# Tropical Diseases/Chapter 48

Section VIII.— LOCAL DISEASES OF UNCERTAIN NATURE
CHAPTER XLVIII
CRAW-CRAW— CHAPPA— CLIMATIC BUBO—
GOUNDOU— AINHUM—BIG HEEL— ONYALAI
CRAW-CRAW AND ULCERATING DERMATITIS
MOST itching papular and pustular eruptions are termed kra-kra by the natives of the West Coast of Africa. Dr. John O'Neil describes under this name a pustular affection which he says is common in certain parts of the West Coast, and which he found to be associated with the presence of a filariform parasite in the papules. O'Neil says that this form of craw-craw resembles scabies; but he adds that symptoms subside in a cooler climate, to return, however, when the negro revisits the hot and damp atmosphere of his native country. The papules occur all over the limbs and body, either singly or in rings. In two days from its appearance the papule, he says, becomes a vesicle, and in two more a pustule.
On paring off the top of the papule with a sharp knife, and teasing up the little piece of integument in water, he found a number of minute filaria-like organisms wriggling about with great activity. Their activity speedily slowed down, and in a short time the worms died. These organisms, according to O'Neil's drawings and description, resemble somewhat mf. bancrofti. The measurements, however, do not quite correspond, the craw-craw filaria being shorter and broader ( 1/100 in. by 1/2000 in.) than mf. bancrofti; moreover, unlike the latter, it presented two black ​markings at the cephalic end. He says that if the section of the papule be made sufficiently deep, five or six of these parasites may be seen in a field.
Craw-craw is said to be contagious. It appears after an incubation period of three days, and is not curable by sulphur inunction.
O'Neil's observations have not been confirmed. I think it is quite possible that the parasite he found was one of the several blood filariæ we now know to be so common on the West Coast of Africa. It is comprehensible that, in a country in which mf. perstans occurs in every second individual, it would be frequently found in such preparations as O'Neil examined. The removal of the top of a scabies or other papule would certainly be attended with some degree of hæmorrhage; in which case, should the patient chance to be the subject of any form of filarial infection, microfilariæ would be found in the preparation. Immersion in water would, as in the case of O'Neil's parasite, quickly kill the parasites. I do not wish to assert that O'Neil's parasite was mf. perstans, but the possibility of this must not be overlooked.
A disease resembling O'Neil's craw-craw was described some time ago by Prof. Nielly under the title dermatose parasitaire. A French lad, who had never been abroad, became affected with a papulo- vesicular itching eruption resembling scabies, in which Nielly found a filariform parasite somewhat like that discovered by O'Neil in craw-craw. It had the same peculiar cephalic markings; in addition, it had a well-defined alimentary canal and rudimentary organs of generation. Nielly found nematode embryos in the blood in this case; so that we are justified in believing that the parasite in the skin was an advanced developmental form of the embryo in the blood, and that both were the progeny of a mature parental worm living somewhere in the tissues. Possibly Nielly's dermatose parasitaire and O'Neil's craw-craw were of the same nature.
Symptoms.— The term craw-craw is very loosely applied. Emily has described under this name a ​papulo-pustular skin affection which is common in certain parts of tropical Africa, and is often the cause of much suffering to the traveller. It, or a similar disease, is by no means confined to Africa, for I have seen it in patients from India, and was at one time very familiar with it in South China. At the earliest stage the disease begins as an itching papule, very possibly at the seat of a mosquito bite. The itching provokes scratching, whereby some form of pyogenic micro-organism is inoculated. Pustulation follows, and is spread over feet and legs by soiled shoes and stockings and auto-inoculation. In this way an ulcerating, pustulating dermatitis is kept up. Cantlie's "foot tetter" is of this nature. The veld sore of South Africa and the "Barcoo rot" of Australia, if not the same, are similar diseases.
