·No text on this page.

·RELIEF ASSOCIATION
BRITISH EMPIRE LEPROSY RELIEF
INDIAN COUNCIL
10
1
FICS
17 nr 7 1928
SIX LECTURES
ON
LEPROSY
With 105 Illustrations
Prepared by
Tht. LEPROS, DCPARTMENT
School of Tropical Medicine & Hygiene
CALCUTTA
In arti Carti LRT COTTAGE

·No text on this page.

·FOREWORD The purpose of this booklet is to form the skeleton of a series of six lectures on leprosy to be delivered to doctors and medical students Any one undertaking to deliver such a course of lectures should himself have had considerable clinical experience of the disease and should am plify the information given in this booklet by reference to other literature on the subject For this purpose the booklet en titled Leprosy Diagnosis Trea ment and Prevention (published by the Br tish Einpne Leprosy Relief Association Indian Council) will be found specially useful Such courses of lectures should be supple mented by clinical and pathological de monstrations is to give a practical knowledge of the diagnos s differential diagnosis and treatment of leprosy a general understanding of the disease Our thanks are due to Lt Col Acton for the use of several of the pictures of skin diseases illustrating the lecture diagnosis Sets of lantern slides corresponding to the pictures and copies of other litera ture connected with leprosy to be had from the Secretary British Empire Leprosy Relief Association Indian Council Delhi (or Simla) SO as well as OI? sre

·No text on this page.

·TABLE OF CONTENTS IFCIURE I CLINICAL STAGES Page Slide 1 1 7 8 9 10 12 13 14 15 16 Leprosy Curves 2 From B3 to A2 3 Four Primary Principles of Leprosv 4 Tirst Lesions Moticed in 99 Patients 5 Types of Farly L sions and their Course 6 Depigmented Patches in 41 Case 7 A. Lesion with Thickened Nerve 9 Three Zone Patches 9 Erythemato: Patch of Hand SO Erythematous I atch or Face IT AIR Patch of Ankle 13 7 hickened Creat Auricular Verve 13 Thickened External Peronen! Serve Supraorbital Verse lupied in Canal 15 Frythenatous l'atch of Left Check 16 Anhydroti Pitch of Chest 17 Anlıydro is of I imts 18 rophe Bliter of ringes 19 Terfarting Licer of loot 20 Abress of land 21 B2 Leon of face in A2 Class Hand Trophy Changes in Face an Hands 13 Left Facial Paralyss Herpes 7 mer 24 B3 Lesing of lace (I conta ) 5 Thekening of the ani tars 26 kalually sy reading B3 Le sons (frou ) Rotally spreadın B3 Lesions ab ck) Rulally pread ng Balen 29 Ies on due to Interfolliculit Granulama 30 Crushe 1 Paper Arxanance 17 18 19 20 21 22 23 24 25 26 27 zy 29 30 31 32 33 ·LECTURE II INFECTION Slide 31 NIap of India M Lepre Leprosy a Bed and House Infection Spot Wap of First noticed Lesions Age of Infection Incubation Period Relative Importance of Secondary Factors Accessory Factors Depression of Resistance Coincidence of Syphilis in I eprosy Proportion of Infectie I epers 32 33 34 35 36 37 38 39 40 41 Page 35 36 37 39 41 43 44 4+ 45 47 5 50 LECTURF III PATHOLOGY Slide 42 M I epræ SI 52 S4 55 56 43 Degeneratie Forins 44 Spread from Initial Lesions 45 Normal Skin 46 Section of Farly I esion (low power) 47 Section of Early Lesion (high power) 48 Diagram of Types of Lesions 49 Section showing Leprous Infiltration 50 Lepra Cells SI Lepra Cells 52 Lymph Gland in Rat Leprosy 53 Human Lymph Gland 54 Section of Module (Hæm I osin) 55 Section of Nodule (Ziehl leelsen) 56 Ascending Nerse Iesion (diagram) 57 Balance betii een Skin & Nerre Leprosy 58 Lesions of Eye 59 Chart of I eprosy of Lungs 57 58 60 61 62 63 64 65 66 68 70 71 73 ·LECTURE IT Drag\OSIS Slide 60 Ear Snipping 61 Staning of Slide 62 Testing of Anesthesia 63 Testing of Thermal Sensation 64. hahn Test Vlaterials 65 Periasis 66 Isoria is (Section of Skin) 67 I inta 6S 1 uberculide 69 Raynaud s Disease Dermal Ic Imaniasis Leuco lerm 2 Ichthyo is 73 Ichthyois (Section of Skin) 74 heratosis Folliculars 75 Sclero lernt 6 Vorphrra 77 Prognosis Page 76 77 78 80 82 83 84 85 86 87 88 89 90 91 92 93 94 96 I FCTL REV TREATMENT 99 101 102 10. 106 105 Slile 78 teatment of Icproxy 9 habn Test 80 Picture of Anti yphilitte Remedies Dict $2 Firrele 83 Barlung 94 Hydnocarpus Tree 8 I Inouarru Fruit and Icases $6 Inuts and Seeds 87 Ister maling by Cold I'rocess Ol Infiltration 49 l ainting with I richloratetic Icd 90 Dkreirance of Ictie Sign 110 TIT H12 113 114 122 124 * ·Slide 91 92 93 94 95 96 97 98 99 Bed of Stream Verve Stretching Ear Trimming Ear before and after I rimmung Chart showing Results of Treatment Contrast Photographs Contrast Photographs Contrast Photographs Contrast Photographs Page 125 126 127 128 129 130 131 132 133 LECTURE VI PROPHYL 4 XIS Slide 100 IOI IO Vother and Fise Children Venly born Child removed from Vlother Small Child Lept from Father Infectious Leper in Hut Fhoto of Leper Asylum Precautions to be taken 135 136 137 135 139 140 103 10+ 105

·VICIURL 1
CLINICAL STAGES
The Course of Leprosy and Classificattort of Stages and Types
SLIDL No 1
LEPROSY CURVES
-ام
11 OCT 1928
hem WW/PA
ni par
forwawang mer kry
Art www
1 groTM
Corpory
AF
re
8 wwwtore wart All Aww in IN
&
The old classituation of leprosy into maculo
antsthetic nodular and micd ciscs is not found 67015
f1ctor when the whole course of the disease is tahen
into consideration as many types of lesions cannot be
de cribed under these housi,
I lc course of typical case of leprosy may be
illustrated by i parabolic cure (slide do 1), the
Tcrtial indicating the number of bacılls in the body and
tlıc horizontil the duration of the di 150 I he greater
the natural resistance of the patient the flitter will the
curic bc, and the less the resistance the more abrupt
will be the rise of the inne After reichi, 1 certain

·or height the cure again descends to the base line, the bacilli having all died out of the body In other words leprosy is a self healing disease, only its course is so protracted, often occupung a large number of years, that this fact is often lost sight of The fewer the number of bacıllı in the body the more is the disease confined to the peripheral nerves As the bacıllı increase in number the nerve signs be come proportionately less It is thus convenient to term the lower part of the diagram the "nerie" A" iren and upper part the "shin" or "B" area Cases of the nerve type (in which there is high resis tance) are represented by a flat curve which never rises above the "A" area, but almost all shın ("B") cases pass through this area more or less rapidly This means that all cases (with perhaps only a few excep tions), are nerve cases to begin with and may be diagnosed from nerve signs clinically before the num ber of bacıllı has increased to such an extent that they can be found on bacteriological examination Again in the descent of the curve towards the "A" area skin cases tend to show more and more nerve signs and the number of bacıllı becomes less When it enters the "A" area again the bacıllı have become so few that they cannot be found on bacteriological ev? mination While in the errly ascent of the curve ("A." or primary nerve cises) the nerve signs are chiefly connected with patches and macules, in the descending passage through the nerve iren ("A2" or secondary nerve cises) the signs are more of the acro terit or "glove" variety and tre connected with trophic signs such as ulcers of the hands and feet, and deformities of the fingers and toes Many cases follow a course represented by a flat curve for 1 certain time (it may be miny years), and then due to sudden lowering of the resistance, the number of bacıllı increases rapidly and the curve pisses upwards abruptly into the "B" rea ·(3) It is convenient to divide the "A"area into" A1" and " 42" according as the case is a primary or secondary nerve one 1 he “B” cases may also be divided into "B1" "B2" and "B", the first class containing those in which bacıllı can be found in very small numbers, the last class containing the cases in which the bacıllı are in very large numbers, while "B2 'cases are intermediate While we speak of types and stages it must be remembered that the two terms are to large extent interchangeable and the type of case may change it any stage The form of chart given in the diagram will be found very convenient for plotting out the course, type and stage of any case while predisposing causes may be represented by horizontal arrows which meet and act upon the curves at various stages, the duration and severity of the predisposing cause being represented by the length of the arrow and the number of its feathers "B" cases which have reached the top of the curve may be recognised by their showing the elimination phenomena which are as follows - (a) The gradual arrest of the progress of a severe ind prolonged reaction even though towards the end of it the patient is so weah and exhausted that such would be the time when and these the conditions under which, the bacıllı would seize the opportunity to multi ply ripidly and invade and sitump the devitalized humın organism, (b) the gradual breaking down and granulation of bacıllı which takes place spontaneously or occurs more ripidly is the result either of treatment or of sonie intercurrent febrile disease, (c) the charac teristic appearınces of shin lesions showing the signs of rapid resolution, (d) rapid disappearince of inflam matory points, resulting from bacıllary embolism in the capillaries caused by bacıllı set free in the blood stream from old lesions during reactions This rapid ·(4) disappearance is in murhed contrast to what takes place in the carlier period of the disease, when similar em boli form the centres of fresh, rdially sprending lesions It is difficult to account for the above elimination phenomena in any other way than by supposing either that marked immunity has been acquired, or that the natural resistance of the body has suddenly increased The latter supposition is however ruled out by the fact that these murhed signs of elimination of the disease are often present, even when pitients are in the stage of cutreme weakness, crused by prolonged reactions There is no clear cut line between any of the types or stages mentioned above, and 1 patient may often be found who is pissing more or less rapidly from onc stage into another, and one part of the body may be typical of one stige while another part is typical of another stage

·SLIDE NO 2
Room B
Rem Ag
Illustrates a common condition in which the
lower extremities are typical of A2 while the face and
ears are still typical of B3 Sceing he is passing from
Bz to Az the case may be denoted as B3 A2 The
patient is represented as passing feet foremost from the
B3 room to the A2 room Likewise we my speak of
A1 A2 cases und Bi B2 cases

·SLIDE No 3
FOUR PRIMARY PRINCIPLES
OF LEPROSY.
LEPROSY
IS A
SELF-CURING
DISEASE
CHIEFLY OF
SKIN AND NERVES.
rEW BACILLI IN NERVE TYPE
MANY BACILLI IN SKIN TYPE
MUTUALLY EXCLUSIVE
SKIN AND NERVE TYPES
RESISTANCE DETER/KINES
NUMBER OF BACILLI
This slide shows in diagrammatic form the four
primary principles which govern the course of leprosy
and which have also been illustrated in the cures

