NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
360
REPORT OF THE LEPROSY COMMISSION :
the trunk and both thighs. Shins of both legs are covered with dark
patches and shiny ; feet are covered with scaly patches. Loss of
sensation in little finger of right hand, and from knee downwards
to tips of toes in both lower extremities.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Gaining sensation in the little finger of right hand.
August 10th.—Minute tubercles on the little fingers of both hands
ulcerating, discharging freely, and then subsiding. There is much
improvement, and patient is gaining more sensation in the little
fingers of right hand.
August 10th.—Salol, gr. xxx, three times a day.
August 16th.—No change.
August 19th.—Fresh minute tubercles have appeared on both
hands.
August 27th.—Some of the tubercles mentioned above have ul-
cerated and are healing up.
Treatment still continued
CASE II.—Hindu, male, aged 26 years ; suffering from TUBER-
CULAR LEPROSY for last ten years.
Present condition.—Minute tubercles on the lobes of both ears,
nose and chin. Skin of face slightly thickened. Skin of the body
discoloured, and covered with dry, scaly patches of a lighter colour
than the natural skin ; and also psoriasis. Discoloration of the skin
of both upper extremities ; both legs are covered with brown patches,
peculiarly shiny; toes are thickened, and there is an ulcer on the
inner side of the right great toe. No loss of sensation anywhere.
Both feet are swollen.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Complains of severe pain over the abdomen and
burning sensation on the soles of the feet after taking the medicine.
Treatment continued.
August 10th.— No improvement.
Salol, gr. xxx, three times a day.
August 16th.—No improvement.
Treatment continued.
August 19th.—Pain over the abdomen, and burning on the soles
of the feet is worse ; ulcer broke out on the dorsum of right foot.
August 27th.—No improvement.
Appendix I to Chapter VIL
361
CASE III.—Hindu, male, aged 32 years; suffering from MIXED
LEPROSY for last nine years.
Present condition.—The skin of the whole face, chin, nose, and
ears thickened and tuberculated ; skin of trunk and extremities dis-
coloured and thickened by a mass of minute inter-current tubercles.
Fingers and feet slightly thickened; brown shiny patches on both
shins ; toes much thickened, nails wasting away. Slight anaesthesia
in hands and legs. This is a more macular form of the disease.
Slight loss of sensation on the soles of both feet.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Several tubercles on the trunk and extremities have
ulcerated and subsided ; gaining sensation in the tubercles of the
face, being very painful to the touch.
Treatment continued.
August 10th.—More tubercles on the trunk and extremities have
subsided. He is gaining sensation in hands and legs. Tubercles
on the face somewhat depressed and not so much elevated, but very
painful. He states he is improving greatly.
Salol, gr. xxx, three times a day.
August 18th.—Tubercles on the face look somewhat depressed
and are painful, and those of the forearms have ulcerated and are
subsiding.
Treatment continued.
CASE IV.—Pariah, male, aged 36 years ; suffering from ANÆS-
THETIC LEPROSY from infancy.
Present condition.—Copper coloured anaesthetic patches on both
cheeks and on the neck. Front and back of the trunk are covered
with similar circular patches, much lighter than the natural skin,
attended by loss of sensation. Similar patches on both upper arms ;
fingers of both hands exhibiting signs of contraction ; little fingers
of both hands are already slightly contracted. The buttocks and both
lower extremities are covered with similar kind of patches, attended
by loss of sensation. Toes of both feet are swollen, and there is a
characteristic deep ulcer under the great toe of right foot.
Total anaesthesia in patches over the trunk and in both extremi-
ties.
July 7th.—Salol, gr. xx, three times a day.
August 3rd.—Gaining sensation in the fingers of both hands.
Treatment continued.
362
REPORT OF THE LEPROSY COMMISSION :
August 10th.—No change.
Salol, gr. xxx, three times a day.
August 18th.—Copper coloured anæsthetic patches all over body
several of them becoming darker and regaining sensation.
Treatment continued.
August 27th.—No further improvement.
Treatment continued.
CASE V.—Muhammadan, male, aged 20 years ; suffering from
TUBERCULAR LEPROSY for last four years.
Present condition.—Slight thickening of the skin of the nose and
lobes of both ears ; discoloration and desquamation of skin of both
upper extremities ; peculiar shiny appearance and dark patches on
both the legs ; both feet slightly swollen ; toes of both feet present a
peculiar shiny appearance. No loss of sensation anywhere.
