within the unit itself, inmen whose work was associated with horses, as is shown
Amongst personnel
fection most
was
closely
greatest in
in table III. Table III
Distribution of 250 consecutive Cavalry Unit cases of oriental sore among unit personnel 123 = 49.2 Syces (grooms), 'followers' 84 = 33.6 Sowares (riders), combatants 43 = 17.2 Other ranks, including officers Note.?Average strength of the unit was? ..
per cent
..
..
Combatants Enlisted -non-combatants, ..
..
..
'
followers'
? ?
350 200
The above tables II and III suggest the close association of those affected and the stable-fly
(Stomoxys calcitrans), which, in addition to the sand-fly, may be an important vector of oriental sore.
Number The number of sores shown in table IV.
ORIENTAL SORE TREATMENT
ATEBRIN
By L. E. ELKERTON,
J,
V
(Tor.)
m.d.
MAJOR,
at the
reported
Single
500 sore
Table I
of
sores
Location
of
sores on
'
??
1937 1938 ... 1939 (first 6 months) ..
??
?
?
'
1,170 the Quetta during
in Note.?The incidence increased laooof earthquake years following the
Prevalence marked predominance Amongst units ?, in men of a Cavalry Unit was apparen
seen
a
of
01
Distribution of 500 consecutive cases 1st January, sore among Military Units, 1939
Cavalry Unit (mounted)
318 = 63.6per
?
Companies Transport (with animals). Indian Hospital Corps (located near cavalry lines). Gunners (with few horses)
Three
,
.
Engineers
All other units
..
..
192 = 38.4 per cent 120 = 24.0 ? 157 = 31.4 ? 31= 6.2 ?
:
500
cases :
34.0 per cent 13.8 ?
170
=
..
..
69
=
..
27 = 5.4
..
..
Multiple '??many types Multiple '?arms and legs
..
.. ..
2
=
0.4
179 = 35.8 53 = 10.6
? ? ? ?
Note.?Exposed surfaces of the body (to which the vector hals access) are the chief sites; of oriental sore. Leishmania tropica The. presence of Leishmania tropica was demonstrated in approximately .40 per cent of
treated; e.g. 22nd February, 1939 June, 1939 of 143 cases examined at the District Laboratory, Quetta, in 57 (40 per cent) the parasite was identified. All cases here recorded were considered clinically to be of the same type. sores
to 29th
Table II
April,
'
all
shown in table II.
to 5th
..
the body 1936 to 1938
Lower extremities Head (particularly face) Trunk (alone)
on
..
..
is shown in table V.
Upper extremity (arms)
ip-q
JS
??
:
Table V
Cases recorded Miliat Indian tary Hospital 458
..
patients
sores
Location
amongst Indian in Quetta sore
.,
is
represent about 40 per cent of all cases. It is suggested that a single sore, naturally acquired, be allowed to run its course, if not on the face, and if protected from bites. The development of an active immunity from one infection with oriental sore is generally accepted. Inoculation with attenuated cultures of the parasite is being successfully carried out in some endemic areas.
period
..
individual
..
Note.?Single
,
1QQR 1936
patients
cases
..
Incidence troops apRecords of the number of Indiansore pearing for treatment of oriental during a ioi Indian Military Hospital, Quetta, table I. are shown in year
troops
sores on
Two sores only Three to seven inclusive More than seven sores
-
Incidence of oriental
of
[__?
here was carried t.lie Hospital, and to Military Quetta, were confined vations, consequently, the Indian Army.
The work
sores
individual
Table IV
Number
I.A.M.C.
of on
..
..
?
55 ?U" 49=
f?
oc
{4=lo
..36
?eU ?
" "
Bacteriology Mention must be made of the Neisseria micrococcus catarrhalis as a secondary invader of an oriental sore. It has been relatively common to find this gram-negative intracellular
[Nov., 1944
THE INDIAN MEDICAL GAZETTE
520
in profusion being actively phagothe neutrophils of an ulcerating oriental sore. Cultures have been made in Iraq and Persia.
diplococcus cytosecl by
Incubation The incubation
period
'period
of
an
oriental
in
sore
Quetta appeared to average six months. This was computed from the mid-summer (August) preceding the appearance of a sore. The Cavalry Unit arrived in Quetta in November 1936, and the first sore was presented for treatment in December 1937, that is, after the first
summer season spent in the station. The average interval between the first appearance of the sore and the time a patient reported for treatment was ten weeks.
