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Dermal leishmaniasis in a newly inhabited section of Aleppo
191 TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE.
Vol. XXXI.
No. 2.
July, 1937.
D E R M A L L E I S H M A N I A S I S IN A N E W L Y I N H A B I T E D S E C T I O N OF ALEPPO. BY
PHILIPP HOVNANIAN, M.D. AND ROBERT JEBEJIAN, M.D., Aleppo , AND
H. A. YENIKOMSHIAN, M.D., M.R.C.P., D.T.M. & H., American University, Beirut.
During the autumn of 1935 and the winter of 1936, an outbreak of Aleppo boil occurred among a group of refugee immigrants in a settlement newly established outside the boundaries of Aleppo City. The settlers had, for the past 10 or 12 years, been living in " camps " within the city, in shacks made of packing cases and kerosene tins; but Aleppo boil had never been prevalent among them. Two months after the first settlers had moved into their new homes, however, the disease appeared among them in an epidemic form, infecting a large majority of them. In many, the lesions were multiple, and some who had had Aleppo boil in the past had it again during this epidemic. The epidemiological and clinical features of dermal leishmaniasis noted in this outbreak seem to us of sufficient interest to warrant publication. For the last 10 or 15 years the city of Aleppo has been expanding rapidly, and new settlements are being established to provide better accommodation for the refugee settlers. These settlements are located in the uncultivated hill country to the north of the city, where, up to the time of the epidemic, no special health problems had arisen. The grounds where the epidemic started, formerly part of an orchard called " Bustan Pasha," are situated just outside the northern limits of Aleppo City and extend over an area with a dimension of about 1 km. east to west and 800 m. south to north. Late in the summer of 1935, the trees were removed, plans were made to put up about 400 brick houses,
192
DERMAL LE|SHMANIASIS.
and building began in the north-eastern section of the plot. Fig. 1 gives the plan of the settlement ; the squares represent the houses which were built up
[]
[]
m~W I ......... []
FIG. l. - - S q u a r e s denote the houses built prior to September, 1936. Black dots denote the distribution of Aleppo boil.
to September, 1936, and the dots denote the distribution of cases of Aleppo boil. Fig. 2 shows one of the newly-built brick houses. Since the building did not start until August, 1935, there was no accommodation but the bare earth
FIC,. 2.--Brick houses showing construction conducive to maintenance of sandfly nuisance. Houses occupied in this state at onset of the epidemic.
FIG.
FIG.
FIG.
FIG.
3a.-Eldest
son
3b.-Eldest 4.--Multiple
son one lesions
FIG.
emetic
FIG.
4.
FIG.
FIG.
3a.
before
tartar
emetic
month after resembling
3b.
5.
injections.
the start of tartar dermal leishmanoids.
emetic
treatment.
5.-S.A. family (except father). The photograph is taken after a course of tartar treatment, which was very efficacious in the children, but had no effect on the nodular lesions of the mother.
PHILIPP PIOVNANIAN, ROBERTjEBEJIAN AND FI. A. XtENIKOMSHtAN.