July 26th..—Salol, gr. xx., three times a day.
August 3rd.—He complains of muscular pains all over the body
which prevent him from sleeping during the night.
Salol, gr. xx, three times a day.
August 18th.—No improvement.
August 21st.—He absconded.
CASE VI.—Muhammadan. male, agpd 20 years ; suffering from
MIXED LEPROSY for last ten years.
Present condition.—Minute tubercles on borders and lobes of both
ears, discoloration and slight thickening of the skin of the face.
Scaly dark patches on both forearms ; fingers of both hands exhibiting
signs of contraction, discoloration and dark patches in both lower
extremities and a peculiar shiny appearance over shins of both legs ;
toes of both feet slightly swollen ; nails wasting away. Discoloration
of the skin of the trunk ; anaesthesia in both upper and lower extremi-
ties.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Improvement not to be seen.
Treatment continued.
August 10th.—Tubercles on the ears ulcerating.
Salol, gr. xx, three times a day.
August 18th.—Tubercles on the ears still sore; those of the
forehead getting smaller in size.
Treatment continued.
Appendix I to Chapter VII.
363
CASE VII.—Hindu, male, aged 30 years; suffering from MIXED
LEPROSY for last five years.
Present condition.—Tubercular thickening of the skin of the
whole face, minute tubercles on both ears and nose ; nose sunk in-
Discoloration of the skin of the trunk, and the latter covered with
psoriasis. Discoloration and slight thickening of the skin of the up-
per extremities, which are also covered with psoriasis. The little
fingers of both hands are contracted ; fingers swollen. Discoloration
and slight thickening of the skin of both lower extremities ; dark
peculiar shiny patches on both shins, and tubercles around both
ankles. Joints of both feet swollen, as well as toes ; nails of toes
wasting away. Loss of sensation over both the upper and lower ex-
tremities.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Gaining sensation in both extremities; minute tuber-
cles on both ears and nose absorbed ; thickening of the skin remains.
August 10th.—Gaining sensation in the extremities ; psoriasis is
fading away ; thickening of the skin of the face gradually going
down ; minute tubercles on the ears subsided, but thickening of the
skin remains ; skin is moist and not so dry as before.
He is much better.
Salol, gr. xxx, three times a day.
CASE VIII.—Hindu, male, aged 18 years; suffering from TUBER-
CULAR LEPROSY from infancy.
Present condition.—Tubercular thickening of the lobes and pinnae
of both ears ; cheeks, chin and nose also affected with a mass of
tubercular thickening. Patches of tubercular thickening over both
the front and back of the trunk. Minute tubercles on both forearms ;
>
and fingers of both hands swollen. Discoloration and slight thicken-
ing of the skin of both lower extremities; dark and peculiarly shiny
appearance of both shins and feet. No loss of sensation anywhere.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Several tubercles on the body and extremities have
been absorbed ; tubercular thickening of the face gradually going
down.
August 10th.—Tubercles on the body and forearms have been
greatly absorbed ; tubercular thickening of the face is gradually going
down.
Salol, gr. xxx, three times a day.
364
REPORT OF THE LEPROSY COMMISSION :
August 18th.—Fresh tubercles appearing on both upper extrem-
ities.
Treatment continued.
August 27th.—No further improvement.
CASE IX.—Hindu, female, aged 20 years ; suffering from TUBER-
CULAR LEPROSY for last five years.
Present condition.—The whole of the face covered with minute
tubercles ; lobes of both ears and nose tuberculated. Both upper
extremities covered with minute tubercles and skin slightly thickened.
Front and back of the trunk also covered with similar tubercles ;
slight thickening of the skin of both lower extremities ; peculiar dark
shiny appearance of both shins. No loss of sensation anywhere.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Tubercles on the face and upper extremities have a
tendency to subside.
August 10th.-Many of the tubercles on the face, trunk, and
extremities have subsided ; dark patches on the shins are lighter.
Salol, gr. xxx, three times a day.
August 18th.-A mass of fresh tubercles has appeared over face
and extremities.
Salol, gr. xxx, three times a day.
August 27th.—Some of the tubercles on the arms have subsided
and fresh ones have appeared.
Treatment continued.
CASE X.—Native Christian, female, aged 14 years ; suffering from
MIXED LEPROSY for last two years.