·SLIDE No 4 THE FIRST LESIONS NOTICED IN 98 LEPROUS PATIENTS AT THE CALCUTTA DISPENSARY I 6. 2 I2 12 3 4 5 6 Anesthetic Patches Sensitive Red Patches White Blisters Skin Crached Nodule Gland Thichened Nerve 3 I 3 7 8 I I 98 Of 95 patients at the Calcutta dispensary the great majority (65) noticed an.xsthetic pitches first of all Other first noticed lesions Here sensitive red and white patches, blisters, cricked shin, nodules enlarged gland thickened nerve Antsthetic patches mly therefore bu tohen as the errliest indication of the discase and doctors should always be on the look out for such ·(8) SLIDE No 5 TYPES OF EARLY LESIONS & THEIR COURSE I I TH NESTNET DPA DLPIO TZO PATO ANAC STMETS DEPIGMENTED Wou RED PAJE NOT ANARSTWT NA TO ANAEST ETK PATCH NERVE THAKENED ANAESTHETIC MATCM MYCH AMAESTHETX WITH MED MANGIN AQ - FW BACE FOUND N MARC HỢ MI MT- LU FOUND NOT AKACST EK THCK RED NOBLE AAN DAN BAKAL Various Ar ind Bi lesions are depicted diagra mmatically in this and the follow twelve slides

·SLIDE NO 6
Depigmented pitches are generally anesthetic to
superficial touch, but small depigmented patches may
be found in early cises without loss of sensation, as is
shown in this slide This child was diaganosed is

·( 10 )
suffering from leprosy because of the history of con
tact with very infectious leper pirents Without such
a history it would have been necessari to wait till
superficial nasthesia developed or till bacıllı could
be found
SLIDE No 7
Shons un insthenic patch with the neryc branch
supplying it so thici ened that it stands out in the photo
graph

·(11)
SLIDE NO 8
ht
Shows depi,,mented patches with a white margin
outside the red murgin Alany of the patches have
run together to form liroer treas

·( 12 )
SLIDE No 9
Slide showing red, crythematous patch of hand
This patch wis anæsthetic and no bacilli could be
found on elamination

·(13)
SLIDE No 10
Ditto of face

·SLIDE NO IT
Anesthesiz und depigmentation of the skin in the
lower part of lesion but erythema in upper part in
which bacıllı were found on bacteriological evamına
tion but superficial inesthesia was absent This
patient only noticed the inesthesia when a large thorn
hned pierced his foot and been withdrawn without pain

·15]
SLIDE NO 12
t
I hicieni, nt Litat rurkular neric ind paralysis
ot funt neric due to nipping of thickened nenic in
stylu mastord foramen

·( 16 )
SLIDE NO 13
Wroca
17
part
SA
My name
V
2
Thichening of external peroneal nerve

·( 17 )
SLIDE NO 14
AL
Paralysis of occipito frontals due to nipping of the
supra orbital nerve as it passes through the bony canal

·( 18 ) SLIDE NO 15 Crythem of the left side of the face with thickening of the supriorbital nene Bacıllı w cre not found on bacteriological examination The shin 178 In rs thetic The occipito frontalis was not pirlysed as the nerve passed through a groove in the bone and 117s not nipped

·(19
SLIDE No 16
}
this slide andıntes inhydrosis of 1 path of shin
the surroundin, healthy shin returned the short func
tus and hnd prichis heat but the central leprous
Te1 Ind no pessp11110n and on therefore unafietted
by prichly heit

·( 20 ) Al lesions are shown in the following seyen sildes SLIDE NO 17 Contrast this slide with the last This patient also has anhydrosis but it is of the love stocking (or acro teric variety) This is an Az or sccondary nerve case The nerve trunks have been bloched to 1 certain citent by the pressure in them of lepromitous tissue and the non medullated, simpathetic fibres have suffered first Such lesions begin at the extremities (finguts or toes), is their nerve supply is the longest and therefore the most affected by pressure, and spread up the limbs Such patients may first come complaining of excessive styeating the result of compensatory hyperhidrosis in the trunh and face to make up for the absence of the seat function in the limbs This patient had

·( 21 )
haolin sprinkled on his body where there was perspira
tion, the haolin stuch, as on the face and trunk Where
there was no perspirition it fell off as is seen on the
limbs, especially below the elbows and knees
SLIDE NO 18
de )
This slide shows i trophic blister after the outer
cpithelium has been removed

·( 22 )
SLIDE NO 19
1
PERFORATING ULCER
Shows a perforating ulcer which a deeper lesion
than the blister in the last slide, but also, like it, due to
bloching of the trophic supply by granulation tissue
pressure in a nerve trunk or its branches

·(23)
SLIDE No 20
Such trophıc lesions may become septic Here
15 an abscess of the hand due to invasion of a trophic
lesion by staphylococci

·( 24 )
SLIDE NO 21
-
!
Shows the clan hind This is due to trophic
wasting of the small muscles of the hand, especially
the interossii and lumbricaics The thenar and hypo
thenar eminences are also flattened due to the wasting
of the short muscles of the thumb and small finger

·( 25 )
SLIDE No 22
quilts
mo
ܝ ܟ
The typical frul appeurante in sccondarı nerve
Icprosi (12 st18) This is due to pirosis of the
muscles of expression and is accompanied as a rule by
partial anasthest of the skin of the face and of the
conjunctua Contrast with facil pıralışıs as shown in
the next slide

·( 26 )
-
SLIDE NO 23
Showing leprotic herpes zoster
1 his patient
suffered great pain for a few days He has alsa facial
paralysis due to nipping of the facial nene, is it passes
through the bony cinal

·( 27 )
B2 & B3 lesions are shown in the next soyen sildes
SLIDC No 24
Showing typical B3 or nodular leprosy
the lion lihe 2ppearance (leontiasis)
Notice

·( 28 )
SLIDE No 25
Showing thickening of the lobules of the curs

·( 29 )
SLIDE NO 26
28
Showing the radial spread of lesions from central
nodules Notice the rared margins and the flat
centres

·(30)
SLIDE NO 27
1 he bach of the same c70

·( 31 )
SLIDE NO 28
Jeans
A less grocs infection of the B. typu
1sp7cing on 1 lower curve than the last
I he patient

·( 32 )
SLIDE NO 29
This slide shows the diffuse granulomatous infiltra
tion of the skin in the interfollicular type The natural
folds of the shin, due to the pulling down of the epithe
lium by the hair follicles and sweat glands, are exagge
rated and thus a mosaic appearance is produced
Notice the contrast to the normal shin

·( 33 )
SLIDE NO 30
This allows the crushed paper" appearance
manifested when 1 case is coming down from the top
of a high curse The absorption of granulomatous
tissue wrinkles the thinned out epithelium, which had
been on the stretch This is one of the signs of rapid

·No text on this page.

·( 35 )
INCIURI II
INFECTION
SLIDEMO 31
This map chons the distribution of leprosy as
estimated by the 1921 census although far from accu
rate it goes a relatively good idea of the incidence of
the disease in different parts of the country
MASIS ANDIA
ENDENCE OF LEPROJY
1
IN DIT 055
Acco to
* *
RE
jam pada pagi in balkong
ยังไง เป็นแนวยางแรง
o

·( 36 ) SLIDE No 32 Shows the ordinary vegetative, uniformly stuined form of lepra bacıllı (mycobacterium lepra) VEGETATIVE FORBIS OF M LEPRE The Organisms present the appearance of uniformly tained rods. Note the tendency to bundle formation Leprosy is 1 chronic disease, relativcly non fatal in character, and caused by the invasion of certain tissues of the body by the bacillus (M lepræ), originally described by Hansen in 1871 While its precise mode of entry is not yet definitely known the organism very probably gains access through a breah in the continuity either of the epithelium of the skin or of the mucous membrane of the nose bility of infection occurring by the ingestion of infected food has been seriously considered against this arc the facts, (a) that leprotic involvement of the gastro-intestinal tract is practically unknown, and (b) that in carly cases at least the mouth and pharynr are seldom affected Still there is no proof that the organisms do not enter through this channel without cousing a lesion The possia ·( 37 ) SLIDE No 33 Note relationship between closeness of contact and occurrence of leprosy BEO INFECTION HOUSE INFECTION ASSOCIATION CHART SHOWING RELATIONSHIP BETWEEN CLOSENESS OF CONTACT AND OCCURRENCE OF LEPROSY LEPROSY IS ESSENTIALLY A 'BED' AND 'HOUSE' INFECTION So far as is at present known, infection invariably occurs by prolonged and intimate contact with a patient in the infectious stage of the disease While this is the most probable mode of spread of leprosy other pos cable methods of transmission have to be considered (a) The hereditary theory - In pre bacteriologi cal days, the view was widely held that leprosy was transmitted by heredity even in the absence of a known bacterial factor, however, the data upon which this theory was based were not particularly sound Sincc the discovery of the specific organism by Hansen, the hcreditary transmission view has been entirely given up bv competent leprologists (6) Hutchinson s fish theory - Jonathan Hutchin con advanced the suggestion that the organism found its way into the body by the ingestion of contaminated and badly cured fish Further investigation quickly showed that the premises upon which the theon was founded were unsound and it accordingly fell into ·( 38 ) disrepute Curiously enough, however, recent work upon certain economic aspects of leprosy has shown that Hutchinson's theory in a modified form may not after all be very far from the truth (c) Insect transmiss101 -The possibility of insect vectors of leprosy has been considered by many workers It has been shown that the ordinary housefly may ingest large numbers of bacıllı 1 hen fed on infective ulcers, and that such bacıllı can be found in the intestinal contents of the insect for several days the causal organ ism has also been found on the feet of flies in similar circumstances These insects therefore my play some part, although it is probably a minor one, in the spread of the disease Blood sucking insects such as mos quitoes, bugs and ticks, have also been suspected from time to time, but sufficient evidence definitely to incriminate any of them has not yet been accumulated Workers in the Philippines have noted a strik ing correlation between the occurrence of leprosy and the presence of scabies not infrequently the appar ent primary lesion makes itself manifest on the site of a recent itch infection But until the incidence of scabies in the non leprous population has been esti mited, the acarus need not be too seriously considered summarise the present position as follows (1) The facts so far 1vailable go to show that leprosy is a rule is directly transmitted to a previously healthy person by prolonged and intimate contact with ? patient in an infectious stage of the disease (2) While the possibility of insect vectors must not be lost sight of much more evidence is necessary before one or more of them can be incriminated We may ·( 39 ) SLIDE No 34 This diagram shows the positions of the first noticed lesions in a series of over 1,050 cases from different parts of India Note the immunity of the scalp and the relative infrequency of lesions on the flexor surface of the neck and in the loin cloth area ato The first noticed lesion tends to occur on those parts of the body most exposed to trauma and irrita uion, eg (1) The extensor surface of the limbs These areas are subject to superficial abrasions and insect bites Moreover they are the parts of the body most com monly laine on at night and are thus most liable to conc into contact with infected bed clothes (2) The ·( 40 ) face This is a relatively common site especially in children here the true primary lesion is probably in the nasal mucosa as a result of scratching, the nose being frequently the seat of reflex irritation from intestinal parasites The facial lesion, although the first one observed, is probably the result of secondary spread along the lymphatics from the nose (3) The ears Consequent on their exposed position, the cars are susceptible to traumatic influences either as a result of changes in the external temperature or of insect bites (4) The feet In races who go about barefooted, and particularly where the ground is hard and stony, abrasions of the feet frequently determine the location of the primary lesion there On the other hand, there are certain zones of the body which are relatively infrequently the sites of early lesions such as the mid line of the body both bach and front, the concavıtı of the nech, and the loin cloth area of the abdomen The scalp, owing probably to the combined effects of its rich vascularity and its dense fibrous structure is practically never the seat of a primiry lesion

·( 41 )
SLIDE NO 35
This churt shows the percentage of cases infected
at the ages 11en (Indian Commission figures)
PERCENTAGE OF INFECTIONS
SEO
he
AGE IN YEARS
CHART SHOWING PERCENTAGE
OF CASES INFECTED AT THE AGES GIVEN
NOTE THAT OVER 80% OF THE CASES
DEVELOP BEFORE THE AGE OF 35 YEARS
Suscepibility to lepross caries with oge Child
ren and adolescents up to the age of 20 are much more
prone to the discrse than are adults
Above the age
of 20 while both seves 1rt of course fiected, males
outnumber females is the proportion of about to I
The reasons for the special susceptibility of children
710 probably onerse (1) the fine texture of the skin
at this period allows ea ils sngsess fo the organism,
(-) the very common habit of nose picking, the result
in many cases of reflet irritation from the gut, (3) the
physiolo,ical stresses to which the growing child is
subject especnlly at puberty, (4) the sntinite contact