Treatment.—Emily describes a very efficient treatment. Pustules are opened, crusts removed, and ulcers scraped. Boric-acid powder is then dusted freely on the parts after a thorough scrubbing with sublimate lotion (1-1,000), boricated vaseline applied on lint, and over all absorbent cotton and a bandage. The dressings are not disturbed for a week, when the parts will be found soundly healed. Such and similar auto-infective diseases of the hands and feet, so common in the tropics, I used to treat with a foot-bath of warm carbolic-acid lotion (1-20), followed by dry dressing with abundance of boric-acid powder, at the same time insisting on destruction of infected slippers, shoes, and stockings.
CHAPPA
Under the name "chappa" Read describes a disease which he has met with in the western district of the colony of Lagos. During two and a half years he has seen six examples, two in males, four in females. He thus describes it:—
"The patients all give the same history. The disease commences with severe pains in the limbs, muscles, and joints. After a few months the pain decreases, and some joints begin to swell and convey the sense of fluctuation. About the same time nodules develop in different parts of the body. These nodules are in the subcutaneous tissue, and are about ​the size of a pigeon's egg. After a time, without the formation of an abscess, the skin over the nodule ulcerates and exposes a circular or oval ulcer with a fatty-looking base. The nodules may be single, but are more often multiple, and may be so close together that when ulceration ensues the ulcers coalesce, forming a serpiginous ulcer. Sometimes the nodules are absorbed without proceeding to ulceration. The ulcers are very chronic and last for years, sometimes healing at one place and gradually extending in another. The joints I have seen most affected are the knee, elbow, and wrist. The sense of fluctuation was so marked in one case that I opened the joint; but no fluid exuded, a fatty-looking material protruding through the incision. The disease after a time attacks the bones, and the joints may become totally disorganized." —(Journ. of Trop. Med. Oct. 15, 1901.)
On comparing the photographs illustrating Read's paper with others of a very similar complaint common among the natives in certain parts of British East Africa, I am inclined to think both sets of photographs represent identical conditions. Possibly " chappa " is a tertiary phase of yaws.
Treatment.— Neither potassium iodide nor mercury avails. Scraping, escharotics, and antiseptics seem to be more effective; but, although the disease may heal under treatment in one place, it breaks out in another.
CLIMATIC BUBO
Scheube has applied the term "climatic bubo" to a type of non-venereal adenitis not uncommon in tropical climates. So far as available statistics show, the disease is especially prevalent among the crews of warships on the eastern coast of Africa. It occurs also in the Straits of Malacca, in China (where I have seen a fair number of cases both in landsmen and in sailors), in the West Indies, Japan, the Mediterranean, and probably in many other places, including, perhaps, in a minor degree, Europe. It appears to be epidemic at times in certain places, and to prevail in groups of individuals living under similar hygienic conditions. Thus, Ruge reports 38 cases in the German squadron blockading the Zanzibar coast in 1888-89; Godding notes its frequency in the British fleet, also on the East African coast; ​Skinner mentions 49 cases occurring in a regiment and battery of artillery: of these, 28 developed in Calcutta, 13 in Hong Kong, 4 in England, 2 in Allahabad, and 2 in Malta.
Symptoms. The disease generally commences with fever of a remittent type in association with inflammatory swelling, usually of a subacute character, of the groin glands. The oblique inguinal glands are those most frequently affected, but at times it is the crural glands that are attacked. Sometimes both groins are affected, sometimes only one, sometimes one groin is attacked after the other. The affected glands slowly or more rapidly enlarge to the size of a hen's egg, or even larger. After several weeks, it may be months, the swelling gradually subsides. Occasionally the periglandular connective tissues inflame, the integuments become adherent, and suppuration ensues. If the suppurating glands be freely incised, or excised, the parts readily heal; but if they are left alone, or inefficiently treated, fistulous tracks form and may take a very long time to heal.
Hitherto no satisfactory explanation of this type of adenitis has been forthcoming. No special bacterium has been demonstrated in the tissues. There are no adequate reasons for supposing, as has been conjectured, that the disease has any connection with plague, or that- it is a form of pestis minor. Most probably the adenitis depends on some virus which has been introduced through an overlooked wound or insect bite on the legs or genitals.