198
for those who moved into the grounds earlier in the summer. The site had not, at that time, been completely cleared of vegetation ; the ground, moreover, soon became littered with rubbish and manure. Mosquitoes, fleas, flies and, especially, sandflies were able, in these conditions, to breed abundantly, affording much discomfort to those who were compelled to sleep in the open and providing a definite menace to the health of the community. Early in October, 1935, about 2 months after the arrival of the first settlers, Aleppo boil began to appear in this new community. In order to give an idea of the mode of onset and the extent of the outbreak, we shall describe the history of the disease in the S.A. family. This is composed of five members : father, mother and three sons. The children were born in the camps, about 1 mile to the south of their present home, where the family had been living since 1922. With the exception of the father, who had had the disease in childhood and bore its scar on his upper lip, no member of the family had previously been infected. This family was one of the first to come to the locality, and began to build their house early in August, 1935. While the construction was going on, they lived in a part of the house which was dark, unplastered, and poorly ventilated, and at night suffered much discomfort from the large number of sandflies which infested the neighbourhood. In September, their eldest son, M., 9 years of age (Fig. 3a and 3b) began to show, on his face and extremities, papular lesions, which throughout the winter remained nodular. None were seen on the abdomen and back. In the spring these lesions, especially that on the nose, started to ulcerate. The family became alarmed and, in April, 1936, brought the boy to one of us (P. H. *) for examination. In the smears taken from the edges of the lesions on the nose of this case we found Leishman-Donovan bodies. On enquiry, we learned that 1 week after the appearance of the lesions in this boy, the second son, 6 years of age, had developed similar eruptions on the exposed parts of his body. When we examined the second son later in April, we found some forty papular nodules on his face, legs and forearms. LeishmanDonovan bodies were seen in smears taken from these lesions. We learned, moreover, that about the time the lesions appeared in the second son, the mother and the youngest son (3 years of age) had the same kind of multiple eruptions. The lesions of the mother and the two younger boys remained nodular, without ulceration, throughout the winter and spring. We were interested to observe that the right cheek of the youngest son was free from boils, and to learn from the mother that this boy slept always on the right side with his cheek against the pillow. Since April, 1936, we have been making periodical visits to this settlement to obtain data concerning the extent and progress of the outbreak and to note the response of the disease to tartar emetic treatment. *It is with deep regret that we report the death of Dr. PHILIPP HOVNANIANin June, 1936. His son, Mr. A. HOVNANIAN,student of Medicine in the American University, Beirut, has carried on his father's part in this work.
194
DERMAL LEISHMANIASIS.
In September, 19,36, the disease had already appeared in forty-five (35 per cent.) of the 127 families who had transferred to the new locality. Detailed study of thirty-two of these families shows that, out of a total of 181 persons (ninety-seven children and eighty-four adults), seventy-eight (43 per cent.) contracted the disease. Of these seventy-eight, fifty-five (70 per cent.) were children below the age of 12. Only 30 per cent. of the adults were infected. The low percentage of adults can be explained by the fact that, out of the total number of eighty-four adults, thirty-five had already had the disease in childhood while in Turkey, and had, presumably, acquired an immunity against the disease. If the number of the adults who had had the disease is subtracted from this total number, the percentage of the incidence of the disease in the adult group is 46 per cent. It is noteworthy that, during this outbreak the disease appeared in three persons of over 60 years of age for the first time in their lives. We have also seen active lesions contracted during this outbreak in seven persons who gave a history of having had Aleppo boil in the past and who have typical scars. All of those cases who had Aleppo boil for the second time had a mild single lesion on the hand, except one who had three lesions. The lesions in all of these cases ran a shorter course than in a first infection, and in three of them healed completely within 3 months. The time which elapsed between the first and second infections in this group varied from 10 to 50 years. As is seen in Fig. 1, the infection was most prevalent in the north-eastern section of the affected area where, in the late summer and early autumn of 1935, building first began. The detailed case histories show that the outbreak of Aleppo boil started suddenly but was of short duration, the disease being almost exclusively confined to those who had moved to their new homes in the summer and autumn of 1935. The first cases appeared in October, 1935, the majority in November and December, fewer in January and February of 1936, until, finally, only two new cases appeared after May, 1936. It is, again, noteworthy that in some of the houses in the north-eastern section no cases of Aleppo boil were found. One particular house, although separated by a distance of only 30 m. from the main group of buildings where the disease was most prevalent, nevertheless remained free from infection. This house was inhabited by a family of six children and their parents, none of whom had previously had Aleppo boil. In spite of the fact that these people had moved to their new home as early as the summer of 1935, they lived in a well ventilated and properly plastered room on the second story where they were not disturbed by sandflies. CLINICAL OBSERVATIONS.
•Some peculiarities of this epidemic are worthy of note. 1. The lesions were multiple. The usual number of lesions was between ten and twenty, although many had from forty to eighty and some as many as
I~HILIPP HOVNANIAN,ROBERTJEBEjIANAND lq. A. YENiKOMSHIAN.