·( 42 ) in which young children at least frequently live with their infective parents The well marked correlation between length of exposure and incidence of leprosy is brought out in studies of the children of leper fumi lies In a recent series of figures from the Culion Leper Colony (Philippine Islands), it is shown that of the children separated from their parents up to the age of one yeir only 5 2 per cent developed the disease, while of those allowed to remain with their parents' up to the age of five years, no less than 62 5 per cent became lepers ·( 43 ) SLIDE No 36 1 his curve shows the incubation period it is er tremely variable, but the average is between 2 and 4 j cars INCIDENCE OF CASES SHOWING SIGNS 3 1 5 7 1 2 INCUBATION PERIOD IN YEARS CHART OF INCUBATION PERIOD NOTE THAT THE AVERAGE INCURATION PERIOD IS FROM 2 TO 4 YEARS The incubation period of leprosy is difficult to estimate on account of the essentially insidious nature of the discise The sudden cracerbition of a hitherto unsuspected lesion may be the mains of drawing Attention to it so that the patient s cstimate of the appearance of the lesion may be totallı erroneous Various computations by different workers ranging from a few months up to ojcars hue been made but concerint11c etimate based on carefully inalysed series of cases place the probable incubation period at comcw here between two and four years In addition to the known bacterial agent (NI leprr), there are certain other factors which are coming to be recognised as of considerable importance in the causation of this dicense

·( 44 )
SLIDE No 37
Shons the relative importance of various secor
dary factors in the causation of leprosy Note the paa
played by syphilis
BAD F00D
SYPHILIS
LARIA
HOOK WORM
DYSENTERY
ALCOHOL
PAD MOUSE LAZINESS
OVERWORK
CHART SHOWING RELATIVE IMPORTANCE OF VARIOUS
SECONDARY FACTORS IN THE CAUSATION OF LEPROSY
SLIDE NO 38
Two empirical diagrams showing importance of
various secondary factors in the causation of leprosy
M LEPRE AND
M LEPRE
ALONE
ACCESSORY FACTORS
CHART SHOWING IMPORTANCE OF M. LCPR/C ALOVE AND
OF M LEPRÆ PLUS SECONDARY FACTORS IN THE CAUSATION
OF LEPROSY

·SLIDE No 39
Resistance to leprosy may be depressed by various
conditions This diagram shows some of them
LXTERNAL TRAUMA
INDOCA
IVSFUNC ON
KALNUTR I ON
Tad
ABONET ON
Mehr
MARITAHIN
1
DIAGRAM SHOWNG FACTORS TENDING
TO DEPRESS LOCAL AND GEXERAL RESISTANCE
TO LEPROSY
That the virulence of this organism is relatnely
los, and that it requires certain adjuv ints in order to
favour its growth and multiplication are shown by the
folloning facts
(1) Attempts ar cuituation of the bacillus out
side the body huse hitherto bocn uniform
ly unsuccessful

·(46)
(2) Efforts at the production of generalised
leprosy in the common laboratory ani
mals by the inoculation of material from
infective human lesions have also proved
abortive
(3) A few instances are on record in which
infective material from leper patients has
been deliberately inoculated into healthy
human beings--again with negative
results
The other factors may be grouped as follows
(a) Coincident diseases such as syphilis, malaria,
hookworm, hala azar, typhoid, chronic constipation
The association of syphilis and leprosy is relatively
common and efficient treatment of the former disease
frequently causes marked amelioration of the latter
even in the absence of leprosy therapy

·( 47 ) SLIDE No 40 The important part played by syphilis is brought out in these diagrams Cases of leprosy uncomplı Cated by syphilis do not give a positive Wassermann reaction when up to date serological techniques are cniployed A CASES O LEPROSY 200 POSITIVE KAHN 69 POSITIVE WM SLIDE (CHART) SHOWING COINCIDENCE OF „YPHILIS AS ESTIMATED BY THE KAHN AND WASSERMANN TETS IN 200 UNSELECTED CASES OF LEPROSY The debilitating effects of the other diseases men tioned above are sufficiently obvious, and it is quite a common occurrence for leprous lesions which have Intherto been lying quiescent to show marked progres sion during convalescence from one or other of these maladies (6) Dietetic factors - recent investigation on soil conditions h7 emphasised the indirect im portance of soil in determining the endemicity of leprosy It has been shown that in miny of the most henvily infected districts in Bengal the souls of an extremely poor quality ind the crops red thereon le insufficient even in ood years for the needs of the populace If we add to this unsatisfactory state of affairs the vagaries of the climate, particularls as regards rainfall and the conse quent non infrequent occurrence of famine conditions, It can readılı be appreunted that many of the inhabı + ·( 48 ) tants of the endemic areas live in a chronic state of semi starvation In such circumstances they depend for their nutrition, such as it is, on the very cheapest “ foods " usually of the badly preserved variety and quite commonly decomposed Modification of Hutchinson's original " fish theory" in the light of the above recently acquired knowledge shows that it contains at least the germ of truth Alcoholic excess favours the incidence and spread of leprosy as of many other diserses A certain village in Bengal enjoyed a period of unesampled prosperity during the Great War oking to a boom in the local shellac industry Many of the inhabitants spent a large part of their une pected wealth on the consumption of alcohol with the result that leprosy which previously had been relatively uncommon, spread rapidly through the populace (c) Certain economic and social factors, such as overcrowded and insanitary dwellings, dirt, and the purdah system also predispose to leprosy by lowering the general bodily resistance (d) More general causes of lowered vitality such as lack of exercise, overtorh, and mental stress also play their parts The first of these is probably the most important in the absence of sufficient and appropriate exercise, the internal secretory glands, and particularly the adrenals, do not function properly The threshold of immunity is therefore lowered and infection tends to occur True immunity to the disease probably does not eust, and serological tests established in order to de monstrate immunity or othenu ise have not given uniform results The gradual disappearance of the discase from Europe after the Middle Ages has been attributed by some workers to the acquisition of im munity A more potent factor was undoubtedly the spread of enlightenment With the gradual abolition of the Feudal system and the formation of more or less stable ·(49) governments, war became relatively infrcquent The hitherto climant necessity for salled cities with their inevitable consequences of over crou ding and dirt, became less marked The population was encouraged to distribute itself more evcnly throughout the country and opportunities presented themselves for pursuing the arts of peace, including agriculture I he only type of immunity in leprosy of which we 1re at present cognisint is that occurring during a cer tain stage of the discase As will be expl uncd more fully in another lecture, reactions occurring during the third stage of the diseasc are followed by dissemination of baulli throughout the body and by the occurrence of fresh lesions Such lesions are howcier temporary and their transient nature can be cyplimed only on the assumption that the piticnt has acquired 1 certun degree of immunity While duration and intimacy of contact 1re of Great important in determining the transmission of Icpro from discased to 1 healthy person the degree of infectiin or othenuse of the former is of consider able significance When the question of clinical signs Is discussed it will then be renlised that different stages of the discuse ire not equilk infective It may be stated generally that durin. the initial and the term and stices of the disease the degree of infectivity is relatnely slight ind in many cases nul ·( 0 ) SLIDE NO 41 Not every case of leprosy is equally infective Note the large number (nearly go per cent) of early non infective Ai cases CASES 99 CASES CASR CBW CASES AN CASES 1$ SLIDE (DIAGRAM TO SHOW THE PROPORTION OF INFECTIVE TO NON INFECTIVE LEPERS IN 200 UNSELECTED CASES FROM THE OUT-PATIENT DEPARTMENT AT THE SCHOOL OF TROPICAL MEDICHE, CALCUTTA SHADED GROUPS INDICATE INFECTIVE CASES UNSHADED NON INFECTIVE CASES of 300 consccutre It is at the half way period that the patient 15 often a menace to his associates As stated at the beginning, leprosy is a relatively non fatal disease per se in a cesses Futopsies at Culion (Philippine Islands) analyced by Pineda in only 7 was death attributable to lepron) fatal issue is due in the creat majority of cases ** secondary or complicating conditions of which the core monest are tuberculosis, nephritis and generalised am loid disease

·( 51 )
NCIURI III
PATIIOLOGY
SI IDE NO 42
to
Leprosy is a chronic disease liused by the presence
of 1 bicillus Icpric (Hansen), in certain tissues of
the body In its ordinary vegetatic phase the organ
ism appears as a uniformis stained rod, strught or
shyhtiv cured and varying in length from 1
9 micron The bacıllı tend to aggregate
together like bundles of cigars they are diffi
cult to stun but once this process has been
accomplished they resist with considerable tenacity
the notion of powerful decolourizing agents such
strono
mineral acids Organisms possessing
this property arc referred to as nud fast and the
following 10 the most important members of the
group
(a) the tuberclc bacıllı-human bounc and
14
a1 1311

·( 52 ) (b) the leprosy bacıllı--human and rat (c) the smegma bacillus (d) certain saprophytes found widely distributed in nature and recoverable from such substances as grass, stran, butter and milk SLIDE NO 43 Shows resistant forms of M leprac Note the coccold and diphtheroid varieties Those types are seen particularly when the resistance of the patient to the disease is rising DCGENERATIVE FORM OF M LEPRE. Note the Diphthero d Cocroid and spore like forms. Leprosy bacıllı possess considerable pleomorphism and in addition to the uniform rod like appearance described above, coccoid, diphtheroid and spore like forms are frequently seen such varieties are probably of the nature of resistant forms and are especially com mon when the environment is unfavourable to the organism, eg during active leprosy therapy

·( 53 )
Very many attempts have been made to culture
the leprosı bacıllı—both human and rat—but in spite
of extended trials on many different kinds of media,
the general consensus of opinion is that these or
ganisms have not yet been definitely grown Animal
inoculation cyperiments in the case of the human
variety have also proved unsatisfactory different obser
vers have succeeded in producing transient lesions in
monkeys by the inoculation of human material, but
anything in the nature of a general infection in this
or any other common laboratory animal has not yet
been 1ccomplished A Japanesc worher claims
to huic produced the diseise in 18 out of 24 dancing
mice by the inoculation of human leprosy material
thcsc results an ut confirmation In the case of rat
Itprosy the disease can be transmitted to other rats
bi intraperitoneal inoculation, by subcutincous injec
tion and cren by simple scanfication of the skin
White mice are also capable of being infected by the
rt strun but lumea pigs and monkeys are immunc

·( 54 ) SLIDE NO 44 Shows how leprosy spreads from an initial lesion through the body DUGRAY O SPREAD OF LEPROSY THROUGHOUT THE BODY In tal Les on (Nrvo Ending s mourd MA Mur wembwe IN Tunt Wy Malam yer SK S Muous androme) rod ?scular spread re- spread Spread by en klation Shin Lesions These have their ongin in 7 point of infection resulting either from (1) zbrusion of the superficial epithelium or (2) bicillary embolism of a capıllary blood vessel The epithelium is not primarily involved -the disease in the first instance is essentially one of the corium ind implication of the more superficial layers is secondary When the leprosy bacillus lodges in the coriun it leads to the formation of granulation tissue microscopic examination there is found dilatation of capillary blood vessels, some oedema and considerable cellular infiltration Ihe cells are of different kinds, (a) young connective tissue cells (fibroblasts), (b) small round cells resembling lymphocytes, (c) large cells with vacuolated protopiasm und vesicular nuclei the so called "lepra cells," (d) occasional 'giant' cells on