Treatment should consist in rest and soothing applications during the more acute stage. After pain and tenderness have subsided, graduated elastic pressure should be applied. Concurrent malaria would call for quinine ; syphilis, for mercury or the iodides.
GOUNDOU, OR ANAKHRE (" GROS NEZ ")
On December 10th, 1882, Prof. A. MacAlister read a paper before the Royal Irish Academy on what were termed the horned men of Africa. In the British Medical Journal of December 10th, 1887, ​Lamprey gave further details, illustrated with drawings, on the same subject. He had seen three such cases on the West Coast of Africa, all of them Fantis; one came from the Wassau territory, one from the Gamin territory, the third was a visitor to Cape Coast Castle. Renner also reports and illustrates a case from the Sierra Leone River.
Maclaud calls attention to what is manifestly the same affection, which, according to him, occurs in a considerable proportion— one or two per hundred —of the inhabitants of certain villages on the Ivory Coast. The natives call it goundou, and, also, anakhre. Maclaud says it is confined to the riverine districts of the Lower Camoe; according to the information he received, if found elsewhere it is only in individuals who had previously resided in this district. Lamprey's and Renner's observations prove that goundou has a considerably wider distribution.
Symptoms.— According to Maclaud, the disease usually commences soon after childhood, although adults also may be attacked. The earliest symptoms are severe arid more or less persistent headache which, after a time, is associated with a sanguino-purulent discharge from the nostrils, and the formation of symmetrical swellings the size of a small bean at the side of the nose. (Fig. 222.) Apparently the swelling affects the nasal process of the superior maxilla. The cartilages are not involved. Although Maclaud does not refer to this point, it may be assumed that the nasal ducts remain patent. After continuing for six or eight months, the headache and discharge subside. Not so the swellings; these persist and continue slowly and steadily to increase until in time they may attain the size of an orange, or even of an ostrich's egg. As they grow, the tumours, encroaching on the eyes, may interfere with the line of vision and finally destroy these organs. There is no pain in the tumours themselves. The superjacent skin is not involved, being healthy-looking and freely movable. The tumours are oval, with the long axes directed downwards and slightly from within outwards. Lamprey's drawings ​give a more elongated form and horizontal direction. The swellings, according to Maclaud, when of moderate dimensions, look something like two half-eggs laid alongside the nose, one on each side. The nostrils are bulged inwards, and more or less obstructed; but, in the later stages at all events, there is no discharge, neither can any breach of the mucous surface be detected. The hard palate is not affected in any way.
Maclaud had no opportunity of ascertaining by post-mortem examination, or by surgical operation,
Fig. 222.—Goundou. (From photograph in the Journ. of Trop. Med.)
the nature of this singular disease. He inclines to the opinion that, in the first instance, the process is started by the larvæ of some insect which find their way into the nostrils. I would point out, however, that the symmetry of the growths is difficult to account for on this hypothesis. Maclaud observed a similar affection in a chimpanzee.
Strachan records and illustrates an instance of goundou in a West Indian negro child. (Fig. 223.) In this case the swellings were congenital, and had only increased in proportion to the child's growth. They were hard, smooth, bony masses, somewhat of the shape and size of an elongated pigeon's egg, and sprang from the nasal process of the superior ​maxillary and nasal bones. For æsthetic reasons they were removed by the chisel, and were found to consist of compact bone with a cancellous core. Strachan states that he had seen two similar cases, and had often noted a "ridge" in this part of the face of West Indian negroes. He suggests that the condition may be an example of atavism, referable to some tribal peculiarity of the original West African stock.
Fig. 223.—Goundou in a West Indian child. (Dr. Henry Strachan.)
Chalmers has given an admirable and well-illustrated account of this affection as seen on the Gold Coast, where it is fairly common and is known as "henpurge." He confirms Strachan as to the anatomical characters of the swellings, which he regards as the result of an osteoplastic periostitis due to yaws. He affirms that the morbid process begins during, or soon after, an attack of yaws, and is correlated in some way to an anatomical arrangement of the blood-vessels of the parts, an arrangement which, he gives the reader to infer, is peculiar to the negro of this part of Africa.
