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Some results of treatment of leprosy in the Southern Sudan
631 rI'RANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL ]~IEDICINE AND HYGIENE.
Vol. XXX.
No. 6.
April, 1937.
SOME R E S U L T S OF T R E A T M E N T OF LEPROSY IN T H E S O U T H E R N SUDAN. BY
H. M. WOODMAN, M.B., B.CH.,* Sudan iVIedicalService.
The following data apply to the biggest leper settlement in Africa. An analysis is given of some 3,500 cases. A term of 6 years has been allowed to elapse before publication of observations and results, and it is felt that this should be long enough to assess the findings as of some definite value, and, as far as Central African leprosy is concerned, be a definite contribution to the advocacy or otherwise of treatment. The area in question has been described by CRUICKSHANK(1932). Country.--The frontiers of the Bahr el Ghazal area of the Sudan and the Belgian Congo, between latitudes 4 ° and 6 ° N., open savannah forest, with a rainfall of approximately 51 in., an altitude of 2,000 ft., and a temperature range from 54 ° to 100 ° F., covers some 15,000 square miles and carries a population of over 120,000. Ra ce.- -The people are entirely of the mesaticephalic Azande tribe, or its partially absorbed subordinates numbering nearly ten ethnologically related peoples. * .'~Iy thanks are due to D r . E. D. PRIDIE, Service, for p e r m i s s i o n to publish this paper.
D.S.O., O.B.E.,
Director, S u d a n M e d i c a l F*
632
LEPROSY IN SOUTHERN SUDAN.
Mode of L~fe.--They are purely agricultural, living on a carbohydrate diet based upon eleusine, manioc, maize, groundnuts, bananas, beans, and forest roots and herbs. They have no meat except in the short hunting season, and are completely deprived of milk. HistoricaL--There is no written record of these people earlier than the eighteen forties. The earliest reliable writers hardly mention the existence of leprosy. I cannot recall any reference to it at all by SCHWEINFURTH,YUNKER, CASATI, EMIN and GESSI. It is not, however, regarded as a new endemic disease by the people themselves. THE CAMPAIGN. A complete leprosy survey of the area was carried out in 1929-30. Patients were convened into three settlements, the biggest with 2,000 patients. The three main principles were :-(1) To register and segregate every advanced case, i.e., C2-3 or active N2, and " mixed " advanced cases. (2) To register and admit all others, from the earliest N1, who were willing to come in. (3) To register and inspect, but not admit, tile remainder and observe them as controls. The following analysis refers to Li Rangu which is the largest of the settlements. Up to date, 2,689 lepers have been admitted to the settlement, of whom 204 are segregated. There are 809 controls outside, not admitted or treated. Throughout the population there is a leprosy incidence of 2.8 per cent. as an average, and 7 per cent. as a maximum (by chiefs). Segregation, being carried out rather differently in different parts of the continent, is mentioned in more detail. This particular method, though by no means ideal, has been found, as far as it goes, to meet the conditions. Standard native mud and grass huts are built at 30 metre intervals, standing back 20 metres from an especially isolated road. Each leper has a hut to himself. If an uninfected wife, husband or child elects to remain with the patient, they will live in the adjoining separate hut. Each hut has its own plantation but extra rations are supplied bi-weekly, supplemented by 6 oz. palm oil, simsim, lulu oil or animal fat (when obtainable). If a leper is so disabled that he cannot help himself at all he has a subchief who is responsible for seeing that a next-door neighbour looks after his cultivation. Other relations are not allowed to sojourn, but no attempt is made to prevent them visiting the patient. Two watchmen are employed to check this. The tendency is for an uninfected wife or husband to desert. On these conditions there is not much difficulty in getting patients to stay.
H. M. WOODMAN.
633
Treatment.
