ULCUS TROPICUM IN FAZILKA

(PUNJAB)

By PRAN NATH LUTHRA, m.b., b.s. (Pb.), D.T.M. (Cal.)

Assistant Surgeon, Civil Hospital, Fazilka

That this disease which in India had so far been prevalent in the province of Assam has

already invaded the provinces of Bombay, Madras, Bengal and United Provinces is evident from recent reports in the Indian Medical Gazette. That the Punjab has formed no barrier to the

disease is indicated by this report.*

*See article on 'Tropical ulcer in the Hi?nr ? j.

of the Punjab '.-Editor, l.M.G. SSar dlstnct

170 THE INDIAN MEDICAL GAZETTE [April-May, 1946

The disease was found assuming a mild epi- demic form in Fazilka soon after the unusually- heavy rains in 1944. Although only 106 cases were seen in the out-patient department and 28 were hospitalized between the middle of August and end of December 1944, the actual figures must have been higher as certainly many cases fail to seek hospital aid. A milder epidemic was also noticed after the

summer rains in 1945. The largest number of cases were seen in the two months immediately following the rains and with the approach of midwinter the cases quickly dwindled.

Fazilka is a small town in the Ferozepore district of the Punjab and is an important centre for wool. It has a population of about 26,000, an annual average rainfall of about 10 inches, and a climate very hot and dry in summer and cold and diy in winter. The rain- fall at Fazilka in 1944 was about 16 inches as com-

pared with about 10 inches in 1943 and 12 inches in 1945.

Almost all the patients were drawn from the poor classes and looked malnourished and anaemic. Two of the cases although belonging to a fairly rich family had poor dietary habits and looked no better in development than the cases from the poorer classes.

Eight out of the 28 indoor cases showed

enlarged spleen and marked anaemia. All of them admitted that they had access to very little or no milk and had seldom taken any fruits.

Clinical picture.?The ulcers were invariably situated on exposed parts of the body, most commonly below the knees. Forearm, hand and nailbeds were involved in a few cases and then only in the females. The ulcers were usually round or oval varying in size from ? inch to

3Jr inches in diameter. One of the ulcers was 10 inches by 5 inches occupying the dorsum of the foot and the outer aspect of the ankle. The

edges of the ulcers were indurated, undermined and raised above the surface. (Edema of the

surrounding tissues was evident in some cases.

Greyish-yellow sloughs and an offensive sero-

sanguineous discharge characterized the ulcers so much so that once recognized the cases could be easily spotted from their characteristic smell. Most of the ulcers were deep in the sub- cutaneous tissues while muscles and tendons were seen under the larger ones. Bone was not reached by any of the ulcers seen by me. Pain and tenderness were constant features. The cases were generally 2 to 3 weeks old when first seen. Ulcers were usually single but in four cases multiple ulcers were seen. In these the ulcers were generally bilateral and in only one case three ulcers were seen on the same leg. The ulcer usually started as a small blister

after some sort of trauma. History of the

following kinds of trauma was elicited : (1) Mosquito bites. (2) Minor scratches and abra- sions. (3) Small old wounds. (4) Leech bite in one case.

In one medico-legal case a superficial linear incised wound developed into a typical round ulcer. Two cases of ulcers over the inner maleolar regions during their hospitalization developed second ulcers on the contra-lateral inner ankle regions.

In these the ulcers started as small mosquito bites which developed into small blisters, grew in size in a couple of days, burst and gave rise to ulcers that rapidly acquired typical shapes.

Corresponding lymphadenitis was not seen

in any of the cases nor were constitutional dis- turbances present.

Age incidence

5-15 years

59

15-30 years

36

30-40

years

40-50

years

10

Total

106

Sex.?Of the 106 cases only 10 were females. Occupation.?Malnourished children of school-

going age born of poor parents, bullock-cart drivers and labourers comprised the majority of cases. Patients were used to walking bare- footed in almost all the cases. Their dietetic habits revealed a gross inadequacy of milk and fruits in their menu. They lived in unhygienic surroundings. Laboratary findings.?Out of the 115 slides

examined with Leishman stain, fusiform bacilli and slender spirochetes were seen in 81. Fusiform bacilli alone were seen in 34.

In a few atypical cases pyogenic organisms only were seen.

Dr. D. N. Roy of the Calcutta School of

Tropical Medicine, who has worked on these ulcers in Assam, very kindly examined a few of the slides for me and confirmed the findings. A peculiar feature was the absence of micro-

organisms in the fluid withdrawn from the blisters of the two indoor cases in which typical ulcers formed later on at those sites. Leishmania tropica was not met with in the

fluid aspirated from margins of the ulcers and the base of the ulcers. Wassermann reaction was negative in all cases

from which blood was sent for examination.

Culturing facilities for studying the morbid anatomy were not available at Fazilka. Animal experiments.?Two dogs were scarified

on the legs and inoculated with discharges from the ulcers. The dogs failed to catch the disease.

Treatment.?Average stay of the hospitalized patients was 14 days under the following treat- ment :?

1. Complete rest. 2. Cleaning the ulcers daily with a solution

of copper sulphate 3 drachms and carbolic acid 1 drachm in 1 ounce of water and dressing with boro-iodoform.

April-May, 1946] TEN CASES OF TYPHUS IN CALCUTTA CIVILIANS : LOWE 171

Half the patients were treated by dressings with magnesium sulphate and sulphonamide powder in equal parts. Their average stay was 20 days. Penicillin dressings were tried in one case only

but there was no acceleration in clearing up of the ulcers with this. Conclusions.?Presence of tropical ulcer has

not hitherto been reported from the Punjab. The clinical description and the bacteriology of the ulcers leave hardly any doubt as to the

identity of the condition. The role of the fusiform bacilli and spiro-

chetes in the causation of this disease is so far unsettled* although evidence in support of their pathogenicity has been advanced now and then. The absence of these organisms from the smears made in the blister stage of the two cases

mentioned, indicates that they are perhaps secondary invaders. Dr. Roy working in Assam on these ulcers also attributed a secondary role to these organisms. That the disease which according to most of

the observers (Rao et al., 1945; Roy, 1939; Panja and Ghosh, 1944) is a disease of the poor and the ill-nourished may still further spread and assume severe epidemic form under the

onslaught of famine, and food shortage threaten- ing India must be seriously considered by the medical profession and the health authorities. The recent spread in places hitherto unaffected should be a sufficient warning. That no treatment is satisfactory makes the

problem still more serious.

Summary

1. One hundred and six cases of tropical ulcers have been reported from the Punjab where the disease had not hitherto been reported.

2. Fusiform bacilli and spirochetes appear to be secondary invaders.

3. The possibility of the disease assuming an epidemic form under the threatening famine in India is predicted.

Acknowledgment I am grateful to Dr. D. N. Roy for his very kindly

lending me the use of his thesis on '

Tropical ulcer

REFERENCES

I/Tanja, D., and Ghosh, Indian Med. Gaz., 79, 17. L. M. (1944).

Rao, M. V. R., et al. Ibid., 80, 128. (1945).

Roy, D. N. (1939) .. The British Encyclopaedia of Medical Practice, 12, 256. Butterworth and Co., Ltd., London.

.

* The pathogenesis of Naga sore has been discussed in a paper entitled '.Etiology and treatment of ulcus

tropicum by G. Panja, in the Ind. Jour. Med. Res., 33, 1, May 1945.?Editor, I.M.G.