19S
eighty-five. The disease was more widespread and severe among the children of from 4 to 10 years of age. Very few children of this age, living in the section where the disease was prevalent, escaped the infection. On the other hand, infants below 2 years of age were not afflicted so badly, probably because infants were usually protected against biting insects by a muslin cover over their faces. 2. The distribution and the appearance of the lesions, in some cases (see Fig. 4) resembled that of dermal leishmanoid. None of the cases, however, gave any history of kala-azar; and constitutional symptoms, such as chills and fever and enlargement of liver and spleen, were lacking. Blood counts in six patients who had extensive lesions showed no definite blood changes, the white corpuscles varying from 8,000 to 10,000 per c.mm. Although infantile kala-azar occurs in different parts of the Lebanon (HITTI, 1926), no cases of kala-azar in adults have been reported from Syria and the Lebanon. 3. One may assume that those who moved into these grounds about the same time and lived under similar conditions were exposed to the infection about the same time. A review of such a group of eases indicates that the lesions appeared 1 to 3 months after exposure. We have noticed that, in general, the disease was more severe and the lesions greater in number in those who seemed to have a shorter incubation period. 4. In seven cases out of a group of seventy-eight, the disease occurred for the second time. This indicates that not all persons develop a permanent immunity to oriental sore, and/or that re-infection may occur if the infective dose is massive enough ! The disease, however, was very mild in those who were infected a second time, and six of these seven patients had only a single lesion. 5. The following are some observations on treatment with tartar emetic. The drug was given intravenously to thirty-five patients three times per week, the total dose varying from 12 to 30 grains according to the age of the patient. It seemed to us that, in general, the greater the number of lesions and the younger the patient, the quicker the recovery under tartar emetic. The response to treatment was very dramatic in cases with multiple ulcerative lesions. Children who had been suffering for 2 or 3 months from extensive ulcerating lesions, where the examination of the scrapings taken from the edges of the ulcers revealed Leishman-Donovan bodies in large numbers, showed marked improvement after two injections of tartar emetic, and the lesions were completely healed within 1 month. On the other hand, patients who had the nodular non-ulcerative type of lesion (see Fig. 5), and others who had only a single lesion, especially the elderly patients, did not show appreciable improvement after a course of tartar emetic. As to the effect of tartar emetic on Aleppo boil, our observations are somewhat different from those of KHALIL (1934). Professor M. KHALIL BEY finds no Leishman-Donovan bodies in the secondarily infected ulcerating lesions and
196
DERMALLEISHMANIASIS.
he denies any specific action to any of the antimony preparations in different forms of dermal leishmaniasis that he has studied in Egypt. DISCUSSION. In this survey we have studied an outbreak of oriental sore in a community which had been transferred to a new environment separated by a distance of about 1 mile from its previous location. The change in conditions, however, was such as to cause an immediate outbreak of the disease in the new settlement. The atmospheric conditions , the climate, the water supply, the food and mode of living remained unchanged. The state of the grounds and the type of house, on the other hand, were very different in the two localities. The kerosene tins and packing cases of which the shacks in the camps were composed may have encouraged the breeding of bed-bugs but were in no way conducive to the breeding of sandflies. • The camp ground, moreover, was clean and free of any kind of vegetation. Conditions in the new settlement, however, were different. The bricks of the houses were made of straw and earth, material in which sandflies breed readily. The ground was piled with rubbish and d~bris and was still, in places, covered with the undergrowth of the orchard which had previously stood on that land. During the building operations of the summer and autumn of 1935, large numbers of sandflies infested the neighbourhood. As the construction progressed, however, houses were plastered and streets cleaned, and the number of sandflies became gradually less. It is significant to note that, as the improvements continued and sandflies disappeared, the outbreak of Aleppo boil subsided. In this connection it should be noted that no outbreak of this disease occurred in any of the near-by settlements, where the grounds had not been cultivated, where there was no vegetation or rubbish and where no large numbers of sandflies had appeared. It is improbable that the new settlers introduced the infection to this locality, since many of the gardeners and their families living on this ground prior to the coming in of the new settlers gave a positive history and bore the scars of the disease, which had obviously prevailed in this region in the past. In Syria and the Lebanon dermal leishmaniasis is known as Aleppo boil. It has a patchy distribution in this country, as elsewhere. Although the disease is endemic in Aleppo, it is more prevalent during some years than others. The theory that the sandfly is responsible for the spread of oriental sore is strengthened through further evidence collected by different observers in this country who have kindly communicated their personal experiences. From Dr. A. ALTOUNYAN, who has been carrying on a wide practice in Aleppo for over 50 years, we have the information that Aleppo boil has always been more extensive and severe in those parts of the city where the hygienic conditions are poor, the streets dirty and the biting insects more abundant. Those families, moreover, residing in the cleaner quarters, who use mosquito nets or live in properly screened houses,
PHILIPP HOVNANIAN, ROBERT JEBEJIAN AND H. A. YENIKOMSHIAN.
