CHAPTER XXX

TROPICAL ULCER

GENERAL CONSIDERATIONS

Under the names tropical phagedaena or tropical ulcer various skin lesions have been described, from all parts of the tropics, which vary greatly in etiology and symptomatology.

These skin ulcers are most frequently observed on the dorsum of the foot or front of the leg but may appear on the hands or forearms and have rarely been reported from other parts of the body.

There is no doubt but that many of the cases reported as tropical ulcer are really manifestations of tertiary syphilis.

Jeanselme has noted the insignificant manifestations of the secondary stage of syphilis in natives of Indo-China and the malignancy of the tertiary ones as regards the skin lesions. In fact a striking feature of the late stages of syphilis in the natives of the tropical world is the frequency and severity of skin lesions and the rarity or absence of involvement of the central nervous system to produce tabes or general paresis.

Again congenital syphilis is common in most tropical countries which have been visited by white men for long periods and Jeanselme has noted the rarity in natives so affected of interstitial keratitis and Hutchinson’s teeth, signs upon which medical men are apt to base a diagnosis of such a condition.

Again, Butler, studying the serological side of 27 ulcerations which clinically could be diagnosed as tropical ulcer, obtained strongly positive Wassermann tests in 26, or 96 per cent. of the cases. Shattuck found that about 94% of the chronic ulcerations of the Philippines could be ascribed to syphilis.

Besides syphilis one must bear in mind the possibility of the ulcers being a manifestation of tertiary yaws, a condition which also gives a high percentage of positive Wassermann tests.

In Guam, the natives separate the ulcerations about the lower extremities from the naso-pharyngeal ones by designating the former cases llagosos and the latter gangosas. It is probable that the leg ulcers are manifestations of the same disease as the naso-pharyngeal ones whether it be syphilis or yaws. These ulcers of the leg in Guam as well as those studied by Butler in the Philippines would certainly be classed as tropical ulcers.

There are undoubtedly many cases which can be explained by infections with ordinary pyogenic organisms of the skin which are enabled to get a foothold in an abrasion or other minor wound, in a person whose resistance has been reduced by such cachexia-producing diseases as malaria, dysentery or ancylostomiasis.

Indeed some authorities attach special importance to the tibial ulcers found in advanced cases of hookworm disease. Some of the sores are due to irritating applications used by the natives of many countries as setons. In many instances the sores are from neglected wounds.

Vincent has called attention to the association of the fusiform bacillus and delicate spirillum, better known in connection with Vincent’s angina, in smears from tropical ulcers.

Such findings have also caused many to consider tropical ulcer as related to hospital gangrene. There is no doubt but that smears from the dirty membranous deposit on these ulcers do frequently show the fusiform bacillus and at times the spirillum, but we also frequently find various fungi in such smears. Very few hold that these have anything to do with the production of the ulcer.

Inoculation experiments have as a rule been indefinite in result.

LeDantec has incriminated a very large Gram-negative bacillus which was noncultivable.

Prowazek believes that he has found the cause in a spirochaete which possesses fewer turns and these more widely separated than those of the spirochaete of syphilis. The association with the fusiform bacillus has also been noted.

Wolbach and Todd note the frequent finding of spirochaetes in tropical ulcers and attach considerable importance to a spirochaete with abruptly tapering ends. The name of Spirochaeta schaudinni has been given to the organism. They also generally found associated micrococci and bacilli as well as the fusiform bacillus.

Other than the noting of granulation tissue and the presence of plasma and small round cells there does not seem to be anything definite in the histopathology of tropical ulcer. This is what one might expect in view of the lack of definite knowledge of the condition.

_Veld sore._—Under the name of Veld sore we have a form of tropical ulcer which is common in various desert regions.

These ulcerations may appear on the face as well as on the dorsal surfaces of the hands or forearms or on the lower extremities. They seem to arise from infections of abrasions of the exposed parts. In the early stages of the lesion the diphtheria bacillus has been frequently isolated and some of the cases have been followed by diphtheritic palsies. It would appear that these lesions have at times been those of cutaneous diphtheria. Such cases were reported by Craig in cases in the Sinai desert. The simultaneous existence of cases of ordinary faucial diphtheria should make one suspicious of the real nature of such ulcerations. Skin diphtheria is more frequent than is generally considered.

SYMPTOMATOLOGY

These ulcers are most frequently found on the dorsum of the foot, over the shin and about the external malleolus. More rarely they involve the dorsum of the hand or back of the wrist.

In the multiplicity of clinical descriptions from various parts of the tropics we obtain two types of ulceration.

One is that of a rather chronic ulcer, which slowly develops from a painless swelling, which is not unlike a gummatous process. Surrounding the swelling there is a circumscribed, reddened, glazed area of skin. After two or three weeks the swelling begins to soften and a serous fluid exudes from its summit.

Ulceration, with the frequent formation of a membrane-like deposit, now sets in and later on we have a more or less punched-out ulcer showing indurated margins. There may be no impairment in the health of those with this type of ulcer.

The other type is generally seen in persons who are much debilitated or suffering from some cachectic state. In the earliest stages these sores seem to resemble an area which has been excoriated and inoculated with vaccine virus, there being a rather dry, angry-looking spot of erythema. This within a few hours may be surrounded by a circle of vesicles beyond which is an encircling inflammatory areola.

There is marked subjective pain and tenderness. The serum from the vesicles fails to show any bacteria and the cellular contents are made up almost entirely of polymorphonuclear leucocytes. Within a few hours to one or two days the area within the ring of vesicles is converted into a dark gray to black pultaceous diphtheroid membrane which when detached shows underlying fungating granulations, covered with greenish-yellow pus. This membrane, if stripped off, tends to reform with great rapidity (twenty-four to forty-eight hours), and in many respects resembles the membrane of diphtheria except for its dark color.

These ulcerations extend with great rapidity and even when showing a tendency to heal may suddenly, from a point along the margin, proceed to form a new area of ulceration, extending somewhat as would a ringworm. When the original site of ulceration fails to heal during a period of several weeks, the edges become rather indurated but do not show the punched-out or undermined characteristics of the first type.

These cases last for months and are far more tantalizing than the former type of ulceration for the reason that from time to time they show a strong tendency to heal, the process clearing up almost entirely, when suddenly the former area of the ulceration is equalled or exceeded.

TREATMENT

Many of these ulcerations yield readily to salvarsan and in such cases we naturally think of a syphilitic or framboesial etiology.

Castellani has recommended a protargol ointment, 5 to 10%, which is applied to the ulcer after previous flushing with hydrogen peroxide or other antiseptic lotion.

At times thorough cauterization with pure carbolic acid followed by neutralization with alcohol may shorten the process.

Iodide of potash benefits some cases but has no effect on others and the same is true of mercurial treatment.

An 8% ointment of scarlet red should be tried on these sores when treatment with ordinary applications fails.

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