N.I. Spriggs, AstleyV. Clarke
1918 The Lancet  
IN THE LANCET of Feb. 23rd Mr C. R. C. Lyster and Captain W. H. McKinstry appropriately describe a case of oriental sore met with in England and recommend chlorine ionisation and hypochlorite dressings. It is probable that in the future more will be heard and seen of oriental sore and of other forms of leishmaniasis in England, both amongst native troops visiting the country and amongst British troops returning home from Palestine, Mesopotamia, India, and the Mediterranean seaboard. Oriental
more » ... aboard. Oriental sore crops up fairly frequently in the Sudan, and as antimony (tartar emetic) is mentioned only incidentally amongst other remedies which have been tried with more or less success," it appears to us that perhaps it meets with less than its due in the article quoted. Many remedies have been tried, and until recently an ointment of methylene-blue, lanoline and vaseline, equal parts, was a favourite remedy here, but antimony (tartar emetic) is now well established as the drug for leishmaniasis, and it is probably as much of a specific for leishmaniasis as quinine is for malaria. Diagnosis. These sores present themselves in a variety of forms. Sometimes as a misshapen boil, sometimes as an irregular unhealthy-looking indolent ulcer, but in our experience A typical oriental sore on wrist (below) and little finger (above). generally as a superficial sore, chronic, callous, yellow crusted, cracked and indolent, pigmented, round and often resembling the veldt sores met with in South Africa (see figure) . They resist simple remedies, grow slowly, and, in time, get well of themselves. The lymphatic glands are not affected and there is no tendency to a general infection. They leave a soar. often a pigmented one, and do not kill. The following simple method of procedure is all that is necessary to establish the diagnosis: -A. glass capillary tub" is gently worked through the margin of the ulcer by a rotatory movement and p shed into the base just under the surface of the 'ore. The tube is gently moved and serum and debris are taken up into the lumen with very little blood. This is spread out as a film on a slide ad stained with Leishman s stain-one minute in the undiluted stain and five minutes in the diluted gives good results. Then omes examination of the stained film with a 1/12th oil immersion and, if present, the round or ovltl Leishman-Donovan bodies with large purple stained nucleus and characteristic smaller deeply stained rodshaped body are unmistakable. Treatment. The specific drug is antimony, and intravenous injec'ion of tartar emetic, into the median cephalic vein for choice. is the most convenient m-thod of giving it. In-patient treatment is not necessary. We use a solution-gr. to nt. xl. distilled water-and inject daily, increasing the dose to gr. 1 or 1½. The sore i kept clean, protected from atmospheric conditions and from re-infection by a little zinc ointment and dressing Witti regard to the intravenous injection, the tartar emetic solution mus'. be introduced into the lumen of the vein and not around the vein, otherwiqe troublesome necrosis results and phlebitis. Wnen the needle is within the lumen of the vein a backward flow of blood into the syringe proclaims the fact A sharp needle is an important factor and a "Record" syringe of 5 or 10 c.cm. a great convenience. It must not be forgotten that antimony is a cumulative poison and, although eliminated by sktn, Sidneys, and mucous surfacts, it is farreaching and found in organs and tissues, near and distal, long a terwards. Its use is not without da ger. Our practice is to inject carefully small quant ties, gr. to 14 daily, giving a day or two's test and reducingthed 'seif toxiosymptomsintervene. During, or immediately after, injection coughing an a metallic taste in the throat-evide ce of the presence of the drug in the general circulation-is frequently expPrienced; this is an unimportant but interesting phenomenon. More serious symptoms are vomiting, high temperature, weakness, giddiness, delirium, &c. A total of 12-1 grains antimoniumtartaratum injected over a period of a fortnight is about the quantity and time required for an ordinary case of oriental sore by this method. The photograph is of a typical sore as'met with out here, generally on exposed surfaces-face, neck, hands, and feet, often over a bony prominence such as a knuckle or the styloid process of the ulna. The subject appears to us to merit attention on account of the probable more frequent occurrence in the future in England of oriental sore. MANY wounded soldiers, and particularly pensioners, are now to be met with in whom the condition of main-en-griffe exists with no prospect of improvement. Although operative treatment for hopeless ulnar paralysis has been carried out in some cases by tendon transplantation in the forearm with successful results, this does not appear to meet the necessity of giving the man a useful hand, for the disability there persists-viz., the condition of extension of the proximal phalanges with flexion of the distal ones, more particularly in the case of the ring and little fingers. We have been impressed by the importance of this condition and therefore have studied it on the cadaver and can lay down the following points :-** 1. The condition of main-en-griffe can be imitated on the cadaver by pulling on the extensor and flexor tendons of the forearm at the same time, or in the normal arm by simultaneous electrical stimulation of both flexors and extensors. (That is, the forearm muscles are in action while the small hand muscles are not in action.) 2. If in the foregoing experiment on one finger the exposed tendon of its interosseus (perhaps with the lumbrical attached) be also pulled upon, the above unfortunate position does not result. 3. If now this interosseus tendon on each side of a finger be joined to that of flexor sublimis, at a point just distal to where the latter splits, pulling on the corresponding flexor tendon in the forearm gives the finger a useful prehensile power, and the main-en-griffe position is corrected. This operation on the cadaver is relatively easy of performance from an incision on the palmar aspect; it has been done by us on several fingers with apparently the most satisfactory results, and the time it requires after practice is only ten minutes. A n early opportunity will be taken to carry out this operation on suitable patients in Leicester, but the true result cannot be determined for some considerable time, and the best technique will be a matter of experience. At this stage it can only be said that the junction should not be too taut, and the best position for it seems to be close to the splitting of the sublimis tendon. Of course, it may be found more difficult to perform when the small tendon of a paralysed muscle has to be dealt with, but in that case a split off
doi:10.1016/s0140-6736(01)26799-3 fatcat:conh24zfcvd3hkm4yq32pueoby