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 , '

?

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