·( 55 )
SLIDE No 45
Section of normni shin Note the well formed
papillr of the corium there are relatu ely few cells
in the latter arc.
NORMAL SKIN
154
St ne ! 11 mat 1&2

·( 56 )
SLIDE No 46
Section of early leston (low power)
Notice the flattening out of the papillæ of the
corium and infiltration of the latter by numerous cells
of different kinds
THE
SECTION OF EARLY SKIN LESION
LOW POWER
STAINED HAEMATOXYUN W EOSIN

·( 57 )
SLIDC No 17
Section of early skin lesion (high power)
Note, the large cpithelioid cells which form Icpra
cells
THE SECTION OF EARLY SKIN LESION
HIGH POWER
Sta ed Ilxmat
10&Fin
ing cells
Application of various methods of intra vitam
stainınhas apprentis demonstrated that the 'lopra
<cll 15 derised from the so called resting wander
Or histiocytes which are normally
present in the corium and subcutancous tissues 1 hese
histiocytes are essentially phagocytic in nature-they
are probably included in Metchnikoff's 'macropha
Les ind ire now adıys grouped with the hupffer
cells of the Inter and the cells lining the lymphatic
sinuses of lymph lands and spleen under the com
prehensive icrm reticulo endothelial sistem I hc
bacıllı arc in general intracellular and in appropriately
stained sections can be seen crowding the lepra cells

·( 58 ) SLIDE No 48 Three types of lesions of corium are shown diagrammatically as is also the "A," or early nerve lesion and the normal skin Di gran mahc Repr ser lation of ile Skinn Differe ! Stages of Icprosy MA fronte Alle Now the CC (W FMP ARY CR -Apur new 1 "Do TOYL KAR E PIC 31 CCT ON Sve ER Y W MERLO LEAN ལང་པའི་ ག་ Lesions of the corium are divisible into 3 sub types (a) Pupillary (b) Interfollicular, (c) Subfo! liculur ·( 59 ) (a) Papillary -As the name indicates, there is in this variety involi ement of the papıllary layer of the corium re thc 101 of corium immediately underlying the basıl layer of the epithelium The bacıllı are usually relatively fell in number and the infection spreads radially parallel to the skin surface Granu lation tissue is formed here is elsew here this in time becomes organised leading to obliteration of the corrugations of the papillæ and of the interpapillary spaces Resulting from this there is considerablc thin ning of the epithelium which becomes well marked after the process of resolution is completed (1) Interſollunini – In this form the brcıllı have invaded the liver of corium lying betucen thc hair follicles such intolvenient may occur primarily or be the result of 1 downward spread of previous papil Inry type The bulls are much more numerous than in the variety described above and the clinical appear inces are distinctive The natural folds of the shin are criegeritud and deeper than normal and the intcr vening areas of sl in stand out in relief This is duc to the adematous tissue tending to crust upward swelling of the conum this cxelling being resisted by the tension of hair follicles and suent ducts () Subfollenla -Here 1 still decper zone of corium is involved the portion lying below the hur follicles in this subtype the natural folds of thic shin tre obliterated and the hur follicles and their ippendages 1re in time destroyed Consequently when resolution thes place the skin is thinncd out, dry and burles presenting an appearance like crushed tissue paper While clear cut examples of one or other of thesc sub varieties mas be found, they tend to meric thic onc into the other The mode of spread from 1 primary focus is determined by the depth of this lc ion in the Where the superficial part of the corium coriumi ·( 58 ) SLIDE No 48 Three types of lesions of corium are shown diagrammatically as is also the "Ai "or early nerve lesion and the normal shin D: 97anman Repr sertation of Me Sko in Differe i Stages of Leprosy ACA A 17 (W FAP ARY f I FT OY TEHFX CLAR mu E VFB TO S YS WAVE LADY Papa Lesions of the corium ire divisible into 3 sub types — (a) Papillary (b) Interfolliculis, (c) Subfol licular ·(59) (a) Papillary - 4s the name indicates, there is in this variety involvement of the papillary layer of the corium re therrer of corium imniediately underlying the basal laver of the epithelium "The bacıllı are usually relatively few in number and the infection spreads radiallı parallel to the skin surface Granu lation tissue is formed here is elsewhere this in time becomes organised leading to obliteration of the corrugations of the pupille and of the interpupillary spaces Resulting from this there is considerable thin ming of the epuhelum which becomes tell muthed after the process of resolution is completed (6) Interfolheular - In thus form the bacıllı have invaded the later of corium king between the hair follicles such involvement may occur primarily or be the result of 1 downward spread of a previous papil Fary type The brulli nre much more numerous than in the sancty described above and the cimical appear inces are distinctive The natural folds of the shin arc exiggerated and deeper than normal and the mer vening dreis nt shin stand out in relief This is due to the ædemitous tissue tending to ciusc upward stelling of the corium thuis selling being resisted by the tension of hair follicles and suent ducts (c) Subfolluarai - Here 7 stull deeper zone of conium is involteu la the portion lung, below the har follicles in this subtype the natural folds of the shin tre obliterated and the hair follicies and their ippendages Tren time destroyed Consequently when resolution takes pince the slin is thinned out dry and hairles, presenting an appearance life crushed fissue paper While clear cut emples of one or other of these sub varieties may be found, they tend to merge the one into the other the mode of spread from 1 primary focus is determined by the depth of this lesion in the Corium Where the superficial part of the corium ·(60) drained by the superficial lymphatic plexus is involved, a radial centrifugal spread tends to occur, on the other hand, infection of the deeper layers of the conium with corresponding implication of the deep lymphatic plexus results in centripetal spread and nodule formation, a condition presently to be described SLIDE NO 49 Lepreus insitrailen of the skir Notice lepra bicilli scattered through the tissue Many of the organisms uc intra cellular LEPROUS INTILTRATION OF NE SKIN Stained Ziedi Neelsest ·( 61 ) SLIDE No 50 Shows lepri cells containing many bacıllı these cells are probably derived from the reticulo endothelial system HUMAN SKIN LUMEX ENDOTHELJAL CELLS &ULGING INTO OF SMALL BLOOD VESSEL AT & BACILLI THE LEPRA CELLS

·SLIDE NO 51
Herc the lepra bacıllı are seen inside cells and
some in the lymph spaces of the contum An cpithe
Isal process appears in the upper part of the slide
In typical chronic spreading lesion three zones
pre usually discernible (a) an outer flat depigmented
arca, (b) a middle, rassed and somew hat erythematous
zonc, (c) a flattened and depigmented central zone
These appearances are explicable is follows - (a) is
due to interference with the capillary blood supply
The normal pigment of the skin (melanin) is formed
from substinuis probably of an amino acid nature),
brought to it in the blood stream Interference with the
Vascular supply therefore causes the appearances
described (6) results from infiltration by vascular
granulation tissue together with ædema and flattening
of the papıllar, while the central area (0) 19 a conse
quence of fibrosis and cicatrization

·( 63 )
SLIDE NO 52
Shows the lymph gland of in artifically infected
rit crammed full of rit leprosy bacıllı
Stai d Flrtatoxyl n and Carbol ruchsn

·( 64 )
SLIDE NO
53
This microphotograph of 1 hunian lymphatic
glind from the groin shows the germ centres of the
lymph nodes overrun with lepri cells
Lepra Cells at Edges of Photograph

·( 65 )
SLIDE NO 54
Normal skin is seen on the left with nodule on the
right Note obliteration of papıllı and infiltration
of cells
EDGE OF LEPROSY NODULE
ST INED MEMATOXYUN AND EOSIN
***

·( 66 )
IDI \"
lain semular fith (to 100 *
M1, alori muthed 1 pr by j11-27.-
Henjut se}}} Othyran int
ILC EST NASIL
1

·( 67 ) (b) the metastatic I he former is the result of "preid from 1 lesion of the corium, frequenth of the papillary subtype, into the sensory nerve endings and so along the neric trunks In the latter, infection reaches the nerve tiunk is 1 result of bacillary embolism of the vast nervorum of the perineurium Further extension results from the organisms pass ing up and down the lymph channels in the connective tissue sheaths of the nerves In both these there iesults formation of granulation and later of fibrous tisstic the true nerve elements are constricted and if this pressure continues long enough, the avis cilinders are de troyed ·( 68 ) SLIDE No 56 Shows one of the methods in which nerves may be involved-namely by the implication of the fine terminal filiments lying in a discased area of corium OTAGRAM OF ASCENDING NERVE LEPROSY Ascending nerve lesion Normal skin Muscle WILLEM NITE In association with nerve lesions there is constantly found a series of trophic changes affecting particularly the skin and its appendages and giving rise to such con ditions as anhydrosis, anaesthesia, hyperkeratosis, stunted broken hairs, claw like nuls, trophic ulcers

·( 69 )
A curious inter relationship exists between shin
and nerve leprosy
(I) The greater the involvement of skin, the less
the implication of nerves and vice versa
(2) Nerve lesions are associated with comparative
paucity of bacıllı, and (3) as a corollary of the last
statement, nerve lesions predominate at the beginning
of the disease when there are relatively few bacıllı in
the body, and also at the end when the organisms are
diminishing in numbers The reason for this inter
relationship is not known, it has been suggested that
there is a non acıdfast form of M leprae which has a
special affinity for nerves

·SLIDF No 57
Shows the inter relationship between skin and
nerve leprosy
Illustrating the balance between Skin and Nerve Lep o v
SKIN
NERVE
LEPROSY
EP SY
SKIN
NERVE
CM
NERVE
SKIN
MERYE
AS SKN LEPROSY INCREASES
NERVE LEPROSY TENOS TO DIMIN SH
AS EK N LEPROSY OM SHES N RVE
LEPROSY TENDS TO INCREASE
Certain nerves are more constantly affected thin
others their order of frequency is roughly as follons
Ulnar, great auricular, external peroneal,
radial, and less commonly the facial and
supra orbital neries

·( 71 )
SLIDE No 58
Shows the destruction of cornea by leprosy
Lesions of the Eye-Lesions of the eye in leprosy
result either from the actual presence of bacilli therein
or from interference with the neri e supplies to the
»

·( 72 ) eye and its surroundings The former type of lesion 15 secondary to lymphatic spread from a focus in the neighbourhood permeation along the small capıllary blood vessels is less common and direct inoculation of bacıllı into a wound of the eye ball is extremely uncommon Various clinical appearances are present ed depending on the depth to which the infection penetrates (a) in the most superficial variety the picture is that of conjunctivitis (b) this may go on to infiltration of the cornea by sranulation tissue-pannus --which on resolution leaves the ground glass like opacity of the cornea seen so typically in syphilitic infection (c) the various components of the uveal tract may be involved, and iridocyclitis follow Primary implication of the retina and of the optic nerve is rare Eyc lesions may also follon from interference with (1) the superior maxillary division of the 5th cranial nerve, (2) the orbital branches of the 7th cranial nerve The former nerve contuns the trophic fibres to the eyeball and where these are thrown out of action there is loss of corneal sensation, 1 tendency for foreign particles to lodge on the eyeball with corresponding liability to corneal ulceration Lesions of the 7th (facial) nene cause paralysis of the orbicularis oculi, with consequent ectropion and similar liability to corneal ulceration Lesions of the Lungs --The lungs are not infre quently implicated in leprosy The presence of acid fast bacıllı in the sputum at once raises the question of diagnosis between leprosy and tubercle The micro scope is of little value in making the differentiation this can be arrived at in two ways (a) inoculation of the infectie material into guinea pigs In the case of tubercle the animals develop an acute miliary in fection terminating fatally while in the case of leprosy no lesions result (b) The second mode of differen tial diagnosis is the therapeutic one leprosy of the lungs clears up much more rapidly under treatment than does tubercle