JUXTA-ARTICULAR NODULES
First discovered in 1901 by Macgregor, and subsequently named by Jeanselme, these parasitical tumours are now known to occur in the natives of many tropical countries, as Java, Siam, Madagascar, and, especially, tropical Africa, where, owing to concurrence in tropical distribution and similarity in appearance, they are apt to be mistaken for Onchocerca volvulus cysts (p. 788), and vice versa. In both cases these swellings are originally subcutaneous; they increase in size very slowly, and may attain the dimensions of a small orange; they are round or oval, and firm in consistence. They are painless, and very rarely ulcerate or suppurate. The juxta-articular nodules are generally multiple; they occur, as the name implies, in the neighbourhood of joints, occasionally on the external surfaces of limbs, and are arranged symmetrically. They are of a woodeny hardness in contrast to the elastic firmness of the volvulus tumour, and, unlike the latter, of a somewhat irregular surface. In case of doubt, diagnosis may be readily cleared up by aspirating the tumour with an exploring needle. A volvulus tumour will yield a viscid yellowish or turbid fluid containing microfilariæ; a juxta-articular nodule yields no fluid or, at most, a drop of clear serum. At times, though rarely, these tumours disappear spontaneously. If they are inconveniently located they may be excised.
Macgregor and others considered that these tumours were of parasitic origin, and Fontoynont and Carougeau claim to have discovered the parasite as an extremely delicate fungus, Nocardia carougeaui. Clapier, who has given much attention to, and has had long experience of, these tumours in French Guinea, failed to confirm this claim.
AINHUM
This is a disease of a very peculiar character, affecting the toes, particularly the little toes, of negroes, East Indians, and other dark -skinned races. ​Symptoms.—The disease commences as a narrow groove in the skin almost invariably on the inner and plantar side of the root of the little toe. It may occur in one foot only, or in both feet simultaneously, or it may affect one foot after the other. The groove, once started, deepens and extends gradually round the whole circumference of the toe. As it deepens—it may be, though not necessarily, with some amount of ulceration—the distal portion of the member is apt to swell to a considerable size, as if constricted by a ligature. (Fig. 224.) There is little or no pain, although there may be inconvenience from the liability to injury to which the dangling and now everted toe is exposed. In the course of years the groove slowly deepens, and finally the toe drops off or is amputated. The groove may either correspond with a joint or it may be formed over the continuity of a phalanx. In rare instances, after the two distal phalanges have dropped off or been amputated, the disease recurs in the stump, and the proximal phalanx in its turn is thrown off. Of the other toes, the fourth is the one which is most frequently affected; very rarely is the third, or second, or great toe attacked. In the Army Medical Museum at Washington, U.S.A., there is a wax model representing a case of this or a similar affection, in which all the toes had been thrown off and the disease was making progress in the leg. Fig. 224.—Ainhum.
Ainhum is very rare in women or children, being most common in adult males. It runs its course in from one to ten or even more years.
On section it is found, as a rule, though not invariably, that the panniculus adiposus of the affected toe is much hypertrophied, that the bone is infiltrated ​with fatty matter, and that the other tissues are correspondingly degenerated. Sometimes the bone is thinned, or even altogether absorbed. At the seat of constriction a line of hypertrophy of the epithelial layers, and of atrophy of the papillary layer of the skin, together with a band of fibrous tissue more or less intimately connected with the derma, surrounds, in whole or in part, the narrow pedicle.