Present condition.—Lobes and borders of both ears covered with
tubercles ; chin, nose, and whole of the face covered with minute
tubercles. Slight thickening of the skin of both upper extremities ;
fourth and fifth fingers of right hand and little finger of left hand
slightly contracted. Discoloration of the skin of the trunk and of
lower extremities. Dark peculiar shiny patches on both shins ; feet
somewhat swollen. Left fourth toe and right second toe ulcerated.
Complete anaesthesia of both lower extremities.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—Gaining sensation in both lower extremities.
Treatment continued.
August 10th.—Improvement very slight.
Appendix I to Chapter VII.
365
Treatment continued.
August 19th.—Itchy sensation all over the body.
Treatment continued.
August 27th.—She is getting good appetite ; no further improve-
ment.
CASE XI.—Hindu, female, aged 12 years ; suffering from TUBER-
CULAR LEPROSY for last two years.
Present condition.—Cluster of tubercles on the nose, chin, and
ears ; skin of the whole face covered with minute tubercles. Both
upper extremities covered with tubercles ; a large tubercle situated
on the dorsal aspect of right middle finger; fingers of both hands
slightly swollen. Discoloration of the skin of the trunk. Dark shiny
patches on both feet ; toes thickened ; nails gradually wasting away ;
ulcer on the under surface of right second toe. No loss of sensation
anywhere.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—No change.
Treatment continued.
August 10th.-—-Tubercles on the face are slightly depressed.
Salol, gr. xxx, three times a day.
August 18th.—Complains of severe pain over abdomen ; tongue
sore ; ulcer on the right foot getting worse.
August 27th.—No improvement. As she is suffering from dy-
sentery the medicine is stopped.
CASE XII.—Native Christian, female, aged 15 years; suffering
from TUBERCULAR LEPROSY for one year.
Present condition.—Skin of face somewhat shiny, and lobes of
ears slightly thickened. A raised eruptive tubercular patch on the
back, also on right upper arm, left forearm and left thigh. No loss
of sensation over these maculae. Peculiar shiny scaly appearance
of both shins.
July 26th.—Salol, gr. xx, three times a day.
August 3rd.—No change.
Treatment continued.
August 8th.—Eruption has a tendency to subside; there is some
improvement.
Salol, gr. xxx, three times a day,
August 8th.-Eruption
is getting less and the thickening de-
creased.
366
REPORT OF THE LEPROSY COMMISSION:
Treatment continued.
August 27th.—There is some itching over the eruptive patches.
Treatment continued.
ADDENDUM.
Since the return of the Commissioners to England Dr. Cook has
continued the above treatment, but apparently without success, as
may be gathered from his letter.
[GOVERNMENT
LEPER
HOSPITAL,]
Madras, nth November 1891.
From—Surgeon-Major H. D. COOK, M.B., Supdt., Govt. Leper Hospital,
Madras ;
To—A. A. KANTHACK, Esq., F.R.C.S., St. John's College, Cambridge.
In continuation of my letter of 31st August 1891, I have to inform
you that the salol treatment was continued up to 12th October 1891,
thereby terminating the three months' treatment suggested by me—a
trial sufficiently long to evince the virtue of Salol as a specific in
leprosy. A few of the twelve cases under treatment derived some
benefit, while the others improved in parts previously affected, but
have broken out in parts formerly unaffected. Tubercles have sub-
sided and already existing ulcers healed up, but after some time fresh
tubercles and ulcers appeared. In addition patients complained of loss
of appetite, lassitude and a disagreeable burning sensation in the
stomach, eyes; in fact throughout the body. Considering that leprosy
is a disease, requiring a steady persevering course of treatment, ex-
tending over a period of three months, if necessary a year, a specific
that would recommend itself and combat successfully with the disease
must necessarily possess properties of a progressively beneficial nature,
so that its continued use would have no disagreeable counteraction ;
it must have tonic and alterative properties, and be such that its use
could be continued for a long time without the least ill-effect. Salol
in my estimation is of no therapeutic value in leprosy; in fact,
I consider it a decided failure.
Appendix II to Chapter VII.
367
APPENDIX II.
EXPERIMENTS ON THE ACTION OF TUBERCULIN IN LEPROSY.
