CHAPTER XXIX

GRANULOMA VENEREUM

HISTORY AND GEOGRAPHICAL DISTRIBUTION

=History.=—It is generally stated that Daniels first noted the disease in British Guiana, in 1896, but Daniels regards the disease previously described by Macleod from India under the designation “serpiginous ulceration of the genitals,” as referring to granuloma venereum.

=Geographical Distribution.=—Cases of the disease have been chiefly reported from British Guiana and the West Indies. It is now recognized, however, that it occurs in India, China and Northern Australia as well as in some of the islands of the Pacific. It also occurs in Northern and Central Africa.

Grindon has reported 3 cases from the United States.

ETIOLOGY

Various spirochaetes have been reported as present in the lesions. The finding by Wise of spirochaetes resembling _Treponema pallidum_ has not been generally accepted.

Donovan has reported the presence, in scrapings from the ulcerations, of an oval bacillus (1½ × 2 microns) which was contained in large phagocytic cells. There were sometimes several such bodies in a single cell.

Flu has recently reported the presence in plasma cells as well as occasionally in other cells of a capsulated organism which he believes related to the Friedlander group. His cultural work has not been conclusive. It is probable that this capsulated organism is merely a secondary invader.

There is also a suggestion of the cellular reaction characteristic of the chlamydozoa.

The disease is rather more common in women than in men and is rarely seen before the period of puberty. It is thought that it is transmitted by sexual intercourse.

PATHOLOGY

The pathological process manifests itself as a small round cell infiltration of the superficial portion of the corium. The growth is well supplied with blood vessels. Giant cell formation and caseation have not been noted. There is an abundance of plasma cells.

There is a marked tendency to the formation of fibrous tissue.

SYMPTOMATOLOGY

The disease usually first shows itself as a papule or vesicle on the penis or labia minora. The process extends and the thin epidermal layer rubs off leaving a surface of granulations which bleed easily and give off a creamy discharge which is frequently very offensive.

[Illustration: FIG. 128.—Venereal granuloma. (After Martini; from Mense.)]

The process usually extends from the penis to the groins by continuity and thence down the inner surfaces of the thigh. When the glans penis is involved there may be a fungating growth suggestive of epithelioma. In the female the process extends from the labia minora into the vagina and also to the labia majora and thence to the perineum and perianal region. Recto-vaginal fistulae often result. The process extends more rapidly and markedly when invading mucous membranes.

While the granulomatous process is advancing there is frequently cicatrization of the areas previously invaded forming a scar tissue which breaks down easily. There is little pain or itching and the general health is not impaired.

There is no enlargement of the lymphatic glands. Although the process extends by continuity yet it may also pass to parts in contact with the diseased area. While healing of affected skin tends to occur that of mucous membrane does not.

There is really very little tendency to ulceration.

DIAGNOSIS

It is usual to suspect a syphilitic process but the absence of gland involvement and secondary manifestations of syphilis negatives this.

It may be suggestive of tuberculous or epitheliomatous processes. The marked chronicity and tendency to scarring are striking.

TREATMENT

Excision of the entire granulomatous area going well into the normal skin has been thought by some to be the only cure.

Ordinary antisyphilitic treatment does not seem to have any effect and the good reports that have been made as to therapeutic success with salvarsan may have been due to diagnosing a syphilitic process as granuloma venereum. Radiotherapy has been recommended.

Local treatment with antiseptic or deodorant washes or ointments is necessary in these cases.

_Antimony Treatment._—Breinl reports success in treatment by using tartar emetic injections. This treatment is now the standard one and the drug is given intravenously as described under treatment of leishmaniasis. It is also recommended to apply locally compresses soaked with a ½% solution of tartar emetic.

SECTION VI

TROPICAL SKIN DISEASES

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