CHAPTER XLII

CLIMATIC BUBO, AINHUM, GOUNDOU, JUXTA-ARTICULAR NODULES AND VISCERAL MYCOSES

CLIMATIC BUBO

General Considerations

The naval surgeons of various countries have for many years been interested in a condition where inguinal buboes develop which have no relation to venereal infection.

All attempts to find any organism in these lesions have so far failed. Cultures from excised glands or from the necrotic centers of such glands fail to show any growth.

Stained smears and India ink preparations alike fail to show any causative organism. The Wassermann test is also negative. The disease seems much more common in the West Indies than elsewhere, statistics showing it to be about 10 times as often contracted by sailors in those waters as by crews in the seaports of China. In a recent article Rost states that he thinks there is evidence to show that the disease is contracted by sexual intercourse with prostitutes of the colored races. Of his 17 cases all had exposed themselves in this way.

Children never show climatic bubo and it seems peculiarly to affect the young adults composing the crews of ships. Even among the native prostitutes such a condition does not seem to exist and climatic bubo does not affect the male natives.

There may or may not be a periadenitis but there is thickening of the capsule and fibrous septa of the glands. At times an apparently healthy gland may show a necrotic centre, the contents of which, however, will be found to be sterile. One often notes in sections haemorrhagic infiltrations and oedema in the region of the peripheral lymph sinuses. A point of differentiation from ambulant plague buboes is the great increase in plasma cells in climatic bubo. It will be remembered that Cantlie suggested that climatic bubo was an attenuated plague but this idea has never been accepted. It has been suggested that malaria might cause climatic bubo.

Symptomatology

The period of incubation is a rather long one, Rost in a well-controlled case noting a period of at least five weeks. The onset is very gradual, so the first intimation of a swelling in the groins may be when a sense of heaviness is noted in that region after prolonged work. For this reason they have been called “fatigue” glands.

The glands of one side of the groin are usually involved although the swellings may affect both sides. The deep iliac glands also often show marked increase in size but the glands of the other parts of the body, as axillary or cervical, are practically never involved.

The swollen glands are only slightly tender and at first are discrete and not attached to skin or underlying tissues. Later on with the development of a periadenitis they may be firmly attached. In size they are usually as large as a hen’s egg but may become much larger.

The overlying skin is as a rule normal and one may at times palpate a soft center in an otherwise hard gland. Fever tends to come on as an irregular remittent type and I have seen cases showing temperature curves covering periods of two or three months which were not unlike those of Malta fever. With increase in size of the buboes there would be a two or three weeks’ rise to be followed, with the subsidence of the swelling, by lysis and later on to be renewed with reappearance of the bubo.

Climatic bubo runs a protracted course and does not respond at all well to treatment. The cases often develop a moderate secondary anaemia, which is most often noted in the relapse cases.

Diagnosis and Treatment

The history aids in differentiating gonorrhoeal, chancroidal and syphilitic buboes. There is not the hardness and marked absence of tenderness we get in syphilitic inguinal glands, and the reddened overlying skin of the other veneral buboes should differentiate.

Plague buboes are exquisitely tender and the patient usually manifests signs of extreme illness. In climatic bubo the patients rarely seem sick.

Surgical treatment is usually recommended and some advocate a radical enucleation of all glands in the region involved as we find at times apparently normal glands to show necrotic centers. My objection to enucleation is that the deep iliac glands are also often involved and it is not only impossible to remove all affected glands in such an inaccessible region but the surgical risks of wounding the deep veins are great. I have seen this accident occur more than once. Again the radical removal of all glandular structures in the groins, with subsequent scar tissue formation, obstructs lymph return so that elephantoid conditions result.

Rest in bed and hot compresses are of value when periadenitis sets in. When softening occurs the aspiration of the pus with an aspirating syringe and the subsequent injection of glycerite of boroglycerine containing 10% of iodoform are to be recommended. Some apply ointment of ichthyol, others pressure by shot bags. X-ray treatment has been recommended.

Emily strongly recommends the injection of 3 or 4 drops of iodoform ether (5%) into the center of the enlarged gland. This effects a rapid cure. The author also employs other measures such as rest in bed, wet compresses, and light mercurial ointment inunctions over the bubo at night.

AINHUM

General Considerations

This disease, equivalent clinically to a spontaneous amputation of the little toe, has been chiefly noted in the natives of the West Coast of Africa, especially among the Kroomen and in Brazil. Cases have been reported from the West Indies and rarely from the Southern States of the United States. It does not attack white people and the susceptibility of black races is probably connected with their tendency to keloid development.

There have been all sorts of suggestions as to etiology: (_a_) that it is related to leprosy, (_b_) that it is a tropho-neurosis, (_c_) that it results from wearing constricting bands or rings on the toe, (_d_) that it is connected with frequent injuries to the under surface of the little toe.

Pathologically we find a fibrous cord which has replaced the bony structures normally attaching the toe to the foot. We have, according to Unna, a ring-form sclerodermia with thickening of the epidermis causing an endarteritis with the production of a rarefying osteitis.

The disease is chiefly found in male adults between twenty-five and thirty years of age.

=Symptomatology and Treatment=

In 90% of cases the little toe is the one affected, more rarely the fourth toe or very rarely both the fourth and little toe. The little toes may be attacked at the same time but the condition usually first starts in one toe. At first we have a crack in the digito-plantar fold of the little toe. This extends laterally and finally appears on the dorsum. The distal portion of the toe enlarges and becomes bulbous so that it looks like a small potato. The connection between the foot and the bloated-looking toe is a limp fibrous cord which permits the toe to wabble in various directions and to interfere greatly with walking.

