I Reprinted from The Tri-State Medical Journal and Practitioner, St. Louis, November, 1897.J PHAGEDENIC CHANCROID * By A. H. Ohmann-Dumesnil, St. Louis. hE CHANCROID, soft chancre, "chan- crelle" of the French, ulcus molle of the Germans, non-specific chancre of many authors, is a lesion which has caused more mistakes by misinformed °r poorly-posted physicians on the one hand and frauds on the other hand, by quacks, charlatans and unscrupulous |S|i| physicians, than perhaps any other iESI, A'lesion of venereal origin. The term - /?.' w "soft" chancre has been the cause of more mistaken diagnoses than perhaps jj| any other, except, possibly, the other one of "bubo." Any swelling in the groin being a bubo, many imagine that the terms "multiple bubo" and "inguinal adenitis," employed by authors, are equally referable to a simple suppurating bubo, such as we generally find in chancroidal infec- tion. The softness or hardness of a venereal sore is determined, in the first place, by the touch of the examiner; and it is here that much judgment and discrimination is to be exercised. Fear or hesitation may often lead to the erroneous supposition of hardness when such does not really exist. A simple infiltration is very apt to be taken for an induration by the care- less or indifferently-posted investigator, and this sort of a mistake would certainly lead to very serious results, if not to positively disastrous ones, especially in a social way. Again, the name "soft" is apt to lead to serious errors, from the fact that there are chancres which, under exceptional circumstances, are not accompanied by the induration, which is regarded as classic. I will not speak of the differential diagnosis of chancre and chancroid in this place, as I have already done so in.extenso in a former paper in this series.t Suffice it to say that the physician should be certain in regard to the nature of the lesion which confronts him, and act accordingly for the greatest advantage of his patient. And I would advise, in case of doubt, the practice of auto-inoculations, which will be attended by the best and most indubitable evidence which it is possible to adduce under any cir- cumstance, establishing a diagnosis beyond the possibility of a doubt, and thus adding to the certainty of the physician and, as a result, to the comfort of the patient. Make assurance doubly sure if you would gain the confidence of your patient, and always make your prognosis be borne out by subsequent developments. It is in this way only that any one can hope to establish a reputation and make his medical labors appreciated by * Read before the St. Louis Academy of Medical and Surgical Sciences, October 12, 1897. t Tri-State Medical Journal, January, 1896. 2 others and an honor to himself. Furthermore, it is in the field of venereal diseases that these requisites are more expected than in any other one. Under ordinary circumstances the chancroid is an ordinary venereal lesion, which induces no very great inconvenience, yields rapidly to proper treatment, and is followed by a pretty rapid recovery, unaccompanied by any untoward symptoms or complications. The old method of treatment was, without doubt, an efficient one, but was looked upon by patients as worse than the disease. This procedure of applying strong cauterizing agents has been practically abandoned, to-day resort to them being only had in exceptional cases. The favorite applications were nitric acid, chromic acid, Ricord's paste, and stick nitrate of silver, all of which were excruciatingly painful.. That they were efficient is beyond all doubt, but the inflammatory troubles which supervened were often of a most severe character. The fact that chancroid is caused by a micro-organism made such treatment efficient, if unpleasant. For this very same reason modern antiseptic treatment has proven of such value and is much less painful, and equally good, if not better, as it is followed by no disagreeable results due to the therapeutic agents employed. Modern microscopic investiga- tion has certainly done much to ameliorate matters in this respect, as it has done in many other instances. But it is not my purpose to refer to the peculiar clinical characteristics of chancroid, its treatment, complica- tions, and other facts observed in connection with this peculiar process. One fact to which I desire to call attention, however, is that in the ordi- nary form there is, perhaps, no agent superior to iodoformin, which is practically odorless and does not irritate. It, however, releases nascent iodine gradually, and this has the property of not only destroying the micro-organism, but of stimulating the affected tissues just sufficiently to bring on healthy granulation and a rapid restitutio ad integrum. The object of these remarks is not to dwell upon the chancroid in its classic form, but rather upon a form which is of the highest interest as well as importance. It is a well-known fact that occasionally the chancroid takes on a rapid and serious destructive action, whereby the tissues suffer to an alarming extent. They are, in a manner, eaten up, which has given rise to the terms phagedena and phagedenic. There is no doubt that the cause of this peculiar condition is one referable to a mixed infection. The presence of the staphylococcus,or of the strepto- coccus and staphylococcus combined, will .lead to the inception of this peculiar process. The same conditions are observed in other lesions, such as the chancre, syphilitic ulcers, etc. It is at all times a most destructive process, and one which absolutely requires very radical measures. It is, perhaps, most fortunate that it is of comparatively infrequent occurrence; but its possible presence is one of the strongest arguments to physicians of the necessity of not looking upon