·( 73 )
SLIDE No 59
Temperature chart from a case of leprosy of the
lungs
The {fety stand thenompot on the
MIT
15
ON
25
I
.
ht
THE
Sometimes however, tuberculosis and leprosy of
the lungs exist side by side
Lesions of the Abdominal Organs --Leprotic
involvement of liver and spleen is occasionally found
and definite lesions of the lymphatic glands in the
hila of both organs are furls common in relatively

·( 74 ) cises acute cases In the terminal stages of advanced cases, there is clinical evidence of eitunsive derangement of the abdominal visceri this is, however, the result of amyloid disease rather than of leprosy per se Lesions of the gastro intestinal tract are rare Lesions of the Testicles --The testicles are very commonly affected in leprosy particularly in nodular Contraction of the scir like tissue destroys the true testicular elements an 1 result, sterility is a coni mon symptom Lesions of the Ozales and Uterns are uncommon Psychic disturbances ---1he slowly progressive course which leprosy pursues in the absence of effective treatment together with the social ostracism to which patients are commonly subjected lead to mental dis turbances in a certain proportion of cases the com monest of these is melancholii Pathology of Renctions ----Leprosy reactions are characterised by fever erythema, the swelling up of old and the appearance of new lesions They may result from the administration of drugs used the treatment of the disease or they may be second ar to the onset of some other disense such 18 milina However caused they are consequent on 1 temporary lowering of resistance Iwo views have been advanced to eiplun the intimate c?use of renctions (a) They are due to the breaking down of leprous grinulation tissue with setting free of touns in the blood (b) They are inaphylactic in nature As will be explained in other sections, they my be either bencher or the reverse, depending upon the ti,e of the disease in ·( 75 ) ICC IURE IV DIAGNOSIS As a result of the advances in therapy made within thc lut funt vers the medical profession, and to ? lesser atent the 133 public int beginning to regard leprost not is 1 terrible intriction beyond the aid of humın endeavour, but 18 1 discase which in a large pr)poitini of (ises can be illeviated if promptly dia, no ed ud effectively treated The importance of Telo, nising leprost in its earliest stiges t innot be over emphasised Many of the insi,hth deformities which result from lepro and which to the general public at least constitute its most terribic feature, could be obuted if the disease Here dinosed early ind treated promptly ind effectively А consulerable proportion of the cirly cases also non intective and therefore continue at lock while under oing treatment y mental solace the value of which is very considerable The unfimi lirit with the enrliest manfestations which has bithcr to custed among medical men to cther with the ruulsion experienced by the general public at the more mention of the disc7c huve led to the concealment both involuntari and othertise, of many cases Althou,h the 1921 Census gile the number of lepers in India is slightly over 100 000 it has been estimated th it there ire probabli netrly ten times this number I he tho cardinal points in diagnosis are (1) the finding of Icpra bacıllı in the skin or mucous membrane, and (2) the presence of superficial intsthesia are can

·( 76 )
SLIDE No 60
Clipping of Ear
100
EAR NIPPING FOR DIAGNOSTIC PURPOSES
(1) The finding of lepra bacıllı in the skin As
explained in the section on pathology, the epithelium
of the skin is not primarily implicated scrapings of
the skin surface are therefore useless from the diagnos
tic point of view A small clipping of skin sufficiently
deep to involve the corium is taken from an infiltrated
area

·( 77 )
SLIDE NO 61
Stalning of Silde
STAINING FOR
ACID FAST ORGANISMS
CK
C
NR
I hc cut surface is rubbed on 1 slide and the smcar
stained by Ziehl Neelsen's method the presence of red
stained bacıllı in clumps and singly is diagnostic
Certuin obvious precautions huc to be taken---the skin
must be sterilised and the scissors and microscopic
slide flamed to prevent possible contamination by
saprophytic acid fast organisms Where the face is the
seat of lesions, scrapings of the nasal mucosa, or more
simply swabs from its surface frequently yield positive
results

·( 78 )
SLIDL No 62
Testing of Anaesthesia
and
The
(2) In errly cases where nerve symptoms and
signs predominate, bacıllı ve relativelt few in number,
and diagnose rests primarily on the presence of the
second cardinal sign, superficial anesthesia
only prictical method of eliciting superficial anæs
thesia, is to have the patient stripped as far as necessary,
ind blindfolded Various parts of the body are then
lightly touched with a strip of folded paper or ? Wisp
of cotton wool and the patient is asked to lay his finger
on the part touched The presence of inästhes i in
any particular zone is determined by the patient farling
to indicate that area when it is stimulated as described
Not infrequently prior to the onset of anesthesia,
variations in sensation either of the nature of hyperacas
thesır or of paresthesi? cin be detected The
presence of anesthesia ind of lepra bıcıllı are usually
mutuallı escluse in any particular zone bacterio
logical crimination of 1 shin clip from an inesthetic
pitch is therefore 1 useless procedure

·( 79 )
I hese are the c?rdinal signs of leprosy and they
alone justify an absolute diagnosis of the discase there
are, however, certain subsidiary signs wluch taken in
conjunction with the patients personal ind family
history, the endemicity or otherwise of his native place,
cte, mis suggest the possibility of leprosy
The more important of these manifestations are —
(a) Deep analgesia - In the deeper types of skin
lesion this mii bu found, although there is no alteration
In superficial sensation in such circumstances the
patient does not record as painful stimuli of the nature
of 1 pin prick or a cut with a hoife

·( 80 )
SLIDE NO 63
Testing for Thermal Sensation
(b) Thermal anaesthesia may often precede
superficial anaesthesia and is always present in
A2 lesions --It often leads to patients burning their
fingers or toes while cooking It is tested for in the
usual way by means of test tubes containing hot and
cold water

·( 81 ) (c) Depigmentation ---This is a very common and suspicious sign and it is usually associated with anesthesia It is naturally a much more striking ferture in Indian that in European patients The loss of pigment is a partial one and is not comparable in degree to that seen in leucoderma (d) Erythematous patches --In an appreciable proportion of cases, this is the first lesion noticed by the patient where the erythema is widespread, one of the cardinal signs is nearly always 2ssociated (e) Thickened nerre trunks-One or other of the superficial nerves is frequently thickened in nerve leprosy those most commonly involved are the ulnar, the cxternal peroneal, the great auricular, the radial and less frequently the supri orbital and the facial () Hyperkeratosis and parakeratosis with irregularities in growth of the hairs are not uncommon especially in nerve cases from interference with the trophic fibres in the nerves (9) Anhydrosis in isolated patches of skin fre (quently precedes the onset of anesthesia in the same patches there is commonly 7 compensatory hyper hydrosis of the normal shin in the vicinity .. (1) Trophie blisters and later trophic ulcers 210 Tery common in leprosy (1) Nfore indefinite symptoms such as dry rhinitis, ligue nerve puns, and fugitise pireya are often met with in the early stages of the disease Differential Diagnosis - Leprosy has to be dis tinguished from certtın other diseises which simulate it icry closely Of these the chief are the following

·the hahn precipitation test 24 carried out by th On
Photo of Kahn Test Materials
seldom 15 leprosy The Wassermann reaction and
( 82 )
SLIDC No 64
(1) Syphilis - This most frequent cau es
confusion in the secondary stage the serpiginous and
erz thematous lesions of the skin resemble lepros: The
presence of other manifestations of this stage of sphilia
such as mucous patches on the cheeh, mouth and
throat, alopecia, and its together with a fairly pro
nounced degree of secondan anamsa, helping
diagnosis It 25
worth remembering that the
scalp 15
frequenth insolied
in philis but

·( 83 ) naturally, the two cardinal signs of leprosy are absent Not infrequently the two diseases co exist, and until the spriochạtal infection has been got rid of, little improvement in the leprotic condition can be hoped for, even in the presence of the most active antı leprotic mcasures SLIDC No 65 Picture of Psoriasis

·( 84 )
SLIDE No 66
Section ol the Skin in Psorlasis
(2) Psoriasis - The involvement of the scalp, to
gether with absence of bacıllı on bacteriological ex?
mination ind of antsthesia are the most useful
differentiating features betw cen leprosy and psoriasis
Sections of the skin in psoriasis show exaggeration of
pipilir, and of the interpapillary spices, whereas in
Icpro»y the popullr are flittened

·( 85 )
SI IDE No 67
Picture of Tirea
(3) Various forms of Tinea
(a) Tinen i ersicolor - I his affects principally the
face and front of the chest producing ? partul dupig
mentation I vininition of scrapings from the shin
surface reveals the presence of the microsporon furfur
characterised by long mycelium and grape like
branches of spores
(b) Tinen flata - Involves particularly the face
and checks The mycelium is small
(c) Tinea Cruris --Implicates especially the
groins
(4) Syringomyelia --The wasting of the thenar
and hypothenır eminences together with the sensory
disturbances present in this disease may cause confusion
with nene leprosy Loss of superficial sensation is not,
however, a prominent symptom whereas heat and pain
sensations are early ind conspicuously deficient

·( 36 )
SLIDE NO 68
Picture at Tubercullde
ܚܦܫ
(5) luberculous lesions of the skin - The com
monest of these is lupus vulgaris in which the corium
is studded with little collections of tubercle follicle
Which on aggregation form small nodules The
absence of the two cardinal signs serves to differentiate
this disease from leprosy

·SLIDE JO 60
Picture of Raynaud s Disease
(6) Raynaud s disease -- I his may cause confusion
with neric leprosy on account of the glove like distri
bution of the lesions I here is however no an tsthesia
except in parts which live actually become gangrenous,
of which stage the dia, nosis is usually obvious

·( 88 )
SLIDE NO 70
Dermal Leishmanlasis
w
(7) Dermal Leishmaniasis --A form of this
disease is not uncommonly seen in patients who have
either suffered from a previous attach of hala izar or
Who have come from a kr11 1211 endemic area
In its

·( 80 ) earliest stage it takes the form of small, flat partially depigmented spots about the chin, front of the chest, and arms While smears from one of the eicised spots may be negative, Leishman Donovan bodies can fre quently be cultivated from them In addition to the above mentioned skin diseases there are certain others which are intimately associated with dysfunction of one or more of the ductless glands SLIDE No 71 Leucoderma (1) In cases of overfunction of the adrenals, there is depigmentation of the shin-the condition known as leucoderma The dep1, mentation is more marked thin in leprosy and it occurs on parts of the body where

·(90)
pigment is normally small in amount, eo, the palms,
coles and muco cutaneous junctions The disease
starts at one point on the body the herald spot-and in
the absence of treatment, a scrond spot soon appears
at 1 corresponding site on the other side of the body
Various types are described according to distribution
about 25 per cent art syphilitic in ongın
There is
no anästhesia, thichening of nerves, or other sign wu
gestive of leprosy The congenital form (albinism) is
occasionally seen such 1 condition is obvious
SLIDF No 72
Picture of Ichthyosis

·(91)
SLIDE NO 73
Section of skin in Ichthyosis
ICHTHYOSIS HORNI LUCT I\CT CASED RETE THIN
Sta ned llant
1 Еп.
(B) Where the thyroid glind is defective in
function, various skin conditions oucur in all there is
hypertrophy of the skin, and the appetrance of the
lesions varies according to the level at which this hyper
trophy occurs (1) Hypertrophy of the most super
ficial layers causes a dry harsh fish scale lhe appearance
of the skin, the condition known as ichthyosis

