CHAPTER VIII._Leprosy

TREATMENT.

Since many cases of Leprosy terminate in cure by the disintegration

and elimination of the bacilli, one might imagine that it would be a

tolerably easy task to find a suitable treatment for the disease. But

this is far from being the case. Treatment of Leprosy has been carried

out from time immemorial. In the Bible there is little concerning any

treatment which was regularly applied in Leprosy; the disease being

apparently regarded as beyond human power. Later, all possible and, we

may say, impossible remedies, such as the teeth of elephants, the flesh

of crocodiles and serpents, the fat of panthers, lions and bears, and

so on, were applied. In mediæval times, the same class of remedies was

used along with religious incantations.

In the eighteenth century, Schilling tells us he treated leprosy with

success. For the first three months he ordered a rather sparing diet,

consisting of bread, vegetables and soup. The real treatment began

with purgatives, “not mineral ones, because these are dangerous for

lepers, and often produce dangerous diarrhœa,” and was followed by

warm baths, “with circumspection, when the disease is far advanced,

because they produce palpitation of the heart, convulsions and fainting

fits.” In addition to advising frequent exercise in the open air,

Schilling regarded it as important to dilute the diseased humours by

large quantities of purifying fluids, of which he used first emollient

decoctions, and later, powerful sudorific ones. As mild ones he used

barley water, infusions of herbs, Agrimony, Hedera terrestris, Fumaria,

Veronica, etc., to which were sometimes added other softening and

purgative remedies, such as Malva, Parietaria, Senna and Rhubarb.

Of these the patients took, for six weeks, 3 to 4 litres daily. He

then gave powerful resolvents and sudorifics, as Saponaria, Zedoaria,

Sassafras, Juniper, Fol. Scolopendrii, herb. Cardui benedicti, Pareira

brava, etc. The more the patient could take, the more rapid and

complete, according to Schilling, was the cure. Rich food and good

wine might be given. During the treatment the patient had to guard

himself from cold air. After three months the patient was bled, as much

blood being taken as his strength would allow. The external remedies

which were used when there were putrid ulcerations, and when fingers

and toes commenced to fall off, were tincture of aloes, myrrh, and

succini, which were dropped on lint and applied twice a day. Both the

pharmaceutical and the dietetic remedies were to be persevered with

until definite signs of cure were manifest, and the treatment was to be

continued for many months after apparent recovery. Many years ago this

method of treatment was carried out at the Lungegaard’s hospital, but

without success.

We shall next mention all the specific remedies which have been

recommended and have acquired any reputation as effective.

_Madar_ (Mudar) is one of the oldest. It is got from the Indian plant,

Caloptris gigantea (_Asclepias gigantea_). Only the powdered bark of

the root was used. Some of it was sent from India to the Lungegaard’s

hospital, and was given in large doses to many lepers. The effect was

absolutely _nil_; one might just as well have given them flour.

Dr. George Watt enumerates the following plants of which the oils have

been used in India in leprosy:--(1) Albizzea Libbek, (2) Anacardium

occidentale, (3) Gynometra ramiflora, (4) Dipterocarpus turbinatus, (5)

Gynocardia odorata, (6) Hydnocarpus Wightoni, (7) Hydnocarpus venenata,

(8) Pongania glabra, (9) Psoralea corylifolia, (10) Sunocarpus

anacardium, (11) Arachis hypogæa. Of these, only a few merit more

particular mention; the others have been mostly merely popular remedies.

_Cashew-nut Oil_, from Anacardium occidentale, Linn., Cassuvium

pomiferum, Lamk, a large tree very common in the West Indies. The oil

is found in the pericarp, and is extracted by ether, which, after being

evaporated in open vessels, leaves a thick, brownish black oil--the

Cashew-nut oil. This is the oil with which the French physician, Dr.

Beauperthuy, in Cumana, Venezuela, claimed to have cured leprosy. An

English physician, Dr. Bakewell, who had investigated the treatment

of Dr. Beauperthuy, sent a report to both houses of parliament on

the beneficial effects of the treatment, and it thus attracted much

notice. Dr. Beauperthuy’s method of treatment was the following: good

nourishing diet, good hygienic surroundings, frequent warm baths

followed by the inunction of olive oil, and internally 1/15 to 1/20

of a grain of bichloride of mercury twice daily, or, when this was

contra-indicated, 10 to 20 grs. of carbonate of soda. As external

remedies, which Beauperthuy regarded as the most important, he applied

different liniments, such as tincture of iodine, to which were added

potash lye, olive oil, and balsam of copaiba mixed with yolk of

eggs. These liniments he principally applied where herpetic or other

eruptions complicated the leprosy, and to the specific eruptions he

applied solutions of nitrate of silver or sulphate of copper, but

especially Cashew-nut oil. In all this there is nothing new except

the oil; all the other remedies have been long, and still are

occasionally, used. In the Lungegaard’s hospital, the oil was tried on

five patients exactly according to the directions of Dr. Beauperthuy,

and after a trial of several months, the results were anything but

good. The oil induced irritation, redness, swelling and vesiculation;

the leprous tubers and patches remained unaltered, and in one case a

leprous eruption developed, probably produced by the irritation of the

oil. In Trinidad, too, the same results of the application of the oil

were seen, and Dr. Beauperthuy’s treatment has been given up.