chancroids as merely very simple lesions, and of the absolute necessity of keeping a watchful eye upon every case, in order to be able to arrest any phagedena, should there occur any sign whatever that it is about to declare itself. This is necessary, not only for the prevention of'destruction of the most marked character, but to avoid the complete loss of the life of the individual, as has happened in some cases. That such marked symptoms or lethal outcome is not more com- 3 mon than usually observed, is dependent upon a number of circumstances which will be detailed as the consideration of the subject is taken up. It would appear, however, that among the conditions which are nearly always present, and which would seem to act as predisposing factors, may be noted a depraved general condition. Associated with this may be found a state of poor nutrition and more or less malassimilation. Joined to this, and the most important factor, is greater or less inattention to cleanliness, which leads to the easy infection by and growth of the micro- organisms which have been mentioned above. It is also to be noted that, when a chancroid exists, inattention to the lesion or inefficient treatment may also aid, not only in its spread, but in the inception of a marked destructive process which easily converts itself into phagedena. On the other hand, the best of treatment will not prevent the occurrence and development of the latter, unless heroic measures be adopted and pursued. It acts very much in the manner of hospital gangrene, under certain condi- tions. For it has a tendency to attack several individuals affected with chancroid, if they happen to be in comparatively close proximity, such as in a hospital ward. One case will develop phagedena and the infection spreads to the others, implicating all in a very short time. This is another reason to exercise watchfulness and care in the treatment of chancroids, for a little attention will enable the physician to recognize a possibly danger- ous cdse and segregate it before the infection can spread, and thus avert much suffering, destruction of tissue and consequent deformity, not to mention a large number of untoward symptoms. The fact alone, without microscopic investigation to confirm it, that phagedena can spread itself in a hospital ward to other cases of chancroid is certainly proof sufficient tha,t it is due to micro-organisms acting in the same manner as the same factors do in all infective processes. The researches of investigators and of bacteriologists have also demonstrated this, so that it may be now accepted as an established fact. The phagedena in chancroid is fulgurating in character. It acts with almost lightning-like rapidity in some cases, and it is singularly destruct- ive in character. A reference to the medical history of the Mexican War, when the American troops were in a poor physical condition, will reveal numerous records of such cases. The phagedena was so virulent that gangrene set in almost immediately, and was followed by a loss of a part or of the entire penis. It was universally dreaded, and came to be known under the soubriquet of the "black lion." Many thought, as they do now, that both the Mexican and the Chinese "pox" were of a worse character than the same disease in other nations or races. But the climatic and hygienic conditions, no doubt, had more influence than any other causes. But to return to the phagedenic chancroid. The process, whilst destruct- ive, does not follow any regular course. It has a tendency to assume a serpiginous form, and markedly undermines the tissues. This leaves the edges of the integument overhanging, the skin being more refractory to the destruction than its underlying tissues, and there is constantly present a most excruciating pain. There seems to be no limit to its ravages, if permitted to go on unchecked. Several years ago I had the opportunity of seeing one of the most markedly destructive cases which has ever been recorded. The patient, a young man, contracted what appeared to be an 4 ordinary chancroid. Worn by dissipation, rather anemic and thin, he was not in a condition to neglect the lesion as he did. As a result of this care- lessness and inattention on his part, phagedena soon set in and spread with frightful rapidity. It did not limit itself to the external parts, but made its way into the urethra and thence to the bladder. The sufferings under- gone by the patient are simply indescribable. In about a week he was dead, and a post-mortem examination showed that there had been perforation of the bladder of very recent date, as a peritonitis had not established itself. Such cases are certainly rare, but are illustrative of the serious nature which phagedenic chancroid may assume under circumstances favorable to the process. They further show the absolute and great danger which may attend an apparently simple sore which is neglected. The most extensive chancroid, phagedenic in character, which I have ever seen, was one in a negro which involved the entire abdomen and the thighs. He was a hos- pital patient and was fortunate enough to be cured, at the cost of much Fig. i. Multiple Chancroids-Phagedena beginning. suffering and the loss of nearly all of the skin which was implicated. A portion of the integument was replaced by skin grafts, the remainder cicatrizing. The appearance of a phagedenic chancroid is clearly indicative of the condition present. The affected area has a worm-eaten floor, the de- struction is deep, and the edges are undermined. In Figure 1 is given a picture of multiple chancroids beginning to take on a phagedenic charac- ter. The edges of the lesions are still somewhat regular in form, and there can already be seen evidence of the tendency of the lesions to join one another, the intervening bridge