·( 96 ) SLIDE No 77 PROGNOSIS AI Most favourable Bi Less favourable B2 Still less favourable B3 Take longest to cure A2 Bacıllı dying out but deformities remain Diagnose & Treat Early From the patient's point of view this is naturally a most important subject In a disease such as leprosy regarding which so much is still obscure, and for which no specific remedy has yet been discovered, prognosis is necessarily a difficult matter but while this is so, certain general statements can be made (1) The presence of a recognisable and remediable predisposing cause makes for a relatively favourable outlook. As previously noted, cases of leprosy complicated by syphilis often clear up remarkably when the latter infec tion is overcome, and this even in the absence of leprosy therapy The same holds true for other predisposing causes of similar origin, such as malaria, hala azar, typhoid, hookworm infection, etc (2) Recognition of the disease during its earliest manifestations and prompt and effective treatment at this stage naturally offer a much better prospect of cure than the reverse condi tions Cases of the "AI" class are therefore most hopeful in the "Br" category the outlook is also fairly hopeful, while "B2" and "B3" cases are least favourable Even in the last two groups, however, a relative cure is possible in a proportion of cases but treatment must be prolonged In the "A2" group the ·measure ( 97 ) prognosis regarding leprosy itself is good when this phase has been reached the disease is tending to die out Little improvement can however be looked for in such deformities as contractures and trophic ulcers Such lesions represent the ravages left in the wake of the disease and in the great majority of cases they are permanent in nature The importance of impressing on a patient that his ultimate welfare or otherwise depends in no small on himself cannot be over emphasised Hydnocarpus oil and other drugs can do little by them selves in the absence of such essential adjuvants to treatment is appropriate diet and exercise I he rôle of the latter in stimulating the internal secretory glands, eliminating waste products and raising the general resistance of the body has already been alluded to The "Will to get better' is very important and strong determination of the patient is necessary for recovery With regard to early ("Ar' and "Bi ') cases a reliable history of the course of the disease prior to the patient coming under observation will often prove an indirect guide in forming ? prognosis Where, for cximple, 1 depigmented patch, the only discoverable focus of leprosy in the body, has remained the same size over a period of years, it is obvious that the natural resistance to the disease is relatively high and therefore the outlooh is correspondingly more favourable Certain other factors play their parts in this important subject (1) The age of the patient other things being cqual, the outlook for middle aged patients is better than those advanced in years The various excesses incidental to youth frequently have an accelera ting effect on the course of the disease the tendency to the acquisition of the diserce becomes progressively less 18 curs advance (2) Climatic and sanitary curround 11> Leprosı patients do better in a dr) temperate climate thin in 1 moist and hot one The importance of sinitary surroundings is obviou

·No text on this page.

·( 99 ) DICIURI V TREATMENT SLIDE No 78 Letter press on divisions of treatment TREATMENT OF LEPROSY GENERAL 1 2 I'reat accompanying diseases such as syphilis, worms, malaria, other skin diseases, dysentery, consti pation Attend to the diet 3 Fxercise is very important 4 Hygienic and climatic conditions should be favourable 5 The mental factor is very important SPECIAL fodide treatment orally Injection of hydnocarpus oil or its prepara 1101S 3 Fiternal applications such as trichloracetic ncid + Surgical treatment when indicated I 2 I reatment may be divided into General and Special In 1 chronic disease like leprosy in which we have not as yet any drug which can be described as a specific, the greatest emphasis must be laid on the importance of the general resistince of the body to the causal organism In an endemic country very many people are infected with leprosy, but very few of these cier shox any signs of the disciscind there is reason to believe that in a certain proportion of those who do de clop signs these are very slight and disappear again of their own accord without attracting the atten tion of the patient Leprosy differs from tuberculosis ·(100) in that experimental animals cannot be infected with it, It is probably true that healthy human beings share with the lower animals a natural immunity which is sufficient to prevent the development of the disease except when there are massive infections such as are likely to take place if there is close and prolonged contact with a "B2" or "B3" case It follows therefore that if leprosy does develop at is due to a lowering of the general resistance by some other accompanying disease, to some defect in the diet, or to some other circumstinces connected with the patient's life In treatment therefore the first endeavour of the physician must always be to find out and remove what cver cause has lowered the general resistance and land the patient open to the attack of the lepra bacillus dccompanying diseases - In India syphilis is per haps the most important The physician should never lay much stress on the specific history Syphilis is very often hereditary and there may be no signs noticeable which indicate the presence of this disease It is advisable in every case of leprosy to perform a serological test for syphilis The Wassermann test is not always available and is only reliable when perform ed by those who have great experience

·(101)
SLIDE No 79
(hahn Test )
KAHN TEST
06
5
NEGATIVE
STRONGLY POSITIVE
I he Kahn test however, is comparatively easy and
there is reason to believe that its results are more to
bc sclied upon in leprosy than those of the lissermann
No animals are necessary and with sonie experience and
care ro to 20 ser can be tested in two hours The
apparatus is shown in this slide and int slide
No 64 and onsists of 1 rick containing 75
cm
Icm dian test tubes 3 Pipettes, a kitter
bath with a gas or spirit flame ind i centigrade
thermometer the antı, en ind i fes larger test tubes
for titrition in another rack (A demonstration of the
test should be arranged for by the lecturer)

·(102)
SLIDE No 80
(Picture of Anti syphilitle remedies )
ANTISYPHILITIC REMEDIES
to be wd who ml
kenre la
ENDLA
VERYL
LOS PR
lod (BP
Ye
The most effective treatment for syphilis is a triple
one using (1) Novarsenobillon si doses increasing
from 30 to 60 centigrammes given once a week intra
Venously, (2) Bismuth suspension intramuscularly once
a week, and (3) Ung Hydrarg inunction daily
When si arsenic ind bismuth injections have been
given, the anti syphilitic treatment should be suspended
for a month and then the Wassermann or hahn test
If still positive, another course should
be given similar to the last
There is sometimes danger of producing a
dangerous leprous reaction when arsenic preparations
?re given intrni enously and care must be taken to avoid
thıs, especially in the second stage, 1 e in “Br" and
"B2cases
taken again

·the curve, ( 103 ) A combined treatment of leprosy and syphilis is given by injecting o 25 per cent solution of avenyl in hydnocarpus oil or esters In treating accompanying syphilis with arsenic preparations special care must be then in "Br" und "B_" cases which are passing up othersy ise leprous reactions may be pro duced which will cause a further spread of the disease In such cases subcutaneous injections of sulfarsenol are safer than intrivenous injections of neosalvarsan Malaria is another common cause of the lowering of general resistance 15 are ankylostomiasis and other worm infections, and these may cause development of leprosy in its early stages Malaria on the other hand may cause rapid improvement in "B3" cases, as it causes breaking down of large numbers of lepra cells and the contents of these, when set free indule tempor arily a state of high specific immunity which causes rapid destruction of the lcprous infection The same holds good for such febrile diseases as hala izar, enteri smallpos, etc. they cruse the spread of leprosy in cases which are passing up the curve by lowering the general resistance, but induce rapid improvement in "B3" cases which have reached the top of the curve or are coming down

·( 104 )
SLIDE No 81
(Diet Silde)
DIET
IN PREVENTION & TREATMENT OF
LEPROSY
IN THE PUNJAB WHERE THEY EAT THIS DIET THERE A PRACTKALLY HO LEPROSY
WHOLE
WHEAT BREAD
MILK
1 TO 2 SEERS A DAY
FOR THE ADULT
BUTTER IS
BETTER THAN OHEE
VEGETABLES
STEAMING OF VECETABLES
PRESERVES ALL THE FDOD
IN THEM
DALL
FOOD MUST BE FRESHLY PREPARED - NO STALE
OR PRESERVED FOOD MAY BE EATEN
FOOD MUST NOT BE RICH OR OVER COOKED
DO NOT OVER EAT — HAYE RECULAR MEALS
EGGS ARE GOOD FOR THOSE WHO CAN TAKE THEM MUCH
MEAT OR FISH IS BAD IN A HOT CLIMATE
Diet -As there is reason to believe that diet has
in important bearing on the incidence of leprosy this
must be carefully regulated

·( 105 ) Food must be fresh Tinned and salted or other wisc preserved foods should be avoided Over cooked, recooked, highly spiced and stale foods are all harmful Ment and fish should be fresh and taken only in small quantities No food which is known to be difficult of digestion should be taken Fresh vegetables should be caten freely, especially those that can be eaten rais--such as lettuce and tomatoes Vegetables should not be overcooked Plenty of fruit should be eaten Fresh dairy produce, milk, butter, eggs (rau or only slightly cooked) are very viluable Too highly milled rice ind grun should be avoided, as the part removed by over milling has valuable properties Various pens, lentils and beans are uscful articles of diet Alcohol should be ab olutely noided Tea, coffee and tobacco, if indulged in should be restricted to moderation Equally important with the nature of the diet is the amount eaten and the way in which it is eaten Leprosy is 1 disease of famine lack of nourishment lowering the resistance of the body But it must be remembered that excessive eating is also decidedly harmful and the patient should um at still feeling hungry when he has finished his meal Menis should not be hurried and plenty of time should be taken to masticate cach mouthful thoroughly A short rest before and after meals ts ndi antageous ·( 106 ) SLIDE No 82 Exercise Exercise -Suficient, well regulated exercise is most important in leprosy There are two reasons for this -(1) In a disease in which there is a tendency to weakening of the muscles one of the best correctives is to exercise all the muscles so as to keep up their tone The health of the whole body and the power of digestion and absorption of food and the elimination of waste products are all aided by suitable exercise (2) As in tuberculosis, ciercise has the effect of setting free in the body certain antigens from the bacıllı which cause the disease and these poisons induce the formation of antibodies which tend to limit or destroy the disease The presence of these antibodies consti tutes acquired immunity Tuberculosis is 1 disease which attachs the vital organs of the body, such as the lungs, and because of this there is grave danger from thing too much or too violent exercise in consumption,

·( 107 )
But in
as too much of this poison would be set free
Ieprost the case is different is the vital organs are
suldom affected After coming in from evercise it is
well to take the temperature as it serves to shon whether
there has been suficient erercise tihen at that time If
the temperature is rused above normal and remuns up
for more than one or two hours it proves that c cessive
cxercise has been indulged in The patient will find as
1 rule that with practice he gradually becomes able to
stand more ind more ejercise
In this way the general resistance is raised ind
the risk of harmful reactions is lessened
is enabled to stand far lar, er doses of injections without
local pain or general reaction
As to the forms of exercise walking, is one of the
best and this may be supplemented by Swedish drill
dumb bell exercises, etc 111 active games are useful
Work in the garden and in the field is most excellent,
and many of the deformities which render such work
impossible to the poorer lepers would never bove
occurred if they had persisted in doing such work from
the beginning
The patient

·( 108 )
SLIDF No 83
Bathing
La
Shın sanitation 18 leprosy is a skin disease the
sentition of the skin should be carefully attended to
7 he whole body should be rubbed duly with chaul
moogra or hydnocarpus oil and extra friction should be
applied to the parts of the body which are affected by
the disease It is best to carry out this rubbing before
thing the bath so that the excess of oil may be removed
The daily bath is of course absolutely essential and
it is well to follow up 1 hot bath with a cold plunge
The hot bath has the cffect of flushing the skin with
blood and thus helping to cause absorption of
nodules