The course of the disease extends over several years if the toe is not amputated by cutting through the fibrous pedicle or as the result of ulceration from injury to the pedicle.

GOUNDOU

General Considerations

This is a disease which almost exclusively affects the black race and is chiefly found in the West Coast of Africa, where it is called big-nose or dog-nose. It is also found occasionally in China and the Malay Peninsula.

The prominent root of the nose is due to exostoses from the nasal processes of the superior maxillary bones.

Nothing definite is known as to etiology. Suggestions have been made that it is connected with yaws, syphilis or leprosy. Again that it is due to rhinoscleroma. Maclaud thought the hypertrophied tissues to be incident to irritation from dipterous larvae in the nasal fossae. Pathologically we have spongy bone covered by a thin layer of compact bone.

Symptomatology and Treatment

At first there is complaint of headache and an associated nasal discharge. At times the nasal passages may be obstructed by the developing growth, which however usually projects externally on both sides of the root of the nose just below the inner angle of the eyes. Breathing through the nose is not as a rule interfered with.

The bony exostoses develop in a downward and outward direction. The shape is generally oval. The disease commences in childhood and the bony outgrowths slowly increase in size so that by adult life they attain the size of a walnut. The overlying skin is normal and not attached to the bony tumor. As the tumors grow they tend to interfere with the vision of the patient. This is purely from obstructing the lines of vision as the growth does not usually invade the orbits. The treatment is entirely surgical and consists in chiselling away the bony outgrowth.

JUXTA-ARTICULAR NODULES

General Considerations

These nodular masses were first noted by Macgregor from cases in New Guinea but since then have been described from various parts of the tropical world.

These tumor masses were given the name juxta-articular nodules by Jeanselme, who studied the affection in natives of Siam. It may be stated that at present we know nothing definite as to etiology although several authors have reported fungi as the cause. This fungus has been stated to be a species of _Nocardia_. Some of the cases which have been reported would seem to be late manifestations of yaws.

Symptomatology and Treatment

These tumor masses vary in size up to that of a golf ball and are very hard in consistence. The skin over them is at first freely movable, but later on may become attached. They are located subcutaneously, especially about the external surfaces of the extremities and particularly in relation to the joints. They are not sensitive and rarely or never suppurate. The course is most chronic and but rarely do they become absorbed.

[Illustration: FIG. 144.—Juxta-articular nodules. (After Steiner; from Mense.)]

In those parts of Africa where the tumors due to _Onchocerca volvulus_ are found there may be confusion in diagnosis but these filarial nodes are elastic. By aspirating the swelling microfilariae should be found in onchocerciasis.

The treatment of juxta-articular nodules is by excision should they give trouble.

VISCERAL MYCOSES

The majority of cases of visceral mycoses reported from tropical regions have been considered as caused by species of _Monilia_, but not infrequently fungi of the genus _Cryptococcus_ have been incriminated. As a rule the mycosis is reported as occurring in cases which had been regarded as pulmonary tuberculosis. In some of the cases there were cutaneous lesions, enlarged glands and even generalized conditions as well as lung involvement.

Among the fungi reported for the lungs we have: _Rhizomucor parasiticum_, _Nocardia pseudotuberculosis_, _Aspergillus fumigatus_, _Penicillium crustaceum_, _Monilia tropicalis_, _Monilia candida_, _Cryptococcus gilchristi_, _Coccidioides immitis_ and various other species. A satisfactory study of the true nature of the causative fungi has been made in only certain instances and a scientific investigation of this phase of tropical pathology is desirable.

_Bronchomoniliasis._—Castellani has used this designation for two types of cases in which various species of _Monilia_ have been reported as causative. In one type the symptoms are mild with but slight impairment of health, there being only a cough with expectoration of muco-purulent sputum. No fever is present. In the severe type we have the symptomatology of pulmonary tuberculosis with abundant reddish-gray sputum. In both types the diagnosis is made by finding the fungi in perfectly fresh sputum. This should be cultured in a hanging-block culture using Sabouraud’s medium. The mycelium and budding forms can best be studied in such a preparation. Negative findings for tubercle bacilli are important in diagnosis. Potassium iodide is recommended in treatment.

_Sporotrichosis._—The infection with various species of _Sporotrichum_ usually gives rise to gummatous lesions along the lines of the lymphatics of the extremities. These tumor masses break down and discharge a yellowish-brown pus. Rarely the process generalizes, then often invading the lungs. Culturing of the pus or sputum is necessary for diagnosis. In cultures the sporothrix shows a narrow (2µ) mycelium with grape-like clusters of oval spores at the end of a filament. The treatment recommended is iodide of potash.

_Blastomycosis._—The causative organism, _Cryptococcus gilchristi_, is found in the purulent discharge as oval to round, doubly contoured, budding yeast-like cells 10 to 16µ. In cultures we have formation of a mycelium resembling that of an oidium. The lesions may be solely cutaneous or generalized in which latter case the lungs are apt to be involved giving a condition resembling pulmonary tuberculosis.

_Coccidioidal granuloma._—This is a very rare and fatal infection caused by _Coccidioides immitis_, a fungus somewhat similar in cultures to _C. gilchristi_ but differing in tissues in that it gives rise to endogenous spore formation in the cells found in the granulomatous material. The spores are about 3µ in diameter and contained in a large cell (30-60µ) which does not bud. We may have skin lesions accompanying visceral involvement or the latter alone. When involving the lung the infection closely resembles pulmonary tuberculosis. The spores metastasize readily by way of the lymphatics involved and we may have a picture of pyaemia. Skin lesions, when present, are ragged and punched out. About 40 cases have been reported, chiefly from California.

## PART II

DIAGNOSTICS OF TROPICAL DISEASES

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