of sound tissue breaking down and ulcer- ating. The patient in this case made a comparatively rapid recovery, as the destruction had not yet become extensive or very deep. The trouble being comparatively in its inceptive stage, there was but little difficulty ex- perienced in jugulating it. In some cases the tissues look not only worm- eaten, but as if a rat had gnawed off certain portions, and the appearance 5 presented is a hideous one. Thus, in Figure 2 is shown a case in which the penis looked as if it had been run over by a wagon-wheel. The pos- terior surface of the organ was involved from the perineum to the glans, which had remained intact. The tissues were destroyed extensively, although the urethra was spared. The phagedenic process was plainly apparent, large shreds of dead, suppurating, and even putrefying, tissue existing. The whole surface looked ragged and bled at the slightest touch. The de- stroyed surface was about three inches in width at its broadest part. The general increase in size can best be judged by a reference to the illustra- tion. The appearance of the affected surface can also be seen and the amount of destruction noted. Yet, notwithstanding the deplorable condi- tion which existed, a rapid improvement manifested itself directly after the phagedenic surface had been thoroughly cauterized with fuming nitric acid. A subsequent iodoform and gauze dressing acted so well that the patient left the City Hospital, where he had been treated, before the trouble Fig. 2. Extensive Phagedenic Chancroid of Penis. was entirely healed. His subsequent history is unknown to me, but there is no doubt that the healing process which had well progressed continued without any further incident. When phagedenic chancroid attacks a woman the destruction is always greater than in a man, owing to the fact that a much larger surface is pre- sented by the external genitalia. It is not unusual for the labia minora and clitoris to be destroyed, the labia majora also suffering severely. In Figure 3 may be seen a picture of a case in which both labia minora, the right labium majus and the clitoris were destroyed. The encroachment of the process on the right buttock is also plainly seen, as well as the iso- lated patches of destruction separated from the main phagedena. It is not at all unusual for the phagedenic process to encroach upon the vagina, and subsequently lead to a greater or less atresia or stricture, caused by repar- ative cicatrization. In the case shown in Figure 3 there existed a foul, 6 sanious secretion of ill-smelling pus, considerable in quantity and of a highly corrosive character. Throughout the pus shreds of disintegrated tissue could be observed. The treatment of phagedenic chancroid is one which needs more than ordinary care and attention, as has already been said above. The first Fig. 3. Extensive Phagedenic Chancroid of Vulva. thing to do is to give the ulcerated surface a thorough cleansing by means of a warm solution of some antiseptic. The strength need not be particu- larly marked, as the object is to obtain, as far as is possible, a comparatively clean field to work on. If the surface be extensive and offer a compara- tively large area, as in the cases shown in Figures 2 and 3, the patient should be anesthetized, as the pain of the subsequent operation is such as to 7 be unbearable without recourse to general anesthesia. Cocaine is impotent in such an instance, as it does not penetrate to a sufficient depth; and the infiltration method is more tedious than administering an anesthetic. The operation consists in curetting the ulcerated surface, in order to remove all the destroyed and partially-destroyed tissues. Of course, it is not neces- sary to resort to this measure in every case, as some can be very well treated, when the destruction has not become too deep, without having recourse to surgical procedures. In either case, the next step in the treat- ment is the application of fuming nitric acid to the implicated tissues. This should be made as thorough as possible, to avoid the necessity of a subsequent application. The final step is the application of some anti- septic ointment or powder and a proper dressing. An ointment is prefer- able to a powder, because it will not adhere to the wounded surface and permits of a clearer view of the field being had. A good ointment for this purpose is the following: $ Pulv. Campho-phenique gj Ung. Aquse Rosae. M. Sig. - Apply twice a day. A good adjuvant to this is the use of peroxide of hydrogen before each dressing is made. It is a good pus destroyer and has the property of searching out any purulent collection wherever situated. It also possesses the property of destroying the phagedenic tendency by its action on the micro-organisms which are the cause of it. At each dressing the utmost vigilance should be exercised to discover any possible point which might have escaped, as this would form a new focus to cause a recurrence and foster further extension of the phagedena. Generally, under proper treatment, the healing process is at best but a slow one; still, it is progressive-and the duration is entirely dependent upon how early the trouble was recognized and how energetically it has been treated. Overtreatment is to be avoided, as it may prove a source of irritation instead of the contrary. One thing which is to be avoided in the treatment of phagedenic chancroid is the use of iodoform. Whilst this remedy is ex- cellent in ordinary forms of chancroid, it does not seem to exert any but a deleterious action in the malignant dr phagedenic form. At best, under the most skillful treatment, no bright hopes can be held out to patients. The process can be arrested and a cure effected, but deformity cannot be prevented, and, in most instances, cannot be repaired.