·(109) All irritating skin diseases are specially harmful and tend to spread the disease as the bacıllı are con veyed from one part of the skin to another and probably from one person to another by scratching the shin Bou el sanitation - Constipation is very prejudicial in leprosy The nerve pains of leprosy are generally greater when the bowels are not thoroughly opened If there is not a free daily evacuation an attempt should be made to regulate the bowels by altering the diet An increase in the amount of fresh vegetables and fruit is often sufficient Where this is not enough such mild Invatives as senna, liquid paraffin, etc, may be used Ihc presence of intestinal worms has probably much to do both with the spreid of leprosy and the severity of the attack The scratching of the mucous membrance of the nose which is a common sign of the presence of worms, is probably largely responsible for the inoculation of the bacillus in the body Hookworm with its debilitating effects, tends to make the disease more severe The Mental Factor is a very important one the patient is not cheerful or hopeful he has much less If his diseise deprives him of his work he is not to mope and think about himself too much It is important therefore that neric (4) cases, which are not infectious should continue with their work while under treatment provided their work is of a healthy nature and does not prevent their getting, sufficient exercise and relivation This is another reason for the importance of earls dingnosis and treatment 1s if treated in time and efficiently few patients would reach a stage at which they would require to leave their work Climate - 4 dry temperite climate is the best Fitremes of heat or cold, especially when accompinied by a high degree of humiditi, are unfavourable chance of recovery ·(110) SLIDE No 84 (Hydnocarpus Tree ) SPECIAL TREATMENT Certain vaccines and various forms of chemiotherapy are of distinct value in the treatment of leprosy, but we have tried in this short lecture to confine our elves to the lines of treatment which we have found the most effective of all While potassium iodide is perhaps the most power ful drug we have in the treatment of leprosy, especially in cases of the skin (B) type, hydrocarpus (or chrulmoogra) oil and its preparations are invaluable in all stages of the disease, and especially in the earlier cases of the nerve (41) type In India he oil of Hydnocarpus wightianu is undoubtedly the cheapest and best when obtained from a reliable firm

·( 11 )
SLIDE No 85
Fruits and leaves et Hydrocarpus wightlana
lhe oil is obtuned by pressure from the sceds, o
which there are several inside every fruit

·( 112 )
SLIDE NO 86
Photo of Hydnocarpus wightiana, Tarak toge
hurch and Gynocırdı1 odorita
Fruit
Seeds
Shelled seeds
زباں
0
She led seeds
cut intro
showing rad cle
GOdorata
T Kurzi
Hght Ana
The secds must however be ripe and fresh, oth
wise the oil obtained from them is irritating,
fresh, ripe seed is clear and translucent
When
and style it is more opique in appeirince
The oil is prepared for injection by adding 4
cent of doubly distilled creosote and sterilising in ru
ber cipped bottles bi rusing the temperature to i.
if undue pain
degrees centigrade for half an hour
caused by injections it will probably be due to impu
oil or to oil citricted from oudised seeds The specu.
rotation to the night should be over 50 degrees and the
is the best test of its purity
*

·pun (113) I he do e recommended is 2 (C rising to do CC tulice weekli giucn by subcutaneous infiltration Nost dults, whose muscles trt firm through abundant Vigorous exercise can stund 10 cc slith practically no If 1 patient complains of prolonged pain and induration at the site of injection of a moderate dos of pure oil it is 1 sign that he is takın, insufficient (ierac SLIDL No 67 (Maxi a ester 11 bottle by cold process) r MANUFACTURE OF ESTERS BY COLD METHOD c 546704 LSTERS 17 C MONOA XE GLYC OL AN ACIO KYON CARTUS a M THE 10. Mert LA The esters prepared from whole hydnocarpus oil are thinner than the oil and are therefore more quickly absorbed especially in patients who are not tahing ufficient clcroise is the 100 more irr ini, on INILCIon It is well to me them with an equal quantity of pure olne oil adding al o 4 per cent creosote I his misture is sterilised in the sinie Wly 1t 120 degrees centigrade for half an hour and its dosant i theme 7 that of the oil 2 to 1o CC I he esters can be pre pared from the oil by the very simple method illustrie id in the slide or can be bought ready for use ·114 ) SLIDE NO 88 (Subcutatecus infiltration of Hydrocarpus oll) Methods of Injection --Hydnocarpus oil and its preparation, hydnocarpus esters, may be given either intramuscularly or by subcutaneous infiltration The other preprration, sodium hydnocarpate, a 2 per ent solution in normal silmne is given intra enously by 1 method described later Intramuscular Route - The patient should be comfortably scated on 1 stool and the needle inserted at right angles to the skin surface to the depth of 1 to 11/2 inches After injecting the oil or ester olive oil mixture and withdrawing the needle deep massage should be applied to the point of injection for five minutes so as to distribute the drug through the muscu lar tissue, otherwise a hard lump may be formed The injections should be given twice a week on the opposite sides alternately Subcutaneous Infiltration - I his is to be given under the skin of the eitensor surfaces of the limbs Two injections are to be given per weeh, ie, 8 injections per month 1 he extensor surfaces of the limbs may be infiltrated successively in the following order on eich occasion right upper limb, left upper limb, right buttoch, left buttock, intero esternal surface of right thigh antiro external surface of left thigh, postero el- ·( 115 ) ternal surface of right thigh, postero external surface of left thigh The postero external surfaces of the calves may be used instcad of subdividing the thighs, but come patients find the injections in the calves more painful than clochure I hus ifter 1 month the injections tre repented in the same order, the drug huung had time to become absorbud completely in the interval Infiltration is carried out in the following 12y An eitensor surface of one of the limbs is selected I he slin is sterilised by rubbing with alcohol or painting with iodinc solution A 10cc syringe is used with 1 sharp needle of medium thickness, about 1/2 inches in length I he required dose having been placed in the syringe, the needle is inserted through the skin and presed through the subcutaneous tissuc up to the hilt in a direction parallel to the surface of the shin tahi. ture that the point remains in the subcutaneous tissue and does not esther re enter the skin or pierce the deep fascia The former may be followed by sloughing of the skin and the latter by pain due to piercing incricor coulung due to piercing a vein half to one c of the drug is injected the needle is withdrawn till it all but comes out again through the shin und is then pushed forward once more fun piral lel to the hin surinec but at 1 different angle An injection of 1 similar amount is again made and this is repcited till 4 or 5 injections have been made The needle is then withdrain completely from the skin and another neighbouring piece of skin is infiltrated in 1 similar 117 ntil the stringe is empty Pressure must be applied for 1 few minutes at the points of insertion of the needle to present a reflow of the drug from the puncture holes Before living injections it is well to mp up the free to be infiltrated between the forefinger and thumb to nithe sure that there is no hardness due to a previous infiltration or to iny other cause ·( 116 ) The more evercise patients take the more quichly is the drug absorbed Patients with hird, firm, well developed muscles stand large doses ind feel practically no pun except that caused by the insertions of the needle Injections should not be given too fast is the tissues are apt to be injured by rapidly forcing them isunder, the drug not having time to find its wy into the interstices 3 or 4 minutes should be required to inject 1o CC Hydnocarpus oil tends to become thick in the cold weather and should bc hented to 1 few degrees above body temperature by standing the con tainer in hot water Caution - In tuberculous patients hydrocarpus oil and esters may provoke very severe febrile reaction due to the breaking down of tuberculous tissue Much smuller doses will break down tuberculous tissue than will break down leprous tissue and the danger of a tuberculous reaction is for greater than that of a lepro is reaction Wherever there is reason to suspect tubercu losis it is wise to begin with small doses, hetp record of the temperature and increase the dose gradually, while at the sime time taking careful means to increase the general resistance of the patient Sodium Hydnocarpate Another method of treatment is the injection of ? 2 per cent solution of sodium hydnocarpate in normal saline intravenously If this solution is injected direct into the veins they become blocked up after a few injec tions If however, the solution is placed in a 20C syringe ind 3 or 4 times its volume of blood is sucked up and mixed with the solution the veins are not destroyed In sucking up the blood heep the syringe absolutely horizontal, mix by making a sudden revolution of the syringe through 180 degrees and revolving it back again after a few seconda This process may be repeated till complete mixing takes place Then press home the ·( 117 ) piston and inject the solution blood mnture into the venn Dose 3 to 6 cc twice 1 neek Potassium lodid. Administration I his drug appears to have the cffect of breaking up "lepra cells and thus bnnging into contact with the tiesues the brcıllı which had been shut off from them Ihe result is the occurrence ot one or more of 1 series of phenomen i commonly known as the leprous reaction the signs of which are as follows Suelling up of existing leprous lesions und their cngorgement with blood Skin lesions, which had been flat and comparatively inconspicuous bctori hc come thickened and erythem tous affected nerc trunks become swollen and tender lymph glands become en Turged ind prinful frequently the testicles if they are discad become increased in size and cause pain the nose may become blocked and cpisti vis may occur bone and joint prins in arms and le, mai cause great distress in fact signs of engorgement and inflammation may occur in any orgin of the body in which z leprous infection exists 2 Bacillimi Ihc breihin, up of luprom? cts free balli and one of these and their way into the blood I he formation of fresh nodules due to bacıl Tiry emboli in the end capillaries of the shin If the treatment is carried out according to the rules advised howcier these nodules are not perminent and disappear 7,, in in teu dus + Rise of temperature in proportion to the C1 Crity of the reaction - The tim in carning out jodide treatment is to cau e breakın, down of leproma and elimination of the broken down material The doce should be regulsted by the mount of reaction produced, ciccole reictions 3 ·The size ( 118 ) being avoided, and by the power of the patient to elımı nate the broken donn material The reaction level varies in different patients At the beginning of treat ment it is necessary, by gung small doses and gradually increasing them, to find the reaction level of the primary dose and the rate of increase must be judged by (a) the severity of the infection and (b) the reaction level, which with experience the physician is able to judge to a certain extent The following rules may be used as a guide to the dosage of iodide in the different types and stages of leprosy (a) In "B" and "B" cases ben in with a grain a day and increase the dose daly by one grain until there is a reaction as indicated by a rise of temperature to more than 99° and swelling and redness of the lessons in the skin, or marhed tenderness of nerve trunis In "A" "B" and A' cases begin with 5 grains and increase by 5 grains daily up to 30 gruins or until a reaction is produced (b) When the tempertture has become less than 99º and the swelling and other signs of reaction have become less, continue the iodide giving the same dose is produced the rection Iodide should nou be then only once or twice a week and not daily (c) When no reaction follows a dose increase the next dose When there is fever or swelling do not increase it (d) The rate of increase must depend on the severity of reactions produced In some “Band "B'"c14cs it is possible to raise the dose only very slowly, increasing by i grain at a time In most "A and 'B'" cases it is possible to double the ·dose erch time till a reaction is produced, or a reaction may not result even with the maumum dose of 270 grains In such cases incrence may be made as follows 5, 10, 20, 25, 30 grains, given daily, in one dose, then 60, 90, 120, 150, 180, 210 210 grains given to days in the week, at 3 or 4 days inter 21 I hese larger doses may be divided into two, half being taken at 5pm and half at bed time Until experience has been guined it is well to proceed slowly in B ૧nd B''ind' A ca es so as to void cxcessive reactions In 'A' cases the pains in the noric trunks ind in the bones of the legs and forearms may be dis tressing (e) When rerctions last more than 48 hours or of the patient feels weah after the reaction has passed off sodide should be given only once i wech, otherwise twice the week (/) If the patient still feels weak ? more pro longed rest from iodide mus be given occisionally und miron, arsenic and strychnine tonic administered, but it is important to carry on the treatment with 75 little intermission as the severity of the reactions and the strength of the patient permit (9) Potassium iodide may be prescribed in the form of 1 muyturt but it is more conse ment to pre cribe it in the form of 1 rain, 5 stain, or zo grun tablets according to the size of the dosc which is being taken These should be dis olied in a large glass The larger the quantity of viter then the les rush there is of lodısı being produced of water ·(120) " (h) Between 5 gruns und 30 gruns there are sometimes symptoms of iodism or there may be in iodide rash, but as ? rule these do not occur or arc less marhed when the dose is larger than 30 bruns, and in our experience they give very little trouble if the drug is then as advised above (1) The patient's temperature should be record ed at least 4 times a day when this is pos sıble, as this is very useful in the regula tion of the dosage But even when this is not possible (as in the case of illiterate out patients) treatment cin generally be carried on satisfactorily, the general ap pearance of the patient, the condition of his skin lesions and his symptoms being used as guides Controllıng the Reaction In patients in whom the reaction level is lon ind in those who have larger numbers of ripe "lepri cells ready to break up, er en small doses of iodide may cause reactions which continue for several days or even wechs When fever und selling of lesions last for more than three days give potissium antım tart, 002 erim in 2 ccs of sterile siline intravenously cvery second day and an iron, arsenic and late tonic till the signs of reaction disappear I hen stop the antimony and begin the iodide again If there is a punful nerve reaction three minns of u Icco solution of adrenaline chlor (P D & Co) in 30 minıms of saline should be given intramuscularly and the dose repented in 5 minutes if the nerve pains have not subsided in that time Sodium salicylate 4 runs, dissolved in 5 le of normal siline and given intrni enouslı, relieves joint and bone pains Subcutaneous infiltrntion along the line of a painful nerve with 10 cc of normal saline containing o 25 cc of adrenaline chloride solution and os gramme of sodium bicarbonate often relieves the pain for a consi derable time The injection should not be made into the nerve ·(121) In such cases, as we have mentioned above, it is gencrally found that the reaction level is graduallı rais ed and thit the reaction cause by jodide becomes less in severity and only lasts for 1 to 3 d15, passing off as the druy becomes eliminated from the body It is then possible gradually to ruse the dose without fear of a prolonged reiction Great care should be taken if there is any sign of sritis or heratitis Iodide should be stopped at once and the pupil dilated with atropine When the pupil i well dilated and the reaction has passed off proceed slowly with iodide watching for any return of reaction in the eye Sught reactions with a dilated pupıl are weldom harmful and may gridually lead to complete clerrin, up of the disease in the cie In using iodides in rural dispensaries it is generally found that reactions thou, h they may be suiere at the time, piss off within 48 hours even in 'B' cases at the beginning of treatment 1 his is doubtless due to cier use tihen by the patients in doing their work ind in walking several miles to attend the dispensary Pro lon,cd reactions are more common in in patients of leper hospitals or 7suluns who lead 7 more lercurely life

