CHAPTER XXXIX
ULCERATING GRANULOMA OF THE PUDENDA
Geographical distribution.— Neal, Ozzard, Conyers, and Daniels describe a peculiar form of ulcerating granuloma affecting more particularly the pudenda in dark -skinned races. Their observations were made in British Guiana, and principally on West Indian negroes. Daniels believes that he has seen a similar or the same disease in Fijians. The "serpiginous ulceration of the genitals" referred to by McLeod, and more recently by other writers in India— especially by Maitland— is the same, or a similar disease, examples of which I can recollect having seen in South China. Taylor of New York has seen it in whites in the United States, Goldsmith has met with it in aboriginals in North Australia, and Renner in West African negroes. Doubtless, therefore, although hitherto little notice has been taken of this disease, it is widely distributed in the tropics.
Etiology.— There is reason for believing that the disease is generally, though not invariably, a venereal one. Maitland has seen it in the mouths of a husband and wife. He considers it may be inoculated on other forms of venereal sore, such as an ulcerating bubo, and that a compound sore may result.
Spirochætes resembling S. pallida and S. refringens have been described by Wise as occurring in the ulcerations in British Guiana, but the nature of their relation to the disease has not been made out.
Donovan described certain parasitic elements in scrapings from the deeper parts of the Madras form of these sores. The parasite (Fig. 93) is like a short bacillus with rounded ends, measuring 2 μ by 1 μ. It occurs in mononuclear cells and in great profusion. The parasites are sometimes scattered irregularly through the protoplasm of the affected cells; more often they are arranged in little round clusters of eight or ten. Recently de Souza Araujo and others in Brazil have confirmed and extended Donovan's discovery. The Calymmatobacterium granulomatis, as they term the germ, is capsulated, non-motile, Gram-negative, non-spore-forming, does not liquefy gelatin nor coagulate milk. Under cultivation it is polymorphic, occurring as cocci, diplococci, bacilli, diplobacilli, and filaments, all forms possessing a
Fig. 93.—Parasitic elements in ulcerating granuloma of pudenda.
mucous capsule. It retains its virulence in experimental animals as far at least as the hundredth sub-culture on gelatin. In sections of the affected tissues the bacteria are seen to lie both inside and between the cells as capsulated cocci or diplococci, in chains or in zooglœa masses.
Age and sex.—Ulcerating granuloma has riot been observed before puberty; it has been found only after 13 or 14, and up to 40 or 50. It occurs in both sexes, but particularly in women.
Symptoms.—The disease commences in the great majority of cases somewhere on the genitals, usually on the penis or labia minora, or on the groin, as an insignificant circumscribed, nodular thickening and elevation of the skin. The affected area, which on the whole is elevated above the surrounding healthy skin, and is covered with a very delicate, pinkish, easily-rubbed-off epithelium, excoriates readily, exposing a surface prone to bleed and break down, although rarely ulcerating deeply. The disease advances in two ways: by continuous
Fig. 94.—Ulcerating granuloma of pudenda in the male.
eccentric peripheral extension, and by auto-infection of an opposing surface. In its extension it exhibits a predilection for warm and moist surfaces, particularly the folds between the scrotum and thighs, the labia, and the flexures of the thighs (Fig. 94). Its extension is very slow, years elapsing before it covers a large area. Concurrently with peripheral extension a dense, contracting, uneven, readily-breaking-down scar forms on the surface travelled over by the coarsely or finely nodulated elevated new growth which constitutes the peripheral part of the diseased area. Occasionally islands of active disease spring up in this scar tissue; but it is at the margin of the implicated patch that the special features of the affection are best observed. In a case of some standing there is found a large area of white or irregularly pigmented, perhaps excoriated, unsound, contracting, folded and dense cicatrix surrounded by a narrow, serpiginous, irregular border of nodulated, somewhat raised, red, glazed, delicately skinned or pinkish, superficially ulcerated or cracked new growth.
In the case of the female (Fig. 95) the disease may
Fig. 95.—Ulcerating granuloma of pudenda in the female.
extend into the vagina, over the labia, and along the flexures of the thighs. In the male it may spread over the penis, involve the glans, scrotum, and upper part of the thighs. In either sex it may spread in the course of years to the pubes, over the perineum, and into the rectum, the recto-vaginal septum in the female ultimately breaking down. At times a profuse watery discharge exudes and even drips from the surface of the new growth, soiling the clothes, soddening the skin, and emitting a peculiarly offensive odour. In this condition the disease, slowly extending, continues for years, giving rise to inconvenience and perhaps seriously implicating the urethra, vagina, or anus, but not otherwise materially impairing the health. The lymphatic glands do not become affected. The disease continues entirely local. Histologically this disease is allied to rhinoscleroma.
Histology.— On microscopical examination the new growth at the margins of the sore is found to be made up of nodules, or masses of nodules, consisting of round cells having large and, usually, badly staining nuclei. These cells are embedded in a delicate fibrous reticulum. The nodular masses are, for the most part, covered by epithelium, their under surfaces merging gradually into a thick, dense fibrous stroma in which small clusters of similar round cells are here and there embedded. The growths, though very vascular, contain no hæmorrhages; and there are no signs of suppuration or of caseation, no giant cells, and no tubercle bacilli. In vertical section of the small nodules the round-cell mass will be found to be wedge-shaped, the base of the wedge being towards the skin; the deep-lying apex is usually pierced by a hair or two. The growth is found around sebaceous follicles, blood-vessels, lymphatics, and sudoriparous glands; but it is especially abundant, and most deeply situated, around the hair-follicles.
Diagnosis.— Malignant and syphilitic ulcerations of the groin are common enough; the disease under notice, however, differs widely from these— clinically, histologically, and therapeutically. It is characterized by extreme chronicity— ten or more years; by absence of cachexia or of any tendency to cause death; by non-implication of the lymphatic system, and by non-amenability to mercury and iodide of potassium. The disease which it most resembles is lupus vulgaris. From this it differs inasmuch as it is practically confined to the pudendal region; affects mucous as well as cutaneous surfaces; tends to follow in its extension the folds of the skin; is not associated with the tubercle bacillus, giant cells, caseation, or other evidences of tuberculous disease. Treatment.— Scraping and caustics, including the actual cautery, have been freely employed; but, although some improvement may be effected by these means, new nodules almost invariably spring up in the resulting cicatrix. Until recently complete excision, where practicable, offered the best chance of permanent cure; of course, such a proceeding had to be undertaken before large areas and important passages had become involved.
Judging from its relatively superficial nature and close resemblance to lupus, it seemed probable that ulcerating granuloma might prove amenable to some form of radiotherapy. This is actually the case, and X-rays are now regularly and successfully employed in Madras in the treatment of the disease. Of 37 cases treated in this way in Madras Hospital in 1908 all proved successful within an average period of two months. In three of the cases which could be followed up there was no recurrence four months after their discharge.
Treatment by intravenous injections of tartar emetic, introduced by Aragua and Vianna in 1913, has proved remarkably successful. Improvement invariably sets in, and, although in a small proportion of cases relapse occurs, in the vast majority the cure is radical. The initial dose should be 5 c.c. of 1 -per-cent, solution in normal saline, cautiously increased to 10 or 12 c.c. given daily or every second day. At the same time the sore should be dressed twice daily with compresses soaked in the 1-per-cent. solution, diluted if necessary (de Souza Araujo). The tartar emetic solution may be combined with or supplemented by the X-rays.