197
have either escaped the disease altogether or have had only small, insignificant lesions. Mr. J. KUENZLER, of the Swiss Mission, Beirut, who has spent more than 35 years doing hospital and missionary work in the Near East, describes similar conditions in a severe epidemic of Aleppo boil which occurred in Ourfa, Turkey, a district where the disease is endemic. During 1916-1917 there were many Kurdish and Armenian refugees in Ourfa who were brought in from the northern parts of Turkey. These people were forced to sleep in the open, having very little clothing to cover them. The epidemic was severe ; the lesions, which were scattered over the exposed parts of their bodies, were multiple, and in one patient Mr. KUENZLER was able to count as many as 260 lesions. He witnessed another epidemic where orphans, being transferred from Turkey to the Lebanon, had to spend some nights during summer in the open in districts where Aleppo button was prevalent: similar conditions were present. Mr. KUENZLER also stated that in Ourfa new cases of Aleppo boil almost always appeared during the last 3 months of the year. In the light of this observation it is suggestive that the epidemic described in this paper also began in October and reached its height during November and December. The fact that sandflies are most abundant in Aleppo during the summer and Aleppo boil only appears in autumn may be significant in determining the incubation period of the disease.
SUMMARY,
A. A sudden outbreak of dermal leishmaniasis occurred in a group of people who moved from one locality in Aleppo City to another only 1 mile to the north. These people had been living in Aleppo, in camps," for 10 or more years. While in the camps they lived in wooden and tin shacks, had no special complaint against sandflies, and dermal leishmaniasis was not prevalent among them. B. The new houses into which they moved were built of straw and mud bricks. The area to which they transferred was formerly a fruit orchard, the grounds of which were not completely cleared of vegetation when the new settlers came in August, 1935, and sandflies were very abundant. C. The cases of dermal leishmaniasis were more prevalent among the people who settled in this area earlier (August to September, 1935), and very much less among those who came in later (during the winter, spring and summer of 1936) when the grounds were cleared and sandflies reduced in number. D. This outbreak was characterized by multiplicity of lesions and the prevalence of the disease among children of from 4 to 10 years old. Seven cases were observed who suffered from dermal leishmaniasis a second time. Children and those who had multiple ulcerative lesions responded to tartar emetic. Those who had nodular or single lesions did not appreciably benefit from tartar emetic injection. "
198
DERMAL LEISHMANiASI$.
E. No such outbreak of Aleppo boil occurred in similar settlements located on small hill-tops north of Aleppo where the grounds are uncultivated and there is no vegetation, where there are no manure heaps and where no particular complaint against sandflies was made. F. Circumstantial evidence collected in this epidemic is in agreement with the conception that the sandfly is the principal if not the only vector in transmission of Aleppo boil. REFERENCES.
ALTOUNYAN,A. Personal communication. HITTI, J . K . (1926). Infantile kala-azar in Syria. ft. ~lmer. reed. Ass., 87, 1032. KHALIL BEY, M. (1934). Dermal leishmaniasis. A study of an endemic focus in Egypt. Arch. Schiffs- u. Tropenhyg., 38, (10), 417. KUENZLEa, J. Personal communication.