In connection with the treatment of leprosy mention must be
made of a series of experiments with Koch's fluid which Surgeon-
Major H. D. Cook of Madras kindly performed for the Commission.
Twelve lepers were treated with tuberculin, obtained from Dr. A.
Libbertz of Berlin. The observations were made, with but faint hope
of achieving any therapeutic success, but rather to test the diagnostic
value of the medium. For assuming tuberculin to be a specific in
tubercular affection, it could à priori scarcely be considered probable
that as such it could have been of any use in leprosy, even though one
must allow a certain pathological resemblance between the two dis-
eases. Besides, by the time the tuberculin reached India the majority
of men expressed their doubt as to its efficacy even in tubercular
disease. Various physicians, 1 notably amongst them Dr. P. S. Abra-
ham, Dr. Arning, Dr. Goldschmidt and Drs. Babés and Kalindero
have tried the injection of Koch's fluid, but in no case has there been
any permanent improvement, and hardly even any temporary benefit.
Difference of opinion has been expressed as to value as a diagnostic
means of tuberculin, that is, whether or no the injection of tuberculin
is followed by a general and local reaction of a characteristic type.
It was especially to test this point that the Commission requested
Dr. Cook to try the effect of tuberculin on a number of lepers, care-
fully selected, free from any suspicion of tubercular disease, repre-
senting the various types of leprosy. No advanced cases were
employed.
Dr. Cook's detailed report will be found appended. Here a short
extract, with -the conclusions based on the experiments, will be given.
The patients were all male Hindus, young adults suffering from leprosy
in its less advanced stages. Four were affected with the anæsthetic
form of the disease, four with tubercular leprosy, and the remaining
tour with the mixed form. Each patient was observed for a few days
previous to the commencement of the injections and the day before,
the temperature taken at morning, noon, and night. Then a minimal
dose of tuberculin was injected ('ooicc), sometimes into an apparently
healthy part, at other times into the diseased tissues. An interval of
twenty-four hours always elapsed between two successive injections,
(1) Journal of the Leprosy Investigation Committee, No. 2, February 1890, page 110, et seq.
368
REPORT OF THE LEPROSY COMMISSION:
and to begin with, the dose was increased by 'ooicc until '005 was
reached, when it was ventured to increase it by '002cc ; '01 was the
maximum dose ever given. The temperature was carefully observed
every three hours, and whenever it rose above 102.5° the dose was not
increased, but the same or a smaller dose given, until the temperature
remained at or below 102.5° for some time. Injections were never
continued, until the phenomena of reaction had abated.
No case was in any way, generally or locally, improved, although
the treatment was continued for at least three weeks. One or two
patients were decidedly the worse for the injections, being reduced in
general health. In two instances the patients acknowledged a return
of sensation into a primarily anaesthetic region, but this passed off
quickly. In another case several ulcers healed up and remained so at
the time the treatment was discontinued ; in one instance tubercles in
the face became less prominent. But with these exceptions the im-
provements were but slight and momentary, or altogether absent, so
that the lepers lost all faith and patience. In four cases the use of
tuberculin was followed by a general outbreak of psoriasis all over
the body. These were of the mixed or tubercular type.
A general reaction was absent in two anaesthetic cases, one tuber-
cular and one mixed case (or in four out of twelve cases). In seven
cases,—one anaesthetic, three tubercular, and three mixed—it was
well marked, while in one case it was but weak. The mere absence
or presence of a general reaction, therefore, cannot be made the
criterion between leprosy or tuberculosis, as was at one time assumed
by Dr. Arning. 2 In Dr. Cook's patients tuberculosis was out of
the question.
According to Professors V. Babes and Kalindero, 3 the general reac-
tion in the case of leprosy essentially differs from that established in
tuberculosis. There is no doubt from a perusal of Dr. Cook's cases
that, in accordance with these authors, a stronger dose is required to
produce a febrile reaction in leprosy than in tuberculosis. Again the
twelve cases confirm the statement of the same writers that in leprosy
the general reaction, instead of in about six hours, does not ordin-
arily appear until twenty-four hours after injection. The cases offer,
however, no evidence that the fever and concomitant symptoms last
longer than in tuberculosis. But they may be said, on the whole, to
confirm the other statement that after the first reaction a second
appears on the following day, and at times even a third the day
after (cf. Case XII). Local reactions failed in almost every case,
(2) Deutsche Med. Wochenschr, 1890, 50.
