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.