Even before Dr. Beauperthuy’s remedy had lost its reputation, a new

specific remedy appeared in the East Indies, viz., _Gurjun oil_,

introduced by Surgeon-Major Dougall, of the Andaman Islands. The oil is

procured from several species of Dipterocarpus, principally D. lævis,

D. tuberatus, and D. trinervus. Dr. Dougall’s method of treatment was

the following: good nourishment, fresh air, and a mixture of gurjun

oil and lime water internally and externally. For internal use he

gave a mixture of equal parts of oil and lime water, which forms a

tolerably thick emulsion, 15 grains morning and evening. Externally,

he used an ointment of oil 1 part, and lime water 3 parts. With this

the patients rubbed the whole body for two hours both forenoon and

afternoon. The body was thus covered with a sticky layer, to which dust

and dirt adhered. To remove this, the patients rubbed themselves every

morning with dry earth, and afterwards took a bath in running water,

before again applying the oil. The prolonged rubbing he considered not

only beneficial to the skin, but useful as a gymnastic exercise. Of

twenty-four lepers whom he treated in this way for six months, all,

without exception, improved; all ulcerations healed without again

breaking down; and, what is most remarkable, the anæsthesia almost or

completely disappeared.

According to his description of the patients, some of them evidently

had syphilis, some chronic eczema, and some psoriasis. Their

ulcerations had been so neglected that flies laid eggs in them, and

it is little wonder that they healed under the cleanliness which Dr.

Dougall induced. That old anæsthesia should disappear within six

months, is, to any one who knows leprosy, absolutely incredible.

In the summer of 1887 the Lungegaard’s hospital got a sample of the

oil, and nine male lepers underwent Dr. Dougall’s treatment, the only

difference being that they took a warm bath instead of a bath in

running water, which Dr. Dougall probably ordered because he had no

bath-rooms at his disposal. Every morning and evening the patients

took 15 grains of the mixture of equal parts of oil and lime water. In

the forenoon, from 9 till 11, and in the evening from 5 till 7, they

rubbed each other in a room at a temperature of 26 to 28° R., with oil

1 part and lime water 3 parts. In the morning they rubbed themselves

with dry earth, and took a warm bath before re-applying the oil. The

treatment led to no results. In some of the patients the disease

advanced very little, but, nevertheless, the gurjun oil had no effect.

As leprosy, so far as we know, is the same disease in the East Indies

as in Norway, it was surprising that the gurjun oil should cure it in

the one place and not in the other. Later trials of the treatment in

India have had the same negative results as in Norway.

_Chaulmoogra_, which the medical department of Madras has used with

success, is the oil pressed from the seeds of Gynocardia odorata,

Lindl. Hydrocarpus odoratus, Lindl. The oil is given internally (2

grs. in an ounce of milk) twice daily, and externally, there is rubbed

in a mixture of oil 1 part, and olive oil 16 parts, followed some

hours after by a bath. We are told that the progress of the disease is

stopped by a persevering use of the oil. The skin becomes smoother and

more elastic, the patient becomes more energetic, the discolorations

disappear, and so too does the anæsthesia, either partly or completely.

Ulcerations heal, but promptly break down again. Besides the treatment,

a generous diet is given, especially vegetables, milk and meat; spices

and spirits are not allowed. Dr. Arjoon says that the tuberous form

heals more easily than the mixed leprosy, and that anæsthetic leprosy

is the most obstinate. When the disease is inherited there is no hope

of a cure, and it is only in early cases that a cure can be expected.

Further, he thinks that the permanence of the cure is doubtful.

In the Lungegaard’s hospital three tuberous and two anæsthetic patients

were treated with chaulmoogra oil. The treatment was continued from

eight months to a year, but the results were, as with the other

remedies, _nil_.

Father Etienne sent to the Lungegaard’s Hospital from Port of Spain,

Trinidad, a quantity of pills containing a vegetable, Hoang-nan, which

he had received from some missionaries in Ting-King. He had used the

pills for three years in leprosy with surprisingly good results. In

several patients all the external symptoms of the disease disappeared,

and he had good hopes of their complete cure. His report seeming

to guarantee the remedy, it was given a trial in the Lungegaard’s

Hospital. After prolonged use it proved to be absolutely useless, and,

since no more has been heard from him, Father Etienne has probably been

disappointed with his later results.

Father Damien also received from Ting-King a supply of pills for the

cure of leprosy, which were, no doubt, of the same nature. He found

them to consist of alum. sulph., pts. 1.5, Realgar 2.5, and Hoang-nan

2.5.

Hoang-nan belongs to the _Euphorbiaceæ;_ the cortex contains a powerful

poison which is the active remedy. At first Father Damien believed

the remedy to be of some benefit “to us poor lepers”--he was then a

leper--but further experience showed him that the remedy was, like so

many others, unsatisfactory.

The last remedy to be mentioned is one which once attracted much

notice, and on which the French academy allowed Dr. Gibert to write a

report. The remedy is _Assacou_ or _Ussacou_, Brazilian names of the

tree _Hura Braziliensis_, Martin, of the family _Euphorbiaceæ_. It is

considered very poisonous.

Several physicians in the West Indies have tried it, and amongst them

Dr. Maldur, who treated four lepers in Santa-Caza da Misericordia,

with, he believed, great benefit; other trials, however, failed, and

the remedy has been laid aside.

The foregoing reports of the results of the treatment of leprosy with

different specific remedies, are taken from the experience of the late

Dr. Danielssen, who spent half a century trying to cure leprosy, and we

shall now give some of the various methods of treatment he used.