Nothing is known as to the true nature and cause of this disease, to which the European and white-skinned races are not, but to which the African races, particularly the negroes of the West Coast, are especially liable. Some have suggested that it is a trophic lesion depending upon some nervous affection. The occurrence of severe loin pains, which Dupouy says he remarked at the commencement in some of his cases, as well as the tendency of the affection to run in families, as noted by Da Silva Lima, affords a certain amount of support to this view. Others suggest that it is a manifestation of leprosy; others, that it is a form of sclerodermia; others again, and on equally inadequate grounds, that it is produced artificially by intentional ligation or by the wearing of toe rings. My own impression is that it is provoked, at all events in the first instance, by wounds so easily inflicted on bare feet in walking through grass or jungle. The fold o skin in which the lesion of ainhum commences is very liable, especially in the splay ed-out toes of the negro, to be wounded in this way. If we examine the under-surface of the joint flexures of the toes in many individuals of this race, even of those not affected with ainhum, we often find the skin, particularly at the proximal joint of the little toe, thick, rough, scaling, and sometimes even ulcerated. One can understand that continual irritation of this sort, produced and kept up by wounds from sharp grasses or jiggers (Wellman), would in time give rise, especially in the dark-skinned" races so prone to cheloid, to fibrotic changes in the derma, which might very well end in a sort of linear cicatricial contraction, and ultimately in slow atrophying strangulation of the affected member. The disease is said, however, ​to have been seen in those who wear shoes; but, unless it could be shown that such individuals had always worn shoes, this objection to the explanation offered would not apply. I have seen a negro in whom the entire integument of the little toe was involved in a sclerodermia, and the part in consequence was shrunken and hidebound, whilst the little toe of the other foot was affected with well-marked ordinary ainhum; the process was diffuse, as it were, on the one side, localized on the other.
The tail in certain species of monkey is liable to a similar disease. I have had under observation for some time a pet monkey in which the part corresponding to the distal vertebra dropped off in consequence of an ainhum -like linear constriction. Two months later the next vertebra was similarly amputated, and later a third groove formed a little higher up the tail.
Treatment.— It has been suggested that division of the constricting fibrous band would delay the evolution of the disease. In the early stage this might be tried. When troublesome, the affected toe should be amputated.
BIG HEEL, OR ENDEMIC HYPERTROPHY OF Os CALCIS
Maclean (Journ. ofTrop. Med., November 1, 1904) describes a peculiar form of enlargement of the os calcis which he observed at Kaziankor, Gold Coast, West Africa, among Fantis and Kroos. The disease begins somewhat suddenly, being preceded by fever and accompanied by pain and tenderness which reach their maximum in about a month, gradually diminishing during the succeeding one or two months. Concurrently with the pain a swelling of the external surface of the os calcis, rarely of the tarsal bones, makes its appearance. Sometimes one heel only, sometimes both heels are affected. The swelling may be so considerable as to be quite evident both to touch and sight. It subsides to a certain extent, though not altogether, as the pain diminishes. Locomotion is seriously interfered with by the pain, ​but there is no implication of joints. The disease relapses from time to time, more especially during the rainy season. In one case recorded by Maclean severe pain would be provoked at any time by application of cold water.
Maxwell (Journ. of Trop. Med., March 15, 1905) reports a similar condition in natives of Formosa. As in Maclean's cases, the patients were young adults from 20 to 25 years of age. In Maxwell's cases the disease, although very painful, seemed to be of a more chronic character. In one instance the patient's sufferings were much relieved by trephining the affected bones. This curious condition somewhat resembles goundou. So far, we have no clue to its etiology. It is probably not syphilitic. Iodide of potassium did not relieve Maxwell's cases.
ONYALAI
Yale Massey describes (Journ. of Trop. Med., September 1, 1904, April 1, 1907), under the above title, a peculiar disease occurring among the natives of Portuguese West Africa, and also on the Lualaba River. It is characterized by the formation of a number of vesicles, distended with blood, from ¼ to ½ in. in diameter, on the hard palate and on the inside of the cheeks. Some of the vesicles are umbilicated. They differ from ordinary blood blisters by the presence of numerous trabeculæ and the semi-coagulation of the contents; this makes the vesicle difficult to empty. The urine apparently invariably contains free blood. Occasionally the disease is accompanied by fever, and although with one exception all Yale Massey's cases recovered within a week to ten days, the natives regard the disease with dread owing to its reputation for deadliness. The etiology is quite unknown.