CHAPTER XXVII
GANGOSA
HISTORY AND GEOGRAPHICAL DISTRIBUTION
=History.=—It is known that in 1828 a Spanish Commission, investigating the diseases of the Ladrone Islands, reported the existence, in those islands, of a disease which was called gangosa, by reason of the muffled character of the voice, the Spanish word _gangosa_ meaning muffled voice. The Commission recommended that cases of this disease, as well as those with leprosy, be isolated, thus showing that the disease was differentiated from leprosy at that time.
Daniels, who studied similar naso-pharyngeal lesions in Fiji, considered the disease as a sequel of yaws and stated that if it were not a stage of yaws it was probably a separate and distinct disease. Leys, who studied gangosa in Guam, in 1904, gave it the name rhino-pharyngitis mutilans and described it as a disease _sui generis_.
=Geographical Distribution.=—The disease is very prevalent in Guam, and is also present in other islands of the Caroline group. It exists in Fiji and many cases have been reported by Numa Rat from the island of Dominica, in the West Indies. Cases have also been reported from the Philippines and Ceylon.
ETIOLOGY AND EPIDEMIOLOGY
=Etiology.=—The two most prominent views as to its etiology are that it is a sequel of either yaws or syphilis. The fact that gangosa responds to antisyphilitic treatment is no proof as to its luetic origin because yaws yields equally well to such remedies.
Gangosa cases also give a considerable percentage of positive Wassermann reactions, 105 positives in 281 cases. Halton who made these tests found 100% positive reactions in cases of yaws and 46% of positives in those who had had yaws several years previously.
The main points against the syphilitic nature of the disease are absence of either congenital or acquired syphilis among the natives of Guam. There is an absence of Hutchinson’s teeth and interstitial keratitis. Leys states that neither primary nor secondary syphilis had been seen in a native of Guam during a year in which a very large number, including several prostitutes, had been treated. Recently a positive luetin reaction has been obtained in 253 out of 369 cases of gangosa, of which 143 were papular type reactions, 65 pustular and 45 torpid reactions (taking ten days or more for the reaction to manifest itself). The syphilitic and yaws antigens seem to be reciprocal so that these tests do not throw out yaws. The great stumbling block of the advocates of the luetic etiology has been to show the presence of syphilis among the people of Guam. Under tropical ulcer it will be noted that Jeanselme failed to find the eye or teeth signs of congenital syphilis among natives of Indo-China with the disease.
[Illustration: FIG. 125.—Cases of Gangosa from Guam. (U. S. Naval Medical Bulletin.)]
Kerr, who has been an advocate of the yaws etiology, has shown that of 315 cases of gangosa, 205 could show yaws scars and knew where the mother yaw had been and of the entire 315 only 18 claimed never to have had yaws and failed to show scars.
Rossiter, who observed active ulcerations of the nasal septum and hard palate in the case of a two-year old Samoan child, following yaws, states that he found yaws treponemata in smears from the ulcerated areas.
=Epidemiology.=—If gangosa is a sequel of yaws then the same factors which are operative for yaws apply to gangosa.
PATHOLOGY
Sections made from the ulcerating margins of the nasopharyngeal lesions have failed to show treponemata when stained by Levaditi’s method. In sections of such tissue stained by Giemsa’s method I noted a rather marked infiltration with lymphocytes and a great number of mast cells. Fordyce has noted the presence of giant cells.
From the histological study one can only state that the lesions present the characteristics of the granulomata.
A remarkable feature of the disease is the rapidity with which ulceration destroys cartilage and bone. The nasal duct seems to be prone to attack and it is through this channel that the process reaches the eye to bring about its destructive tendency in that organ.
Of 81 cases studied by McLean and Mink the eye was involved in 21. The larynx was involved in 33 of these cases. It is the frequent perforation of the hard palate that gives these patients the nasal voice, whence the name of the disease is derived.
SYMPTOMATOLOGY
Patients with the disease have rarely been observed prior to the full development of the mutilating ulcerations. In a few cases, however, it was noted that a patch of membrane first appeared in the region of the soft palate. This membrane rapidly became honeycombed and an examination three or four days later showed underneath a deep ulcer, surrounded by an area of marked congestion.
The ulcerating process advances rapidly, destroying bone as well as soft parts. The process seems to extend from within outward, giving a funnel-shaped loss of tissue. The ulceration advances upward and forward, destroying the nasal septum and structures forming the tip of the nose, leaving the upper lip as the lower border of this external opening.
The active process tends to become quiescent in one or two years, the cases then showing extensive loss of tissue with cicatricial borders. Occasionally active ulceration may again set in after a period of quiescence.
The voice character is that of any case where there is a perforation of the hard palate and is not distinctive of the victims of this disease.
During active ulceration there is a malodorous sero-purulent discharge which makes the patients very objectionable. These cases seem to suffer very little impairment of the general health even when the process is active.
Although the destructive lesions about the nasopharynx and the region of the face are the most striking ones it would appear that similar ulcers on the extremities are of the same nature as those more prominently situated.
In an examination of the blood of 10 of these cases in Guam I did not observe any abnormal findings, other than an eosinophilia, which was present to an equal degree in those unaffected. Musgrave and Marshall reported a slight leucocytosis in their case.
DIAGNOSIS
Gangosa is chiefly to be differentiated from leprosy, syphilis and lupus vulgaris. Its more rapid course should distinguish it from leprosy and lupus and the history from syphilis.
TREATMENT
Odell found that a thorough antisyphilitic treatment cured these ulcerations. He used mercurial injections. Recently salvarsan has been used with striking curative results. It has been thought that local application of tincture of iodine was effective in stopping the progress of the early ulcerations but this would seem doubtful, it being advisable immediately to give salvarsan.
On account of the offensive odor of the discharge solutions of permanganate of potash have generally been used.
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