Early in the development of bacteriological research, Dr. Danielssen

already suspected the bacterial nature of the disease, and began to use

germicides.

_Carbolic acid_ was given in solution, 8 grains to 8 ounces, 1

tablespoonful four times daily, and he went so far as to give 20 grains

to 8 ounces in the same way. Externally, he applied carbolic acid as an

ointment or a lotion. It was used by fifty-three lepers from three to

eighteen months, but had no effect on the disease.

_Creasote_ was used in 1838 by the late Dr. Hjort, and later by

Danielssen, without any good effect. Prof. Langerhans of Madeira, told

Dr. Danielssen that he had seen several lepers on Teneriffe, whom Dr.

Perez, at his suggestion, treated with creasote in increasing doses,

with good effect, and he therefore asked Dr. Danielssen to try it once

more. Consequently, creasote in pills (0.025 gr. in each pill) was

administered to five tuberous lepers, in an early stage of the disease.

They took the pills for six months without any effect on their leprosy.

Two of them took the pills for fifteen months, and as many as 20 pills

a day. The pills did neither good nor harm; their influence on leprosy

was _nil_.

In the early years of the Lungegaard’s hospital (1849-50) glacial

phosphoric acid was largely used without benefit.

_Phosphorus_ was given in doses of 2 to 3 milligrammes daily. After

some months it was given up because it caused indisposition and

destroyed the appetite, while the leprosy remained unaltered.

_Arsenic_ has been used by many physicians in the treatment of

leprosy. Dr. Danielssen tried it in the form of Fowler’s solution, and

the so-called Asiatic pills, in gradually increasing doses, but the

prolonged use of arsenic, instead of doing good, made the patients

worse, causing gastro-enteritis and emaciation. The emaciation caused

diminution in the size of the tubers, which has been regarded by many

physicians as an improvement; but this is a fallacy, for, when the

patient regains his former good condition, the nodules regain their

former size.

_Ichthyol_ was tried internally in the form of pills, 10 centigrammes

thrice daily, increased up to 2 grammes daily; but no benefit was

observed, although it was continued for almost a year.

From Dr. Englemann, in Kreuznach, Dr. Danielssen got a sample of

Kreuznach salt, and directions how to use it. The bath was prepared

thus: 3 lbs. of common salt, 4 lbs. of Kreuznach salt, 264 litres of

water. Temperature 35°C. After the lapse of a week the Kreuznach salt

was increased to 6 lbs., after a fortnight to 12 lbs., and after three

weeks to 16 lbs. The patient remained from one-and-a-half to two hours

in the bath, and no other medicine was taken. Forty-six baths were used

by five lepers, four tuberous, and one anæsthetic. At the same time,

a young man with a recent eruption of leprosy was sent to Kreuznach

to take the baths under Dr. Englemann’s directions. After a year Dr.

Danielssen saw him again, when no improvement was to be observed, and

the same was the result in the cases treated here.

_Mercury_ in its different combinations has been tried internally and

externally, but instead of producing any good effect it has rather made

the condition of the patient worse.

_Iodine_ has been used as iodide of potassium, and externally as

tincture of iodine and iodine ointment. At the beginning of his studies

in leprosy Dr. Danielssen had great confidence in iodine, but he soon

learned what a very dangerous remedy it was in this disease. Even small

doses of iodine produce new eruptions of leprous tubers or patches,

and Dr. Danielssen therefore ultimately used it as a test in cases of

apparent cure. When a patient was considered cured, he gave him iodide

of potassium, and if no new eruption developed, the cure was considered

complete.

Some years ago Dr. Unna, of Hamburg, claimed to have cured three

lepers, and Dr. Danielssen, using Unna’s method, cured one. The

treatment is the following: Internally, pills of ichthyol in increasing

doses; externally, the rubbing of arms and legs morning and evening

with an ointment of 10 per cent. pyrogallic acid in lanolin, and

the breast, back, neck, and cheeks, with 10 per cent. chrysarobin

in lanolin; the covering of the forehead and chin with a plaster

consisting of chrysarobin, salicylic acid, and creasote, which is

changed every second or third day. This treatment was continued from

December 16th, till January 11th; then followed a few days of plain

baths, and then the same treatment again. In the Lungegaard’s hospital

Dr. Unna’s treatment was tried by thirteen lepers, five nodular, four

anæsthetic, and four mixed. The results of the treatment were not so

satisfactory as in Dr. Unnas hands, and there was certainly no question

of a cure.

_Koch’s tuberculin_ was administered to five anæsthetic, three

tuberous, and three mixed cases, as a rule, daily, from January 8th to

May 8th. The dose at the commencement was 1 milligramme, and in several

cases as much as 320 milligrammes were finally injected. The injections

were made, sometimes daily, sometimes at intervals of a few days,

according to the degree of reaction which followed the injections.

In some cases the injections had to be stopped very soon, because

they produced fresh leprous eruptions; and in one case bacilli were

found in the blood. It seemed as if the tuberculin had set the bacilli

afloat. We came to the following general conclusions:--(1) Tuberculin

administered to lepers produces a general and local reaction, usually

forty-six hours after the injection, seldom after twelve hours, and

very seldom after two to three days. The local reaction becomes evident

later. (2) These reactions do not beneficially influence the leprosy,

they rather aggravate the disease by causing fresh eruptions just as

iodide does. (3) Tuberculin does not kill the lepra bacillus. (4)

Immunity against tuberculin can be attained, but this immunity does not

influence the progress of leprosy.