·( 122 )
SLIDE No 89
(Painting or lesions with trichloracetic acid )
NO
Counter 11 ritation - This is a factor which we can
not afford to disregard in the treatment of leprosy It
has been applied in difterent forms from time immemo
rial Rubbing on chauimoogra, & rin and other oils
while sitting in the sun is beneficii not because any
yppreciable quantity of the oil is absorbed through the
shin but because of the counter irritation produced by
the oil, the friction and the sun's rays

·(123) Another useful method is pamun, on trichlorce tic acid This may be used in threc strengths, i ini solution in distilled wates for printing on nodulca i in 3 ori in s solutions for painting on to diffuse lesions This produces destruction of the more superficial flyers of the stratum corneum with congestion and selling of the underlying tissues I he shin which first appears White, soon becomes birch and the superhcial epithe hun peels off in some 7 days I he application may be repented after about 10 day In many ( 15cs the Icssons disappear rapidly under the applzertions swollen skin lessons bein, reduced to their normal size depigmented pitches C300% their pigment and sensation returning to uisthene Trens The burning sation crused by the application, which Insts for 1bout 2 minutes 2S 25 1 rok wellin, ly borne by the patient because of the evident improvenient that is quitklı noted The puntins, on diffust shin lesions 1 antsthetne or depsmented patches should not be mcrdone sight rmount of application is induited by very slight Whitening which appears as the solution drics Tretle of the solution should be put on the brush Hi the Sithtis white appu?rince shoes not appear when the first implication drica it should be applied 74, +18 the skin beams too shortc duc ta the application of toe much of the rud ulcertuou (1111 follox Other countlr arrituts ind (ustis hoc fccn usca with the <3336 byte 1011 euch 18 trbon dronde snow carbui aud et but uch of none wha mort lective or c) csipplied is tri chlorzetu wa Very ·( 124 ) SLIDE No 90 (Letterpress on disappearance of active signs ) DISAPPEARANCE OF ACTIVE SIGNS Bacteriologically negative on repented shilled es iminations extending over 6 months Disipperrance of eri themi No change in size or appearance of existing lesions over a period of 6 months No nen lesions during sanie period Other lesions may be considered as permanent Continue treatment until all active signs have disappeared Length of treatment nd after treatment -Treatment must be carried on until repented, careful bacteriological examinations have failed to demonstrate bacıllı over 1 period of at least say months ind till 211 signs of active nerve lesiony hue been ibsent over a similar period Before declaring the disappearance of active signs the patient should have taken 240 grains of potis rodide tuce a week for three months without showing any signs of reaction during that time ·( 125 ) SLIDI TO 91 Bed al stream silde } ne- Ilus slide represents the co s see nn nf 7 treim Il stuepus the bih slows to the water cove the deeper the water below the natur edhe so the more rapid the improvement up on the plant of the total disappearance of all active sins the most ripid the improvement thereafter ind the shorter the subsequent period of treatment rua arcu and tire 1 run the slower the im proiement up to the point of disappearance of 2}} actie signs, the toner will the subsequent treatment have to be

·( 126 )
SURGICAL TREAT NILNT
When there is only one lesion in the body it may
often be removed by evcision, the sides of the wound
being sewed up Lven af some bacıllı are left they are
likely to be destroyed by the plastic process set up by
the excision It is always well however to give the
ordinary treatment is well as there may be infection in
the nerves or lymph glands
SLIDC No 92
(Nerve stretching )
**
When a nerve is much thichened, especially in the
case of the ulnar or peroneal nerve where it is bound
down to the bone by strong fibrous tissue, much benefit
may be derised by cutting down on the nerve, freeing
and stretching it This may often prevent such con
ditions as perforating ulcer, drop foot and claw hand

·( 127 )
SLIDE No 93
(Ear Trimming )
I rimming of the car in B' (750$ is often very
bencficirl and the appearance of the patients thereby
rapidly improved I spearl climp should be applied
and the part beyond the clanp cut off with the knife,
purc carbolic red being applied to the riu surface
before think off the timp I here is very little bleed
ing or pun accompinying this simple operation Care
must be then not to cut off too much tissut Thc
pli tie process re ulting, reduces e cilin and the
inícction still further

·SI IDE NO 94 (Ear before and after trimming ) ·( 129 ) SLIDL No 95 (Chart she was results of treatment) YOTL TYP or D SEAL P SULT OF T AT ENT SIMCC CACLOT AL A 1 74 4 9 18 4 SIGNS c W WE DOCASE > to 1 1 % D M 7 79 1 MPROVED 2 20 1 ✓ 13 4 SAME Tom 2 1 1 o C 14 85 183 13 71 T

·(130)
SLIDE No 96
Contrast Photos

·( 131 )
SLIDL No 97
Contrast Photos

·( 132 )
SLIDE No 98
Contrast Photos

·( 133 )
SLIDE No 99
Contrast Photos
Fiat

·No text on this page.

·NICURI SI
PROPINYLAXIS.
SLIDE Vo 100
(Molher und ers children )
1 prst is spread by cho prolonnect contact with
huimhli infue trou ( 0: and B, Cases In the
side the nuther (1łu, hlı intuemu leperl 178 nursed
huile(hiktsun and ill of them thon igns of Icprast
312 in this »71hit the sites fon s post rather than
or erect begiats who 10 often non infectious
(1964

·( 136 )
SLIDE No 101
(Newly born child temoved from mother)
want to
It is necessary therefore to remove the ch Id from
the mother at birth
Children are much more liable to infection than
adults, though often they may not develop the disease
till they become older
Servants often transmit the disease to their employ
ers or to the children of the household whom they tend
Leprosy is not always recognised and a highly infectious
servant may live in a house for a long time without his
employers being aware that there is anything wrong
with him

·( 137 )
SLIDE No 102
(5 ma}} child kept from that )
SI
When the inthus 1 housthulu is an inſtitious
or B, ) 1st le should halt 1 sepirate room
usth <sparitt furniturt tinen, citu, and other utensils
Thuhuldun sunuld never be allowed thirth it rom
or to do nerr the father 3nd other people should only
enter the room when it c181 and suuld the pret zu
tsons unft 16 117ching the hands of

·( 138 ) SLIDE NO 103 (Infectious leper In hut ) ANO A single infectious leper in a village may infect large numbers of persons Villagers should therefore be warned of the danger and taught to isolate such a patient, providing him with a hut outside the village, supplying him with food and not allowing him to cnter the village or have any close contact with others Whenever a village doctor or public herith officil sees in infectious case he should not be content with trenting this one patient He should follow him up to his home and find in what circumstances he is living und he should see that the patient and his relatives and neighbours understand wherein the danger lies and what may be done to 11 oid it He should at the same time Ciamine those who hue been in contact with him for earls signs of the disease and instruct them what will be the first indications, supposing the infection should develop later ·(139) Local self isolation, carried out by a village it elf, is the best method of pruention in rural arcas, especial ly if arrangements can be made for treatment of those isolated In town the patient must isolate himself in a scpirite room of his house SLIDE TO 104 (Photo e! Leper Asylum) IT W licn such isolation is not possible infectious cases should be rolitci in public institutions such 15 luper emlonies or ho pitals The old leper zylum is suitable for the in whom the discic has produced murhed deformities and who has lost all hope of recovery or of user returning to thuir homes It is 7 mistake to let them mu with reniedible and hopeful cises 26, whule leprosy stselt is contamous the spirit of despair which is engendered by hopeful case« miung with these hopeless ones is niuch more contagious I his slide shows in deal leper institute ·( 138 ) SLIDE NO 103 (Infectious leper in hut.) wer A single infectious leper in a village may infect large numbers of persons Villagers should therefore be warned of the danger and taught to isolate such a patient, providing him with a hut outside the village, supplying him with food and not allowing him to enter the village or have any close contact with others Whenever a village doctor or public health officil sees in infectious case he should not be content with treating this one patient He should follow him up to his home and find in what circumstances he is living and he should see that the patient and his relatives and neighbours understand wherein the danger lies and what may be done to avoid it He should at the same time tvamine those who have been in contact with him for early signs of the disease and instruct them what will be the first indications, supposing the infection should develop later ·( 139 ) Locul self isolation, carried out by a village itself, is tlic best method of prevention in rural areas, especial ly of arrangements can be made for treatment of those isolated In town the patient must isolate him elf in a separate room of his house SI IDC No 10+ (Photo et Leger Asylum) 11 hen such solation is not possible infectious cases should be i olnted in public institutions such as leper colonies or hospitais The old leper sulun is suitable for the c in whom the disease his produced marked deformitics is who have lost all hope of recoven or of dicr returning to their homes It is 1 m take to fut them me with remediable and hopeful cases as, while leprosy itself is contigious, the spirit of despair shich is engendered by hopeful cases mixing with these hopeless oncs is much more contagious This slide shou an ideal leper institute

·(140)
SLİDE No 105
(Letter Press)
PRECAUTIONS
TO BE TAKEN BY
1
DOCTORS AND ATTENDANTS
Never touch an infectious leper or any 1
which he has used or touched without thoroughly w
ing the hands immediately afterwards
In nttending to lepers or dressing their wo
use rubber gloves where possible, at least this shoul
done in cases which we highly infective accordır
the description above
3 Those coming in contact with Icpers sh
heep themselves in good health by mcins of abun
fresh air light, cxcrcise and suitable dict