and destructive ulceration ensues. The disease does not implicate the^ whole of the structures of the skin. Many of the hair follicles escape destruction and in places the deep laj^ers of epithelium remain intact. If the granulative tissue be removed, hairs may be seen here and there protruding through the base of the sore, and when a healthy process of repair has been excited in the sore numerous islands of new epithelium may be seen siudding the surface of the granulations, affording proof that all the epithelium had not been destroyed. The jelly-like tissue, although superficial over a great extent of the sore, may be seen here and