Dr. Carreau, in Guadaloupe, treated a leper with _chlorate of

potassium_, he believed with great benefit; he gave the remedy in

enormous doses. Dr. Hjort had, already, in 1838-39 tried this remedy

without effect. Dr. Beaven-Rake has also tried the remedy according to

Dr. Carreau’s directions, but also without result. Dr. Danielssen, too,

tried it, but without any benefit.

During the last few years the following remedies have been tried in

the Lungegaard’s hospital: Hydroxylamin, Europhen, Naphthol, Salol,

Methylene blue, Aristol.

_Hydroxylamin_ forms colourless crystals, easily soluble in alcohol

and glycerine. It is decidedly poisonous, and is, according to some

authors, a more powerful reducing agent than chrysarobin or pyrogallic

acid; 2 to 5 hydroxylamin to 20 glycerine and 80 alcohol, was painted

on the patches of four maculo-anæsthetic lepers. In two of them there

developed, after the painting, an erythema, during the persistence of

which the painting was discontinued. The painting was continued for two

months, and then a 2 per cent. hydroxylamin ointment was applied, but

as no amelioration could be noted after four or five months, the remedy

was laid aside. In four tuberous patients the painting could only be

continued for two or three days, because the spots re-acted severely,

grew red and painful, and vesicles formed. The tubers somewhat

diminished, but otherwise the condition remained unaltered.

_Europhen_ has some resemblance to iodoform, but gives up its iodine

less readily. It is a fine yellow powder, insoluble in water, but

soluble in alcohol, ether, chloroform, and oil. A solution in oil was

used for hypodermic injections: at first 0.015 europhen was injected,

and after a month 0.025. At the end of another month an eruption

developed in one of the patients; in the others no effects were

evident, and thereupon 0.030 was injected. After three weeks an iodine

eczema developed in three of the patients, and a leprous eruption in

another, and consequently no further trials were made. Dr. Julius

Goldschmidt of Madeira, has also used this remedy, and considers one of

his patients as almost cured, while four others remain unchanged.

_Aristol_ was tried by three patients, partly internally, dissolved in

ether, and partly externally, in the form of ointment; the effect was

the same as after the use of iodide of potassium, and it was stopped

after three weeks’ trial.

_Naphthol_ and _Salol_ were tried for a long time, but the effect was

almost _nil_. Salol has also been used by Dr. Lütz in the Sandwich

Islands, and by Surgeon Major Cook in Madras, but though some

amelioration in the condition of the patients has been noted, no case

has been cured.

_Methylene Blue_ was given to one tuberous patient, both internally

and hypodermically. The skin, especially the tubers, became deeply

blue, but a microscopical examination showed the bacilli unaltered. The

treatment was continued from May 20, 1891 till January 30, 1892. Some

tubers diminished a little, but most of them became larger, so that the

disease as a whole grew worse.

_Nerve stretching_ was first tried by Dr. Gerald Bamfert, who stated

that he had done the operation with success on an anæsthetic patient,

in whom both hands were atrophic and sensibility much diminished. The

ulnar nerve was stretched and incised longitudinally. The sensibility

in the right hand re-appeared immediately after the operation; and

after some days the muscular power was almost completely restored. In

three anæsthetic patients in the Lungegaard’s hospital the operation

was performed; the ulnar nerve was stretched and incised along a length

of three to four inches. All went well, only the anæsthesia remained

unchanged; neither sensibility nor muscular power was restored. Dr.

Beaven-Rake, who has done numerous nerve-stretchings in Trinidad, says,

“on the whole the results of nerve-stretching for anæsthesia cannot be

considered satisfactory.”

Dr. Beaven-Rake has also done the operation for pains in the limbs, for

which hypodermic injections of morphine have been successfully used in

the Lungegaard’s hospital.

_Electricity_, both faradic and galvanic, has been used for anæsthetic

leprosy, and electric baths, but no good effect has been attained.

Surgical measures are often needed. Section of the cornea, as

introduced by Dr. Boeckmann, in the case of tubers growing into it, has

already been mentioned, as has the operation of tarsoraphia interna in

ectropion of the lower eyelid. Iridectomy has often to be performed,

when the pupil has been obliterated by adhesions of the iris or by

exudation.

Tracheotomy is necessary when the larynx is occluded by leprous-growths

or by cicatrices.

Necrotomies should always be performed when there is necrosis of the

bones of the hands and feet. It is astonishing how well the wounds heal

in the anæsthetic parts, and patients are spared from long-standing

suppuration by the removal of the necrosed bones.

The best remedy for leprosy Dr. Danielssen found in his experience

to be _Salicylate of soda_. If the patients were badly nourished, he

first administered quinine, iron, cod-liver oil, and nutritious food,

and when the patient’s condition was satisfactory he gave 1.0 gramme

salicylate of soda four times daily, and for six months or a year the

dose was gradually increased. Its good effects were seen in both forms

of the disease. In the maculo-anæsthetic form the patches and the

less extensive anæsthesias slowly disappeared. In the tuberous form,

when not of too long duration and severity, the rapidity of progress

was diminished, and fresh eruptions were prevented. A complete cure

has, however, not been attained, unless, at the same time, there have

been applied regularly “cucurbita cruenta,” steam baths, alternating

with warm water and sea-water baths, exercise in the fresh air, good

hygienic surroundings, and good diet. From time to time irritants

were applied, such as, carbolic and salicylic acids, in the form of

fomentations and ointments. It is only in cases in the first six to

twenty-four months that a favourable issue can be hoped for. The

results of the treatment in the Lungegaard’s hospital are nothing to

boast of, but they show, according to Dr. Danielssen, that leprosy at

its commencement can be cured. In our opinion this is true, but with

the reservation that the cure is not due to the treatment, but is the

natural development of the disease. We have seen cases of leprosy, in

the country, both tuberous and maculo-anæsthetic, completely recover

without any treatment whatever. So far as we know, in most of the

patients discharged cured from the Lungegaard’s hospital the anæsthesia

has increased, which is in conformity with the general progress of

the disease, the nerve fibres continuing to undergo atrophy from the

pressure of the contracting inflammatory tissue in the nerve trunks, as

described above.