(3) Semaine Médicale. Jan. 26, 1891.
Appendix II to Chapter VII.
369
the ulcers, as a matter of fact, healing in only one instance.
Amelioration of the general condition was not observed, but a
general weakness was not uncommon.
The Commissioners, therefore, agree with Professors Babés and
Kalindero that there are essential differences in the character of
the reactions in the case of leprosy and tuberculosis, respectively»
where these are typical ; and that in a number of cases (as far
as it is allowed to argue from so small a number of cases),
Koch's remedy might distinguish whether an affection is leprous
or tubercular, provided it were proven that a typical reaction
follows in all cases of tubercular, but never appears in healthy
individuals. But they think that it can hardly be employed in
the diagnosis of a suspicious trophoneurotic disease, seeing that
of four anaesthetic cases no reaction occurred in two cases, while
in a third case it was very weak. The most marked reactions
occur in purely tubercular and mixed cases. The Commission-
ers also have no doubt that as far as leprosy is concerned, the
remedy is of no therapeutic value, but, on the other hand, may
not be altogether free from danger.
Table to show the Effect of Tuberculin in Leprosy.
Form of Disease.
ANÆSTHETIC
.
TUBERCULAR
MIXED
Num-
ber of
case.
(0
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Reaction.
Very weak—practi-
cally nil
Practically nil
Weak
Well marked
Nil
...
Well marked
Ditto
Ditto
Ditto
Practically nil
Well marked
Ditto
Remarks.
What little re-
action
there
was appeared
only after large
doses were given
when large doses
given
when large doses
given
Im-
prove-
ment.
Nil
,,
»
Nil
„
„
„
»?
><
Other
changes.
Psoriasis.
Ditto.
Ditto.
Psoriasis.
2 B
370
REPORT OF THE LEPROSY COMMISSION:
SURGEON-MAJOR H. D. COOK'S REPORT ON TUBERCULIN.
GOVERNMENT LEPER HOSPITAL,
Madras, June 1891.
From—Surgeon-Major H. D. COOK, M.B., Supdt., Govt. Leper Hospital,
Madras.
To—A. A. KANTHACK, Esq., F.R.C.S., New Club, Simla.
With reference to your letter dated Simla, 22nd April 1891, I have
the honour to inform you that, in accordance with the directions con-
tained therein, regarding the use of " Tuberculin," I began the treat-
ment with it on twelve lepers selected for the purpose on the 27th
ultimo and continued it till the 20th instant.
A minute diagnosis of each of these twelve cases being recorded
(as per cases attached), they were inoculated with solutions of tuber-
culin carefully prepared by the local Chemical Examiner to the
minimum strength of '001, and gradually increasing it at each succes-
sive injection performed every alternate day. When the temperature
exceeded 102.5°, the minimum strength or one of less strength than
that used at the previous operation, as the case required, was injected,
till it reached '01cc.
From the careful observation of their temperatures with a clinical
thermometer, every third hour, five times daily, and duly registered,
the only effects noticeable were an increase of temerature, only tem-
porarily attaining a maximum of 105 o in three cases, accompanied
with fever; and an average of 100.5° in others, while in three of
these cases the temperature slightly exceeded the normal.
These symptoms, unaccompanied with the least mitigation of the
disease, were the only results attained, and as the trial given was
sufficiently long to exhibit any virtue, if there be, of the remedy, I have
decided to discontinue the treatment. The patients who were under
treatment got disheartened and one of them got very ill. These
cases were typical of the various forms of leprosy, carefully selected,
and not in an advanced stage, and I may remark here that every
detail of the whole treatment was strictly observed from 27th May
till 20th June 1891. The injections and the registration of tempera-
ture have been scrupulously carried out, so that I can safely say a
fair trial has been given.
Appendix II to Chapter VII.
371
From the above remarks it may be seen that so far no mitigation
of the symptoms has occurred, and therefore I think the "Tuberculin"
for leprosy is a decided failure. It may be said that the injection
should be continued for a long time, but the patients would not sub-
mit to a painful treatment, seeing no good result therefrom.
The Resident Apothecary, Mr. M. Nur Mahomed, has taken great
pains with these cases throughout. Recording temperatures every
three hours in twelve cases is of itself an irksome duty, and my
thanks are due to him for so cheerfully assisting me with the experi-
ments.
2 B 2