Vol. XXXI.
No. 2.
July, 1937.
D E R M A L L E I S H M A N I A S I S IN A N E W L Y I N H A B I T E D S E C T I O N OF ALEPPO. BY
PHILIPP HOVNANIAN, M.D. AND ROBERT JEBEJIAN, M.D., Aleppo , AND
H. A. YENIKOMSHIAN, M.D., M.R.C.P., D.T.M. & H., American University, Beirut.
During the autumn of 1935 and the winter of 1936, an outbreak of Aleppo boil occurred among a group of refugee immigrants in a settlement newly established outside the boundaries of Aleppo City. The settlers had, for the past 10 or 12 years, been living in " camps " within the city, in shacks made of packing cases and kerosene tins; but Aleppo boil had never been prevalent among them. Two months after the first settlers had moved into their new homes, however, the disease appeared among them in an epidemic form, infecting a large majority of them. In many, the lesions were multiple, and some who had had Aleppo boil in the past had it again during this epidemic. The epidemiological and clinical features of dermal leishmaniasis noted in this outbreak seem to us of sufficient interest to warrant publication. For the last 10 or 15 years the city of Aleppo has been expanding rapidly, and new settlements are being established to provide better accommodation for the refugee settlers. These settlements are located in the uncultivated hill country to the north of the city, where, up to the time of the epidemic, no special health problems had arisen. The grounds where the epidemic started, formerly part of an orchard called " Bustan Pasha," are situated just outside the northern limits of Aleppo City and extend over an area with a dimension of about 1 km. east to west and 800 m. south to north. Late in the summer of 1935, the trees were removed, plans were made to put up about 400 brick houses,
192
DERMAL LE|SHMANIASIS.
and building began in the north-eastern section of the plot. Fig. 1 gives the plan of the settlement ; the squares represent the houses which were built up
[]
[]
m~W I ......... []
FIG. l. - - S q u a r e s denote the houses built prior to September, 1936. Black dots denote the distribution of Aleppo boil.
to September, 1936, and the dots denote the distribution of cases of Aleppo boil. Fig. 2 shows one of the newly-built brick houses. Since the building did not start until August, 1935, there was no accommodation but the bare earth
FIC,. 2.--Brick houses showing construction conducive to maintenance of sandfly nuisance. Houses occupied in this state at onset of the epidemic.
FIG.
FIG.
FIG.
FIG.
3a.-Eldest
son
3b.-Eldest 4.--Multiple
son one lesions
FIG.
emetic
FIG.
4.
FIG.
FIG.
3a.
before
tartar
emetic
month after resembling
3b.
5.
injections.
the start of tartar dermal leishmanoids.
emetic
treatment.
5.-S.A. family (except father). The photograph is taken after a course of tartar treatment, which was very efficacious in the children, but had no effect on the nodular lesions of the mother.
PHILIPP PIOVNANIAN, ROBERTjEBEJIAN AND FI. A. XtENIKOMSHtAN.