Treatment ought theoretically to be directed to the destruction of the

bacilli, and this is what Dr. Unna sought to attain by his reducing

remedies, pyrogallic acid, chrysarobin, etc.; but while Dr. Unna and

Dr. Deichmann succeeded in Hamburg, Dr. Danielssen had no success when

using the same remedies. Dr. Danielssen believed that the bacilli were

destroyed by salicylate of soda; but we fear that others will not

succeed with this same remedy.

As we are then, in our opinion, unable to destroy the bacilli with

remedies, either internal or external, it only remains to us to

prevent infection, and that can only be attained by isolation of those

affected. For this isolation no very costly measures are required.

From what we saw in North America in 1888, all that is wanted is

cleanliness, both personal, and in the household. But amongst the

people where leprosy prevails, it is almost impossible to get

sufficient cleanliness thoroughly enforced. We think, therefore, that

the best measures are those which have been taken in Norway, where the

lepers are isolated at their own request, and where the communities can

get rid of the disease, if they will, since the sanitary authorities

have the power to order the leper to live sufficiently isolated from

his family, and, if he cannot or will not assent to this, can compel

him to enter an asylum. At the same time, the doctrine of cleanliness

and isolation and the necessity of their observance in order to prevent

the spread of the disease, is constantly preached.

Since the state pays all the expenses of the lepers in the asylums,

their families are generally relieved by getting rid of the lepers,

who are almost invariably bad workers and unable to earn their living.

These measures are quite adequate in a democratic country like Norway,

where the communities have governed themselves since 1836, and the

results are most satisfactory, seeing that we had in 1856, 2833 lepers,

and at the end of 1890 only about 950, which number, when corrected,

will probably amount to about 1100.

Whether the same measures would be adequate in other countries where

leprosy prevails, we cannot of course say; it must depend on the social

condition of the community. But we are firmly convinced that isolation

_must_ be carried out in some appropriate fashion.

TABLES.

_TABLE I._

KEY:

Column heading

D - Duration of disease in years

Body of table

A - Amyloid

F - Fatty degeneration

L - Leprous

N - Normal

NpA - Acute nephritis

NpI - Interstitial nephritis

NpP - Parenchymatous nephritis

P - Pneumonia

Tr - Tubercular

Ts - Tuberculosis

U - Ulceration

----------------------------------------------------------------------

SHOWING THE FREQUENT COMPLICATION OF NODULAR LEPROSY

WITH TUBERCULOSIS.

---+----+---------------+----------+----------+----------+------------

---+----+---------------+----------+----------+----------+------------

1 | 11 | Normal. | A and L. | A and L. | F. | Amyloid.

2 | 6 | [1] | Leprous. | Tr. | F. | Normal.

3 | 10 | Hydro-thorax. | A and L. | Leprous. | ? | Normal.

4 | 5 | [2] | Leprous. | Amyloid. | Amyloid. | A and Tr U.

6 | 8 | Lobular P in | Leprous. | Leprous. | F. | Normal.

7 | 13 | Lungs | Leprous. | Leprous. | F. | Normal.

8 | 7 | [3] | Leprous. | Leprous. | Normal. | Normal.

9 | 5 | [4] | A and L. | Leprous. | A and F. | Amyloid.

10 | 6 | Œdema. | Leprous. | Leprous. | F. | Normal.

11 | 5 | [5] | A and L. | A and L. | Amyloid. | Amyloid.

12 | 11 | Normal. | Leprous. | Leprous. | NpI. | Normal.

13 | 9 | [6] | A & L. | L (?). | A and | A and Tr,

| | | (?) | | Tr. | Tr peri-

15 | 14 | Tr peri- | Tr. | Tr. | A and | A and Ts

| | and | | | | and

16 | 4 | Tr peri- | Tr, A, | Tr and A | Tr and | A, Tr U,

| | and | | | | Ts.

18 | 10 | Numerous | L and A. | L and A. | F. | [7]

19 | 6 | Numerous | Leprous. | Leprous. | NpI. | Ulcerating

| | gelatinous | | | | and

20 | 15 | Normal. | F. | Amyloid. | Amyloid. | Amyloid.

| | in R. | | | |

23 | 7 | [8] | Leprous. | L and A. | A and F. | Tr U.

| | ectasis and | | | F. |

| | | | | F. |

| | ties and | Tr. | Tr. | | follicles

| | lobular P. | | | | and

| | and pleura. | Tr. | Tr. | in R. |

30 | 4 | Caseous areas | Leprous. | Leprous. | [9] | Normal.

37 | 4 | Left Tr pleu- | Amyloid. | A and | Tr. | A, Tr peri-

38 | 6 | [10] | Leprous. | Leprous. | Normal. | [11]

39 | 6 | [12] | L and A. | L and A. | Tr & A. | Amyloid.

