TROPICAL ULCERS

This term seems to be both a comprehensive and uncertain one
in the tropics, being largely, if not wholly, employed to designate the
occasional accidental terminal ulcerative condition of several diseases;
such ulcers have been referred to in the course of the text in connection
with oriental sore, frambesia, tuberculosis, syphilis, etc. It doubtless
very often means the addition of a pyogenic or other factor to one or
other of the diseases named, and which to a variable extent changes
the ulcerative character of the already existing disease. Manson,¹
Crocker,² and others think there is a suggestive resemblance in tropical
sloughing to hospital gangrene, except that in the former there is a more
marked tendency to self ­limitation; and evidently believe that in many
examples of so-called tropical ulcer the sores of the several diseases
named may have become infected with the virus of sloughing phagedena.
Cabois³ is also convinced that there is a destructive Ulcus phagedæni-
cum, due to the Bacillus phagedænicus. It is probably, however, only
one of many factors; the one possibly that gives rise to the more virulent
cases.

The view that there is no distinctive idiopathic tropical ulcer other
than explainable upon the basis already suggested is, however, the pre­
vailing one. Stitt⁴ found a “number of cases of chronic ulceration in
the natives (Philippines, Guam), especially of the lower extremities,
but clinically they did not differ from ulcerations which might be ex­
pected from badly infected wounds or from the infective granulomata;
in none could one eliminate the possible cause of tuberculosis or infected
yaws when those due to leprosy were set aside.”⁵

Bulkley,⁶ from his observations in the far East, concludes as to

¹ Manson, “Tropical Diseases.”

² Crocker, “Tropical Diseases of the Skin,” Jour. Cutan. Dis., 1908, p. 44.

³ Cabois, Jour. Mal. Cutan., Sept., 1908, H. 9 (“Phagedenic Ulcer of the Tropics”).

⁴ Stitt, “The Clinical Groupings of Tropical Ulcers of the Philippines, with Some
Negative Notes as to Etiology and Treatment,” Jour. Cutan. Dis., 1908, p. 103.

⁵ Stitt states, however, that after much sifting he was able to cull out two types
which appeared to be more or less distinct tropical ulcers. In one there was a history
of a red spot or lump, usually on the outer surface of the lower extremities; after en­
larging several weeks, the circumscribed, reddened, glazed area of skin, giving the sen­
sation of solid edema on palpation, begins to exude serum which quickly dries and crusts;
under this ulceration now proceeds more or less rapidly, the resulting ulcers being shal­
low, with irregular, somewhat undermined edges; later more or less punched out, with
considerable induration; they were not painful, and after variable progress for a few
months to a year began to heal under the crusts, and terminated in a pale, somewhat
puckered cicatrix, with pigmented margins. The other type begins, usually, in those
greatly dibilitated, as a rather dry, angry-looking spot of erythema, becoming sur­
rounded in a few hours with a circle of vesicles beyond which is an encircling inflamma­
tory areola, and marked subjective pain with tenderness; within a few hours to a few
days the area within the ring of vesicles is converted into a dark gray to black pulta-
ceous diphtheroid membrane, which when detached shows underlying projecting
granulations covered with greenish-yellow pus; if stripped off, this membrane re­forms
very rapidly; the resulting ulcers may extend with great rapidity, and show, as a rule,
no disposition to heal.

⁶ Bulkley, “Notes on Certain Diseases of the Skin Observed in the Far East,”
Jour. Cutan. Dis., Jan., 1910, p. 33.

TROPICAL ULCERS                                    863

“tropical ulcers,” “nowhere did I find ulcerative lesions which could
not be more accurately defined and classified. Occasionally on the
lower legs were ulcerations due to traumatism and subsequent pus in­
fection, but I saw nothing peculiar or distinctive." Shattuck¹ found
(in Philippines) that about 94 per cent, could be ascribed to syphilis;
and states “owing to neglect the lesions are unusual in degree, if not in
kind, and they become very destructive; a few were thought to be, how­
ever, due to infections sui generis.”

Ulcerating granuloma of the pudenda² (also described under the
various names of granuloma inguinale tropicum, venereal granuloma,
serpiginous ulceration of the genitals, groin ulceration, etc.) was first
clearly described by Conyers and Daniels, and later by Galloway,
Macleod, Crocker, Manson, Sequeira, and others; and recently in our
own country by Grindon. It is a slowly progressive, destructive, serpig-
inous ulcerative disease of the genito-anal and genitocrural regions, and
is met with in the dark-skinned races (few exceptions); and has been found
rather widely distributed in the tropics, and is occasionally encountered
elsewhere. Its earliest symptoms consist usually of distinct or ill-
defined papular and nodular infiltration, nodule or pustule, which breaks
down. The disease advances, according to Manson, in two ways: by
continuous eccentric peripheral extension and by auto-infection of an
opposing surface. It may involve but a part or almost all of the region
named. In addition to the ulcerative feature there may be papilloma-
tous development. Scar-tissue formation of low vitality follows in its
course. While generally considered as a disease entity it seems not
unlikely, in some instances at least, that it is another example of tropical
ulceration, the ulcerative process being grafted upon another affection

¹ Shattuck, “ Notes on Chronic Ulcers Occurring in the Philippines," Philippine
Jour, of Science," 1907, vol. ii, No. 6.