198
for those who moved into the grounds earlier in the summer. The site had not, at that time, been completely cleared of vegetation ; the ground, moreover, soon became littered with rubbish and manure. Mosquitoes, fleas, flies and, especially, sandflies were able, in these conditions, to breed abundantly, affording much discomfort to those who were compelled to sleep in the open and providing a definite menace to the health of the community. Early in October, 1935, about 2 months after the arrival of the first settlers, Aleppo boil began to appear in this new community. In order to give an idea of the mode of onset and the extent of the outbreak, we shall describe the history of the disease in the S.A. family. This is composed of five members : father, mother and three sons. The children were born in the camps, about 1 mile to the south of their present home, where the family had been living since 1922. With the exception of the father, who had had the disease in childhood and bore its scar on his upper lip, no member of the family had previously been infected. This family was one of the first to come to the locality, and began to build their house early in August, 1935. While the construction was going on, they lived in a part of the house which was dark, unplastered, and poorly ventilated, and at night suffered much discomfort from the large number of sandflies which infested the neighbourhood. In September, their eldest son, M., 9 years of age (Fig. 3a and 3b) began to show, on his face and extremities, papular lesions, which throughout the winter remained nodular. None were seen on the abdomen and back. In the spring these lesions, especially that on the nose, started to ulcerate. The family became alarmed and, in April, 1936, brought the boy to one of us (P. H. *) for examination. In the smears taken from the edges of the lesions on the nose of this case we found Leishman-Donovan bodies. On enquiry, we learned that 1 week after the appearance of the lesions in this boy, the second son, 6 years of age, had developed similar eruptions on the exposed parts of his body. When we examined the second son later in April, we found some forty papular nodules on his face, legs and forearms. LeishmanDonovan bodies were seen in smears taken from these lesions. We learned, moreover, that about the time the lesions appeared in the second son, the mother and the youngest son (3 years of age) had the same kind of multiple eruptions. The lesions of the mother and the two younger boys remained nodular, without ulceration, throughout the winter and spring. We were interested to observe that the right cheek of the youngest son was free from boils, and to learn from the mother that this boy slept always on the right side with his cheek against the pillow. Since April, 1936, we have been making periodical visits to this settlement to obtain data concerning the extent and progress of the outbreak and to note the response of the disease to tartar emetic treatment. *It is with deep regret that we report the death of Dr. PHILIPP HOVNANIANin June, 1936. His son, Mr. A. HOVNANIAN,student of Medicine in the American University, Beirut, has carried on his father's part in this work.
194
DERMAL LEISHMANIASIS.
In September, 19,36, the disease had already appeared in forty-five (35 per cent.) of the 127 families who had transferred to the new locality. Detailed study of thirty-two of these families shows that, out of a total of 181 persons (ninety-seven children and eighty-four adults), seventy-eight (43 per cent.) contracted the disease. Of these seventy-eight, fifty-five (70 per cent.) were children below the age of 12. Only 30 per cent. of the adults were infected. The low percentage of adults can be explained by the fact that, out of the total number of eighty-four adults, thirty-five had already had the disease in childhood while in Turkey, and had, presumably, acquired an immunity against the disease. If the number of the adults who had had the disease is subtracted from this total number, the percentage of the incidence of the disease in the adult group is 46 per cent. It is noteworthy that, during this outbreak the disease appeared in three persons of over 60 years of age for the first time in their lives. We have also seen active lesions contracted during this outbreak in seven persons who gave a history of having had Aleppo boil in the past and who have typical scars. All of those cases who had Aleppo boil for the second time had a mild single lesion on the hand, except one who had three lesions. The lesions in all of these cases ran a shorter course than in a first infection, and in three of them healed completely within 3 months. The time which elapsed between the first and second infections in this group varied from 10 to 50 years. As is seen in Fig. 1, the infection was most prevalent in the north-eastern section of the affected area where, in the late summer and early autumn of 1935, building first began. The detailed case histories show that the outbreak of Aleppo boil started suddenly but was of short duration, the disease being almost exclusively confined to those who had moved to their new homes in the summer and autumn of 1935. The first cases appeared in October, 1935, the majority in November and December, fewer in January and February of 1936, until, finally, only two new cases appeared after May, 1936. It is, again, noteworthy that in some of the houses in the north-eastern section no cases of Aleppo boil were found. One particular house, although separated by a distance of only 30 m. from the main group of buildings where the disease was most prevalent, nevertheless remained free from infection. This house was inhabited by a family of six children and their parents, none of whom had previously had Aleppo boil. In spite of the fact that these people had moved to their new home as early as the summer of 1935, they lived in a well ventilated and properly plastered room on the second story where they were not disturbed by sandflies. CLINICAL OBSERVATIONS.
•Some peculiarities of this epidemic are worthy of note. 1. The lesions were multiple. The usual number of lesions was between ten and twenty, although many had from forty to eighty and some as many as
I~HILIPP HOVNANIAN,ROBERTJEBEjIANAND lq. A. YENiKOMSHIAN.