42 | 2 | Tubercular. | L & Tr. | L & Tr. | Normal. | Tr U.

44 | 8 | Lobular P, | L and A. | L and A. | NpA. | Normal.

48 | 4 | Tuberculosis. | Tr and | Amyloid. | Tr and | A, Tr

| | | A. | | A. | ulcer-

50 | 4 | [13] | Leprous. | Leprous. | Normal. | Tr U.

54 | 5 | Ts of lungs | L, Tr, | L and | Amyloid. | A, Tr U.

55 | 12 | [14] | L. (?) | [15] | Nephr- | Amyloid.

56 | 3 | Tuberculosis. | Cirrh- | L (?) | Normal. | Normal.

58 | 7 | Apical Ts. | Leprous. | Leprous. | NpI. | Normal.

59 | 21 | Œdema. | L (?). | L (?). | NpP. | Normal.

| | | | | Ts. |

61 | 10 | Normal. | Fatty. | Normal. | NpP. | Tr (?)

65 | 9 | Normal. | Leprous. | Leprous. | NpP. | Normal.

66 | 3 | Tuberculosis. | Leprous. | Leprous. | [16] | Normal.

67 | ? | [17] | Fatty. | Tr. | ? | Normal.

68 | ? | [18] | Leprous. | Leprous. | Normal. | Normal.

69 | ? | Tuberculosis. | Normal. | Normal. | NpI. | Normal.

70 | ? | Normal. | L and A. | L and A. | NpP. | Normal.

71 | ? | Normal. | Leprous. | Leprous. | NpI. | Normal.

| | | ous. | | |

74 | ? | Ts of lungs | Tr. | Tr. | Tr. | Tubercular.

76 | 2- | Tuberculosis. | Tr & A. | L and A. | Amyloid. | Tr., Tr.

| 3 | | | | | peri-

77 | ? | Tuberculosis. | Leprous. | L & Tr. | Normal. | Tubercular.

79 | 7 | Cavities. | L and A. | Amyloid. | NpP. | Normal.

80 | ? | Cavities. | L & Tr. | L & Tr. | Normal. | Tr.

84 | ? | Œdema. | L & can- | Leprous. | NpI. | Normal.

86 | ? | Tuberculosis. | Leprous. | L & Tr. | Normal. | Tr.

87 | 1½ | Tuberculosis. | L & Tr. | L & Tr. | Normal. | Tr.

88 | ? | Normal. | L and A. | Leprous. | NpP. | ?

Footnotes

---------

1 Left-sided Tr pleurisy; in lower lobes, lobular pneumonia.

2 Cavities in both apices; Tr peri-bronchitis in the upper lobes.

3 In both lower lobes pneumonia, with commencing cavity formation.

4 In the left lung, cavities in the apex, and widespread lobular

pneumonia. The same without cavity formation in the R.

5 In upper lobes, cavities, and lobular pneumonia.

6 Cavities, tubercular peri-bronchitis, pleural tuberculosis.

7 Peyer’s patches and solitary glands tubercular with commencing

ulceration.

8 Cavities, tubercular peri-bronchitis, and lobular pneumonia in

left lung.

9 R. tubercular, L. hydronephrosis, tubercular cystitis.

10 Tubercular peri-bronchitis and lobular pneumonia; tubercular

pleurisy in left lung.

11 Amyloid, localised tubercular peritonitis around the spleen.

12 Tubercular peri-bronchitis, lobular pneumonia and small cavities.

13 Tuberculosis, numerous large cavities, tubercular pleurisy.

14 Pleuro-pneumonia on right side, hydro-thorax sinistra, hydro-

pericardium, ascites.

15 Leprous (?) commencing amyloid degeneration.

16 Congested, otherwise normal.

17 Double pleurisy, caseous node of the size of a walnut in the

left lung.

18 Marked stenosis of larynx. Both apices infiltrated.

_TABLE II._

THE PROPORTION OF TUBERCULOSIS IN MACULO-ANÆSTHETIC LEPROSY.

---+-----------+----------+----------+----------+--------+----------+---------

---+-----------+----------+----------+----------+--------+----------+---------

| | | | | | |

| | | | | | |arm.

| | | | | | |

| | | | | | |

|between | | | | | |10-15 cm.

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |as a

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | |(?). | | |

| | | | | | |

| |and | | | | |

| | | | | | |

| |(?). | | | | |atrophic.

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

36 | |Degener- | | | | |

| |the | | | | |

| | | | | | |

_TABLE III._--THE PROPORTIONS OF THE TWO FORMS OF LEPROSY.