² Literature of ulcerating granuloma of the pudenda: Conyers and Daniels, “The
Lupoid Form of the So-called ‘Groin Ulceration’ of this Colony” (British Guiana),
British Guiana Med. Annual, 1896; Galloway, “Ulcerating Granuloma of the Pudenda,”
Brit. Jour. Derm., 1897, p. 133 (case report, histology, with reproduction of case and
histologic illustrations (from sections made by Galloway) from Conyers and Daniels’
paper, with review of same); Maitland, Lancet, June 17, 1899 (case report, with his­
tology by Galloway), and British Med. Jour., 1906, p. 1463 (correspondence); Renner,
Jour. Trop. Med., 1903, p. 139 (notes on a case); Gifford, “Infective Granuloma in
Madras,” The Report of the Madras General Hospital, Indian Med. Gazette, 1905, p.
440; Wise, Brit. Med. Jour., 1906, i, p. 1274 (etiology); MacLennan, “Memorandum
on the Observation of Spirochætæ in Yaws and Granuloma Pudendi,” Brit. Med. Jour.,
1906, ii, p. 995, and Lancet, 1906, ii, p. 1217; Seibert, Archiv f. Schiffs u. Tropen-
Hygiene, 1907, p. 379 (review, etiology, and histology, with bibliography); Macleod,
Brit. Jour. Derm., 1907, p. 73 (case presentation, with histology); Sequeira, Brit. Med.
Jour., March 7, 1908 (case presentation; typical groin condition, and also unusual
fungating ulcer at angle of mouth); Cleland and Hickenbotham, Jour. Trop. Med.,
May 15, 1909 (cases seen in aboriginal natives of Western Australia; has also seen sev­
eral mild cases in white man; histology); Manson, “Tropical Diseases”; Carter,
Lancet, 1910, xi, p. 1128 (describes the organisms found by him in 6 cases seen in British
India—“In certain areas lie masses of very large mononuclear cells, their cytoplasm dis­
tended with from 15 to 20 bean-shaped bodies, resembling the gregariniform stage of
a herpetomonas or erithidium”; Donovan, of Madras (cited by Manson), had pre­
viously called attention to these bodies; Daniels, ibid., p. 1648; Rost, München. Med.
Wochenschr., 1911, lviii, p. 1136 (salvarsan treatment negative); Grindon, Jour. Cutan.
Dis., April, 1913 (3 cases; case and histologic illustration; no trace of spirochætæ or
other parasite either with microscopic examination or cultures; brief review, with
references).

864

NEW GROWTHS

by added infection. It has some features of a cutaneous tuberculosis,
with an added pus-cocci infection. Crocker believed this latter an im­
portant factor in its production. Maitland considers that it results
from an added inoculation to an already present venereal sore, such as
an ulcerating bubo. In some respects the creeping and undermining
ulcerating tract starting from a gonorrheal or chancroidal bubo in the
groin in a tuberculous patient, occasionally seen (formerly more than
now) in our charity hospital venereal wards, considerably resembles it.
The malady is met with in both sexes, usually in those between the
ages of fourteen and fifty. The histologic conditions in ulcerating
pudendal granuloma, studied by Galloway, Macleod, Cleland, Siebert,
Grindon, and a few others, show granulomatous changes, with papillary
elongation and some rete proliferation. Various organisms have been
found, among which protozoa-like bodies (Donovan, Carter) and a
few kinds of spirochætæ (MacLennan, Wise), one resembling the Spiro-
chæta pallida; Grindon’s search for these organisms was negative.

Prognosis and Treatment.—Whatever the cause of a tropical
ulceration may be its course is, except in a proportion of the phagedenic
ulcers, slow, and it is rebellious to treatment. Rost tried salvarsan in
1 case, but without result. In some instances, it is true, after some
months or an indefinite time, spontaneous healing ensues, leaving often
disfiguring cicatrices. The most promising treatment seems to consist
of curettage, destructive cautery measures, conjoined with cleanliness
and antiseptics. In Madras, x-ray treatment has proved quite successful
in pudendal ulceration.

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