CHAPTER XI

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CHANCROID OR VENEREAL ULCER.

Since the time of John Hunter and his pupils, who confused the three totally different and so-called venereal diseases, pathologists have drawn a distinct line between _chancre_, which is simply the initial sore of syphilis, and _chancroid_ or _venereal ulcer_, which is a distinctly local lesion, often destructive, but never followed by constitutional disease, except of septicemic or pyemic type. It is usually found upon the _genitals_, about the foreskin, glans, and vulva, but may be met anywhere upon the body where infection has occurred. It is distinctly _auto-inoculable_, in which respect it differs from chancre.

Varying views have been held as to the minute agency concerned in the production of this lesion. The bacillus discovered and studied by Ducrey, in 1889, is now accepted as the exciting cause. This is 1.5 μ long and 1 μ thick, with rounded deep-staining ends and fainter-staining central portion, occurring with great constancy in chancroidal pus, less often in buboes than in ulcers, in and outside of the cells, and in chains. It is cultivated with difficulty, grows best on human blood, takes basic aniline stains, but is easily decolorized by alcohol or by Gram’s method. Characteristic ulcers can be produced by inoculating it, even in monkeys.

Chancroid begins, in twenty-four hours, as a red point or papule, which is quickly converted into a pustule and then into an _ulcer_. The borders of this ulcer enlarge, its depth increases, until after a few days it forms a more or less deep, often undermined excavation, irregular in contour, discharging grayish purulent material. In this respect it differs also from chancre, whose natural discharge is more like serum. In other words, _chancroid is essentially destructive, chancre constructive_, since the latter forms a new-growth which ordinarily has little or no discharge. When the necrosis of chancroid becomes extensive and tends to spread rapidly the ulcer is spoken of as _phagedenic_. This tendency to rapid local gangrene is the combined result, probably, of virulence of virus and lowered local or constitutional tissue resistance. It is consequently most often seen in alcoholics and prostitutes. In rare instances a surface larger than the hand may be rapidly destroyed, every particle of material sloughed being infectious.

In chancroids of the mild variety the discharge may dry upon their surfaces and scabs or crusts result, beneath which, when detached, the characteristic ulcer is present.

Under proper treatment this foul ulcer is soon converted into an ordinary granulating surface, which heals by cicatrization.

CHANCROIDAL BUBO.

Infection, by propagation along the lymphatics, of the inguinal nodes is frequent, and, since the infection is almost always a mixed one, suppuration is frequent.

The pus of a suppurating chancroidal bubo is as infectious as the discharge from the original sore; hence the need of great caution. The edges of the local incision should be promptly cauterized so that they may not become linear chancroids. Phagedena shows itself here as well as about the genitals proper, and differs only in that it makes the case more serious. A chancroidal bubo may, however, subside without abscess formation. The signs of suppuration are those incident to pus formation anywhere near the surface. When pus is present its early evacuation is demanded.

=Diagnosis.=--Chancroid is likely to be confounded with _chancre_ and _herpes preputialis_. It has no period of incubation. Destruction commences after infection, so that within twenty-four hours macroscopic evidence may be observed, and within two or three days the sore has attained distinct size and shape.

_Chancroid._ _Chancre._ _Herpes._

Local ulcer. First local sign of a Local neurosis. constitutional disease.

A distinctly venereal Usually a venereal May be non-venereal, infection. infection. from friction, irri- tation, uncleanliness, etc.

No incubation; lesion Incubation from ten to No incubation. noticed within a few seventy days before days. first lymphatic in- duration.

Commences and remains Commences as a papule, Commences as a crop as an ulcer. or occasionally as an of vesicles. erosion. This _may_ ulcerate later.

Usually multiple. Usually single. Multiple and occurring in crops or series.

Secretion purulent Secretion slight and Little or no secretion. and abundant. serous or bloody.

May occur again and As a rule, it only Patients who once have again. occurs once in the it are frequently same patient. subject to it.

Auto-inoculable. Not auto-inoculable. Not inoculable.

Phagedena frequent. Phagedenic action very Never. rare.

Buboes in about 65 Bubonic enlargement Lymphatics rarely per cent. of cases. nearly always. involved.

Buboes usually Buboes as a rule do suppurate. not suppurate.

=Prognosis.=--Except in the most debilitated and dissipated, in whom phagedena may prove fatal, recovery always occurs, but often with the loss of tissue and disfiguring scars.

=Treatment.=--In mild cases--_i. e._, those showing but little destructive tendency--cleanliness and the use of hydrogen peroxide, followed by local use of any of the ordinary antiseptic powders, or even of calomel, will usually prove sufficient. Sodium sozoiodolate makes an excellent application. It is odorless and non-toxic. At first its use may be preceded by morphine or cocaine, but after a few days it will prove a painless application. If the ulcer manifest any tendency to spread, it should be cleansed, cocainized, and then cauterized with nitric acid or the actual cautery, after which it should be so treated as to encourage granulation. This plan should be followed in phagedenic cases, which may call for general anesthesia, with the use of scissors and a sharp spoon, followed by cauterization of every particle of raw or diseased surface.

Widespread phagedena is more rare now than formerly. Cases which are extensive do best when submitted to continuous immersion of the hips in a sitz-bath as hot as can be tolerated. All aggravated cases call for invigorating and tonic measures, laxatives, improved nutrition, and stimulants.

_Suppurating buboes_ should be incised, usually curetted, and thoroughly swabbed with pure carbolic acid, followed by pure alcohol to neutralize the acid, then packed lightly with antiseptic gauze, and allowed to close by granulation. Virulent cases will be accompanied by sloughing of so much tissue that it is best to remove all sloughs with scissors. Here even stronger caustics will be called for. _Phimosis_ often complicates chancroid, and will necessitate circumcision or incision along the dorsum of the prepuce, with such attention to the parts thus exposed as their condition may require.

=Mixed Chancre.=--Mixed chancre, or the combination of the two lesions, has been already discussed.

=Extragenital Chancroid.=--Extragenital chancroid may occur upon any portion of the body, but is more rare than extragenital chancre. It is characterized by the same peculiarities as pertain to the venereal sores already described, and is amenable to similar treatment.

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