+------------------+-------------------------------------------------+

| | OF EVERY HUNDRED LEPERS FROM 1856 TO 1890 THERE |

| | BELONGED TO THE |

| | NODULAR FORM: |MACULO-ANÆSTHETIC FORM: |

+ +--------+------+--------+--------+------+--------+

| | her. | | | her. | | |

+------------------+--------+------+--------+--------+------+--------+

| part of Norway | 47.7 | 26.6 | 21.1 | 52.3 | 27.5 | 24.8 |

| { Lister | | | | | | |

| { and Mandal | 58.8 | 41.2 | 17.6 | 41.1 | 29.4 | 11.7 |

| { Stavanger | 60.6 | 34.7 | 25.9 | 39.3 | 21.0 | 18.3 |

| { Söndre | | | | | | |

| { Bergenhus | 68.0 | 34.2 | 33.8 | 31.9 | 15.3 | 16.6 |

| { Nordre | | | | | | |

| { Bergenhus | 66.8 | 34.9 | 31.9 | 33.0 | 17.2 | 15.8 |

| { Romsdal | 73.3 | 44.4 | 28.9 | 27.2 | 15.8 | 11.4 |

| { Söndre | | | | | | |

| { Trondhjem | 74.3 | 48.5 | 25.8 | 25.7 | 16.4 | 9.3 |

| { Nordre | | | | | | |

| { Trondhjem | 70.6 | 46.8 | 23.8 | 29.5 | 17.4 | 12.1 |

| { Nordland | 71.5 | 44.1 | 27.4 | 28.5 | 17.1 | 11.4 |

| { Tromsö | 79.1 | 52.9 | 26.2 | 20.9 | 13.1 | 7.8 |

| { Finmarken | 82.5 | 65.0 | 17.5 | 17.5 | 12.5 | 5.0 |

| Sogn | 56.6 | 31.8 | 24.8 | 43.4 | 23.0 | 20.4 |

| Söndfjord | 72.6 | 37.4 | 35.2 | 27.4 | 14.3 | 13.1 |

| Nordfjord | 68.5 | 33.9 | 34.6 | 31.3 | 16.9 | 14.4 |

+ -----------------+--------+------+--------+--------+------+--------+

_TABLE IV._

------------------------------------------------------------------------

THE RESULTS OF ISOLATION IN NORWAY

-----+----------+-------+-----------------------+----------------+------

| commence-| +------+-------+--------+----------------+at end

| ment | New | | | Emi- | At | In | of

-----+----------+-------+------+-------+--------+------+---------+------

1856 | -- | 238 | ? | ? | ? | 2598 | 235 | 2833

1857 | 2833 | 242 | 293 | 3 | 15 | 2339 | 427 | 2766

1858 | 2766 | 210 | 224 | 3 | 3 | 2294 | 475 | 2769

1859 | 2769 | 239 | 213 | 8 | 7 | 2267 | 523 | 2790

1860 | 2790 | 219 | 251 | 1 | 6 | 2218 | 539 | 2757

1861 | 2757 | 219 | 239 | 6 | 14 | 2028 | 711 | 2739

1862 | 2739 | 211 | 215 | 5 | 11 | 2009 | 698 | 2707

1863 | 2707 | 196 | 192 | 5 | 4 | 1947 | 749 | 2696

1864 | 2696 | 201 | 202 | -- | 8 | 1914 | 781 | 2695

1865 | 2695 | 201 | 205 | 5 | 8 | 1910 | 772 | 2682

1866 | 5682 | 203 | 214 | 3 | 10 | 1879 | 795 | 2674

1867 | 2674 | 200 | 191 | 8 | 4 | 1876 | 787 | 2663

1868 | 2663 | 206 | 210 | 6 | 7 | 1865 | 788 | 2653

1869 | 2653 | 183 | 199 | 10 | 13 | 1820 | 787 | 2607

1870 | 2607 | 187 | 203 | 4 | 13 | 1762 | 764 | 2526

1871 | 2526 | 170 | 238 | 2 | 16 | 1681 | 747 | 2428

1872 | 2428 | 131 | 205 | 5 | 10 | 1627 | 708 | 2335

1873 | 2335 | 129 | 177 | 9 | 17 | 1592 | 672 | 2264

1874 | 2264 | 137 | 183 | 6 | 9 | 1566 | 643 | 2209

1875 | 2209 | 134 | 203 | 5 | 14 | 1499 | 623 | 2122

1876 | 2122 | 115 | 187 | 3 | 6 | 1440 | 613 | 2053

1877 | 2053 | 110 | 163 | 3 | 7 | 1372 | 629 | 2001

1878 | 2001 | 105 | 149 | 10 | 8 | 1341 | 618 | 1959

1879 | 1959 | 88 | 162 | 5 | 10 | 1277 | 602 | 1879

1880 | 1879 | 72 | 150 | 7 | 7 | 1178 | 617 | 1795

1881 | 1795 | 60 | 164 | 5 | 8 | 1092 | 608 | 1692

1882 | 1692 | 66 | 137 | 11 | 7 | 1061 | 553 | 1614

1883 | 1614 | 87 | 127 | 9 | 5 | 1022 | 535 | 1557

1884 | 1557 | 55 | 140 | 10 | 2 | 944 | 519 | 1463

1885 | 1463 | 71 | 146 | 9 | 12 | 855 | 522 | 1377

1886 | 1377 | 48 | 135 | 16 | 9 | 748 | 522 | 1270

1887 | 1270 | 47 | 111 | 2 | 3 | 704 | 514 | 1218

1888 | 1218 | 27 | 99 | 8 | 1 | 631 | 524 | 1156

1889 | 1156 | 27 | 86 | 9 | 12 | 551 | 530 | 1081

1890 | 1081 | 10 | 122 | 6 | 2 | 447 | 507 | 954

PLATE VI.

_PLATE VI._

_Fig. 1._--Two cells from a fresh nodule in 1 per cent. osmic acid

(Gundlach, No. viii).

_Fig. 2._--Part of a section of a cutaneous leproma. Round cells with

clear stellate cells between them (Hartnack, No. ix).

_Fig. 3._--From a corneal leproma. Round cells with corneal

corpuscles between them (Hartnack, No. ix).