Treatment by injection of the sore with a solution of atebrin, was being used in 1939 at a Labour Camp Hospital, by Captain I. H. B. Ghosh. The method employed was that devised by Flarer (1938). It necessitates a careful routine : First day, hospital detention with hot potassium permanganate compresses (1/5000), fourhourly to clear secondary infection. Second day, injection with an atebrin solution, of strength 0.05 gramme per c.c. This is done with a fine hypodermic needle inserted radially from several points on the circumference of a sore. The injection is made as superficially as possible, and as little solution is used as seems required by the size and condition of the sore. Later, injections may be
Table VI Incubation
oriental
period of development period cui
2 6 21 42 22
June
1937?One month 1938?Two months 1938?Three 1938?Four 1938?Five 1938?Six 1938?Seven
July
1938?Eight
11 8
From Aug. 1937 to Dec. Jan. Feb. Mar.
Apr. Alay
2nd mid-summer to Aug.
of
required
at
choice by the
this
time
in
surgical specialist, Quetta, as practised Major D. J. P. Parker, who treated cases of oriental sore during the years under review, was scraping '. This consists of surface excision of a sore with a blunt spoon instrument (Volkmann's) under a short general anaesthetic. Unless deeply secondarily infected with bacteria, the wound remains superficial, and is covered with tannic acid powder and a vaseline gauze dressing weekly, which seems most satisfactory; more frequent dressings failing to speed healing. Healing time under these conditions is con'
sidered in table VII.
= =
to
?
9 33 =' 15
?
=
at three- to
the
ten-weeks'
9 per cent
18
=
74 37
1938?Nine
Treatment The treatment
sore: the 223 cases: described is subtracted
?
five-day intervals according
response obtained. Daily dressings follow, in which the appearance of the sore determines the preparation employed, namely, a weak carbolic ointment, an ointment incorporating atebrin, or a third containing alum to stimulate healing. These are occasionally supplemented, when healing is progressing, by the application of elastoplast direct to the surface of the sore. A series of thirty-three cases, treated in this manner at the Indian Military Hospital, is considered in table VIII. Table VIII Treatment
of
oriental
by injection with
sore
atebrin: thirty-three consecutive
Table VII
eighty-seven
.7
sores :
cases
Cases with single sore Cases with multiple sores Average interval between first appearance of sore and time of presentation for treatment was ten weeks. The parasite was identified in 18 cases (54 per cent of this series). Upper extremities alone affected Lower extremities alone affected Multiple sores on the individual Head involved (face ideal for this treat-
18 cases 15 ?
..
Healing
time
of
250
'scraped'
a
cases :
One week ..9-cases .Two weeks ..36 ? .oThree ...83? ? -Total healed three within weeks.
-----
sore :
1936 3.6 per cent =14.4 =332 ?
.0
!?
..
15 6
..
..
.
? ? ? ? ?
51.2 per cent = 16.4 per cent =11.2
5.6 = 4.8 = 10.8
=
? ? ? ?
..
ment)
..
..
(71 per cent) unbroken, non-ulcerating : suitable. Number of cases requiring? One injection only Two injections Three injections Four injections Of
87
sores,
62
Note.?The average healing tiin,e*Ts seen to be four weeks. This takes no account of the condition or type of the individual sore, and._ some.. were grossly
cases ?
12
?
8
?
were
.
.
..
10
..
..
11
..
..
..
..
.
secondarily infected.
..
..
41 Four weeks Five ..28 ? Six .. 14 ? Seven .. 12 ? 8 to 10 weeks 27 ..
oriental
with
1939
9 3
Nov.,
TROPICAL ULCER IN
19441
Table IX
Healing time of One week Two weeks Three ?
atebrin ..
..
!!
?
..10
=12 per cent
=24
..
..
?
?
,,
1^
"
was for all types Note.?The average healing time four weeks.
?f
Comparison
oriental table X. an
considered
Comparison of
methods of treatment '
Injection General ana?sthetic detention
Hospital
Subsequent
Suitable
Average
?
??
care
sore
..
..
healing time
Resultant
scar
?
..
??
..
..
None
Scraping
Ho
^
Daily
stage Best non- Any
ulcerating. Four weeks
p?"Vvee
Good
Minimal
Discussion
an8?^!1?
Scraping' requires a short general solution tic. Local injection with an atebnn ?c P itself. produces some anajsthesia antisep ic cases are given little preliminary 10 hospital deten , '
?