19S
eighty-five. The disease was more widespread and severe among the children of from 4 to 10 years of age. Very few children of this age, living in the section where the disease was prevalent, escaped the infection. On the other hand, infants below 2 years of age were not afflicted so badly, probably because infants were usually protected against biting insects by a muslin cover over their faces. 2. The distribution and the appearance of the lesions, in some cases (see Fig. 4) resembled that of dermal leishmanoid. None of the cases, however, gave any history of kala-azar; and constitutional symptoms, such as chills and fever and enlargement of liver and spleen, were lacking. Blood counts in six patients who had extensive lesions showed no definite blood changes, the white corpuscles varying from 8,000 to 10,000 per c.mm. Although infantile kala-azar occurs in different parts of the Lebanon (HITTI, 1926), no cases of kala-azar in adults have been reported from Syria and the Lebanon. 3. One may assume that those who moved into these grounds about the same time and lived under similar conditions were exposed to the infection about the same time. A review of such a group of eases indicates that the lesions appeared 1 to 3 months after exposure. We have noticed that, in general, the disease was more severe and the lesions greater in number in those who seemed to have a shorter incubation period. 4. In seven cases out of a group of seventy-eight, the disease occurred for the second time. This indicates that not all persons develop a permanent immunity to oriental sore, and/or that re-infection may occur if the infective dose is massive enough ! The disease, however, was very mild in those who were infected a second time, and six of these seven patients had only a single lesion. 5. The following are some observations on treatment with tartar emetic. The drug was given intravenously to thirty-five patients three times per week, the total dose varying from 12 to 30 grains according to the age of the patient. It seemed to us that, in general, the greater the number of lesions and the younger the patient, the quicker the recovery under tartar emetic. The response to treatment was very dramatic in cases with multiple ulcerative lesions. Children who had been suffering for 2 or 3 months from extensive ulcerating lesions, where the examination of the scrapings taken from the edges of the ulcers revealed Leishman-Donovan bodies in large numbers, showed marked improvement after two injections of tartar emetic, and the lesions were completely healed within 1 month. On the other hand, patients who had the nodular non-ulcerative type of lesion (see Fig. 5), and others who had only a single lesion, especially the elderly patients, did not show appreciable improvement after a course of tartar emetic. As to the effect of tartar emetic on Aleppo boil, our observations are somewhat different from those of KHALIL (1934). Professor M. KHALIL BEY finds no Leishman-Donovan bodies in the secondarily infected ulcerating lesions and
196
DERMALLEISHMANIASIS.
he denies any specific action to any of the antimony preparations in different forms of dermal leishmaniasis that he has studied in Egypt. DISCUSSION. In this survey we have studied an outbreak of oriental sore in a community which had been transferred to a new environment separated by a distance of about 1 mile from its previous location. The change in conditions, however, was such as to cause an immediate outbreak of the disease in the new settlement. The atmospheric conditions , the climate, the water supply, the food and mode of living remained unchanged. The state of the grounds and the type of house, on the other hand, were very different in the two localities. The kerosene tins and packing cases of which the shacks in the camps were composed may have encouraged the breeding of bed-bugs but were in no way conducive to the breeding of sandflies. • The camp ground, moreover, was clean and free of any kind of vegetation. Conditions in the new settlement, however, were different. The bricks of the houses were made of straw and earth, material in which sandflies breed readily. The ground was piled with rubbish and d~bris and was still, in places, covered with the undergrowth of the orchard which had previously stood on that land. During the building operations of the summer and autumn of 1935, large numbers of sandflies infested the neighbourhood. As the construction progressed, however, houses were plastered and streets cleaned, and the number of sandflies became gradually less. It is significant to note that, as the improvements continued and sandflies disappeared, the outbreak of Aleppo boil subsided. In this connection it should be noted that no outbreak of this disease occurred in any of the near-by settlements, where the grounds had not been cultivated, where there was no vegetation or rubbish and where no large numbers of sandflies had appeared. It is improbable that the new settlers introduced the infection to this locality, since many of the gardeners and their families living on this ground prior to the coming in of the new settlers gave a positive history and bore the scars of the disease, which had obviously prevailed in this region in the past. In Syria and the Lebanon dermal leishmaniasis is known as Aleppo boil. It has a patchy distribution in this country, as elsewhere. Although the disease is endemic in Aleppo, it is more prevalent during some years than others. The theory that the sandfly is responsible for the spread of oriental sore is strengthened through further evidence collected by different observers in this country who have kindly communicated their personal experiences. From Dr. A. ALTOUNYAN, who has been carrying on a wide practice in Aleppo for over 50 years, we have the information that Aleppo boil has always been more extensive and severe in those parts of the city where the hygienic conditions are poor, the streets dirty and the biting insects more abundant. Those families, moreover, residing in the cleaner quarters, who use mosquito nets or live in properly screened houses,
PHILIPP HOVNANIAN, ROBERT JEBEJIAN AND H. A. YENIKOMSHIAN.