_Fig. 4._--From the border of a corneal leproma. Capillary surrounded

by round cells. Müller’s Fluid (Hartnack, No. ix).

_Fig. 5._--From the inside of a corneal leproma. A capillary

surrounded by round cells in among globi and corneal corpuscles

unchanged or filled with brown granules. Müller’s Fluid (Hartnack,

No. ix).

_Fig. 6._--The brushed-out network of a cutaneous leproma (Hartnack,

No. ix).

_Fig. 7._--From a corneal leproma. Capillary surrounded by round

cells free from bacilli, and outside these, cells filled with

bacilli. Seibert homogen. immersion 1/16.

_Fig. 8._--Cells from a cutaneous leproma. Eosin, Bismarck brown, and

Gentian-violet. Hardening in Fleming’s Solution. Seibert homogen.

immersion 1/16.

[Illustration: PLATE VI.]

PLATE VII.

_PLATE VII._

_Fig. 1._--Cells and globi from cutaneous lepromata. Müller’s Fluid

(Hartnack, No. ix).

_Fig. 2._--Globi from a leprous spleen.

_Fig. 3._--Two globi from the retina.

[Illustration: PLATE VII.]

PLATE VIII.

_PLATE VIII._

_Fig. 1._--Corneal corpuscles filled with brown granules (Hartnack,

No. ix).

_Fig. 2._--From a leproma of the iris. Round cells with stellate

cells (Hartnack, No. ix).

_Fig. 3._--Corneal space with round cells near the corneal corpuscles

(Hartnack, No. ix).

_Fig. 4._--Cells with two nuclei full of bacilli from a cutaneous

leproma. Seibert homog. immersion 1/16.

_Fig. 5._--Two cells with bacilli from a leprous spleen. Fuchsin,

methyl blue. Seibert homog. immersion 1/16.

_Fig. 6._--From a leprous liver. White blood corpuscles with bacilli

in a capillary. Seibert homog. immersion 1/16.

[Illustration: PLATE VIII.]

PLATE IX.

_PLATE IX._

_Fig. 1._--From a leprous liver. Bacilli in an endothelial cell of a

capillary. Seibert homog. immersion 1/16.

_Fig. 2._--Piece of a very leprous liver. Capsule below, cut surface

above.

_Fig. 3._--Cut surface of a very leprous spleen.

_Figs._ 4 and _5_ and _Plate X_, _Fig. 1._--Cross section of the

seminal canals with bacilli around the nuclei of the walls and in

the epithelium; in _Plate X_, _Fig. 1_, is shown an epithelial cell

filled with bacilli.

[Illustration: PLATE IX.]

PLATE X.

_PLATE X._

_Fig. 1._--Epithelial cell from a seminal canal, filled with bacilli.

_Fig. 2._--A globus with a vacuole in which are fragments stained

with Bismarck brown, probably the remains of nuclei.

_Fig. 3._--A globus lying in a cell; the nucleus and a part of the

cell-protoplasm preserved.

_Fig. 4._--An epithelial cell from a seminal canal, filled with

bacilli broken down into granules.

_Fig. 5._--Cross section of a blood-vessel with bacilli in the

endothelium and a white blood corpuscle filled with bacilli.

_Fig. 6._--Longitudinal section of a blood-vessel showing bacilli in

the endothelium, and a fibrinous coagulum enclosing two white blood

corpuscles, one of them filled with bacilli.

_Fig. 7._--Bacilli free between the red blood corpuscles.

_Fig. 8._--A connective tissue space from the tunica albuginea filled

with bacilli.

_Fig. 9._--Cross section of a blood-vessel with bacilli around the

nuclei of the surrounding connective tissue.

All the preparations from the testicle were hardened in Fleming’s

or Müller’s solutions, and the drawings made with a Seibert homog.

immersion lens 1/16. _Plate IX_, _Fig. 5_ with Seibert 1/8.

[Illustration: PLATE X.]

PLATE XI.

_PLATE XI._

_Fig. 1._--Bundle of nerve fibres from a ciliary nerve, the cells of

Schwann’s sheath filled with brown granules.

_Fig. 2._--The myelin sheath pressed in by a cell filled with

granules.

_Fig. 3._--Section from an old leprous macule.

_Fig. 4._--Section from a recent leprous macule.

Both sections stained with Fuchsin and Methyl-green. Seibert homogen.

immersion 1/16.

[Illustration: PLATE XI.]

PLATE XII.

_PLATE XII._

_Fig. 1._--Cross section of a leprous ulnar nerve. The darkly hatched

cells represent those filled with brown granules. It will be noted

that the axial cylinder is wanting in many of the nerve fibres

(Hartnack, No. ix).

_Fig. 2._--A piece of neurilemma with flat connective tissue cells

lying on it, containing brown granules darkened by osmic acid

(Gundlach, No. viii).

[Illustration: PLATE XII.]

PLATE XIII.

_PLATE XIII._

_Fig. 1._--Cross section of an atrophic muscle, growth of nuclei in

the perimysium. Low power.

_Fig. 2._--Cross section of an atrophic muscle with great development

of connective tissue. Low power.

_Fig. 3._--Proliferation of the nuclei of the perimysium. High power.

[Illustration: PLATE XIII.]

TRANSCRIBER’S NOTE-

1. Enclosed italics font in _underscores_.

2. Hyphenation has been standardized.

2. _TABLE I._: Abbreviations have been used as shown in the Key. Longer

entries have been replaced by indexes to Footnotes, which are listed at

the foot of the Table.