197
have either escaped the disease altogether or have had only small, insignificant lesions. Mr. J. KUENZLER, of the Swiss Mission, Beirut, who has spent more than 35 years doing hospital and missionary work in the Near East, describes similar conditions in a severe epidemic of Aleppo boil which occurred in Ourfa, Turkey, a district where the disease is endemic. During 1916-1917 there were many Kurdish and Armenian refugees in Ourfa who were brought in from the northern parts of Turkey. These people were forced to sleep in the open, having very little clothing to cover them. The epidemic was severe ; the lesions, which were scattered over the exposed parts of their bodies, were multiple, and in one patient Mr. KUENZLER was able to count as many as 260 lesions. He witnessed another epidemic where orphans, being transferred from Turkey to the Lebanon, had to spend some nights during summer in the open in districts where Aleppo button was prevalent: similar conditions were present. Mr. KUENZLER also stated that in Ourfa new cases of Aleppo boil almost always appeared during the last 3 months of the year. In the light of this observation it is suggestive that the epidemic described in this paper also began in October and reached its height during November and December. The fact that sandflies are most abundant in Aleppo during the summer and Aleppo boil only appears in autumn may be significant in determining the incubation period of the disease.
SUMMARY,
A. A sudden outbreak of dermal leishmaniasis occurred in a group of people who moved from one locality in Aleppo City to another only 1 mile to the north. These people had been living in Aleppo, in camps," for 10 or more years. While in the camps they lived in wooden and tin shacks, had no special complaint against sandflies, and dermal leishmaniasis was not prevalent among them. B. The new houses into which they moved were built of straw and mud bricks. The area to which they transferred was formerly a fruit orchard, the grounds of which were not completely cleared of vegetation when the new settlers came in August, 1935, and sandflies were very abundant. C. The cases of dermal leishmaniasis were more prevalent among the people who settled in this area earlier (August to September, 1935), and very much less among those who came in later (during the winter, spring and summer of 1936) when the grounds were cleared and sandflies reduced in number. D. This outbreak was characterized by multiplicity of lesions and the prevalence of the disease among children of from 4 to 10 years old. Seven cases were observed who suffered from dermal leishmaniasis a second time. Children and those who had multiple ulcerative lesions responded to tartar emetic. Those who had nodular or single lesions did not appreciably benefit from tartar emetic injection. "
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DERMAL LEISHMANiASI$.
E. No such outbreak of Aleppo boil occurred in similar settlements located on small hill-tops north of Aleppo where the grounds are uncultivated and there is no vegetation, where there are no manure heaps and where no particular complaint against sandflies was made. F. Circumstantial evidence collected in this epidemic is in agreement with the conception that the sandfly is the principal if not the only vector in transmission of Aleppo boil. REFERENCES.
ALTOUNYAN,A. Personal communication. HITTI, J . K . (1926). Infantile kala-azar in Syria. ft. ~lmer. reed. Ass., 87, 1032. KHALIL BEY, M. (1934). Dermal leishmaniasis. A study of an endemic focus in Egypt. Arch. Schiffs- u. Tropenhyg., 38, (10), 417. KUENZLEa, J. Personal communication.