(1) From the opening of the settlement until 1932 alepol was the standard treatment. Given at first intramuscularly and then intravenously with or without analgesics such as carbolic, courses were continued on standard lines until the weekly injection reached a maximum of 7 c.c. of 4 per cent. solution. These courses were later varied in combination with sodium hydnocarpate and gynocardate. At the same time macular and nodular areas were treated with 50 per cent. trichloracetic acid. Those cases which tended to improve reacted more favourably to sodium gynocardate. There was less complaint of pain and less chance of abscess formation. Accordingly : - (2) 1933 et seq.--sodium gynocardate became the standard treatment. The dosage and length of courses varied in certain individual cases and groups of cases but the general procedure adopted was on the following lines : Weekly injections of 3 c.c. of 3 per cent. were given for 3 months, followed by 2 weeks rest. Then 4 c.c. of 3 per cent. for 3 months, followed by 2 weeks rest. Then 5 c.c. of 3 per cent. for 3 months, followed by 4 weeks rest. A second similar course of weekly injections of 3 per cent. solution of sodium gynocardate was given, beginning with 4 c.c. and ending with 6 c.c. and with the same intervals of rest. This course was repeated after the final 4 weeks rest. Further treatment then commenced with weekly injections of 2 c.c. of 4 per cent. for one month and 3 c.c. for 2 months, followed by 2 weeks rest. Then 4 c.c. for 3 months and 2 weeks rest up to 5 c.c. of 4 per cent. for 3 months and a final 4 weeks rest. Cases subsequently continuing on sodium gynocardate injections commence with 3 c.c. of 4 per cent. but do not exceed 5 c.c. of 4 per cent. Iodine was tried for broken-down nodules. Ulcers were dressed with hydnocarpus oil or iodoform. Hydnestyle employed intradermally on nodular cases with some success was found impracticable through shortage of staff. (3) 1935 et seq. Methylene blue was used for selected segregated cases. Courses are given intravenously commencing with weekly injections of 2 c.c. of 0.5 per cent. solution, working up to 10 c.c. of 2 per cent. solution over a period of 12 months, allowing 2 weeks interval of rest every 2 months. At the end of 18 months a maximum of 5 c.c. of 5 per cent. solution was being given. Such a procedure did not give rise to the toxic symptoms (headache, backache, giddiness or syncope), found if the drug is pushed too liberally. (4) 1936. Four groups of advanced cases are now being observed and compared while undergoing treatment respectively by (i) trypan blue, (ii) fluorescein and sod. bicarb., (iii) methylene blue in higher concentrations, (iv) sodium gynocardate.
63'.[
LEPROSY IN SOUTHERN SUDAN.
An analysis is given (Table I) of 1,000 cases indicating progress by categories after 3 years of treatment. The eleven categories given have included the most advanced nervous types under " N2." An interesting table (Table II) is given of a series of early untreated cases for comparison.
TABLE I. ANALYSIS OF OVER 1 , 0 0 0 LEPER CASES UNDER TREATMENT.
Progress of Patients
Total
C1
C2
C3
N1
N2
C1N1
C1N2
LI RANGU.
C2N1
C2N2
C3N11 C3N2 i
Much improved
194
87
Improved
268
134
49
Quiescent
325
108
Worse
189
Cured" TOTAL
"
29 i --
35
6
20
1
10
5
1
34
]3
22
1
4
]5
4
2
87
1
33
20
28
6
13
14
5
10
18
25
6
ll
16
23
l0
25
23
11
11
62
36
1
21
1
1
--
--
--
--
i,038
383
191
134
56
94
18
52
20
24
-8
--
I 58
TABLE I I . ANALYSIS OF SOME LEPER CASES NOT UNDER TREATMENT.
Progress
of Patients
Total
C1
C2
Much improved
27
15
l1
0
1
Improved
14
6
4
2
1
Quiescent
180
100
34
12
18
Worse
25
15
4
1
4
" Cured "
27
9
5
2
6
273
145
48
17
30
TOTAL
C1N1
N1
1
635
H. M. "WOODMAN.
Commentary on Tables I and H .
It will be noted that spontaneous " cures " appear to number about 10 per cent. among the untreated. This is nearly double the percentage (6 per cent.) o f " cured " among the treated. But the cures among the untreated have occurred exclusively among the earliest cases, whereas the other group includes all categories. (By " cured " is meant cases in which no visible lesion is any longer apparent, a n d d o e s not refer to WADE'S definition--" arrested without deformity.")
TABLE I l I . ANALYSIS OF NON-SEGREGATED CASES UNDER TREATMENT~ 3 YEARS ~ATER.
P r o g r e s s of P a t i e n t s
Total
C1
C2
N1
C1N1
.
.
C1N2 .
.
C2N1
C2N2
" Cured "
1
Improved
18
2
5
3
1
2
1
2
2
Quiescent
66
12
12
5
8
6
5
9
9
Arrested
15
10
2
Worse
48
1
7
1
8
2
7
6
11
148
25
26
10
17
11
13
19
22
TOTAL
1
N2
.
2
" A r r e s t e d " b e i n g w h e r e the case has r e m a i n e d q u i e s c e n t over a p e r i o d of t h r e e y e a r s .
The improved (including both " much i m p r o v e d " and " improved ") constitute 44 per cent. of the treated compared with 15 per cent. of the untreated. The proportion of those worse among the untreated is twice as great as among the treated. The most disappointing results are with the advanced nodular and " mixed " cases, the majority of whom are worse. Generally speaking the results weigh clearly in favour of treatment. Conclusions based upon these analyses should be considered in the light of a similar review applied to the subsequent 3 years. Included in Tables III and IV are those cases contained in Tables I and II, with the exception of those segregated, who are referred to later. It would be misleading to compare Tables I I I and IV alone as an index to the efficacy of treatment, for Table III is made up largely of (a) cases who have,
636
LEPROSY IN SOUTHERN SUDAN.
continued treatment because of their persistent tendency to get worse and (b) contains more than 50 per cent. relatively advanced cases of the C2, N2, C1N2, C2N2 categories, though not so advanced as to be considered "infective" and therefore segregated.
Commentary on Tables I I I and I V .
Spontaneous " cures " have declined to 2.8 per cent. of the earliest cases. Under treatment only 12 per cent. show any further improvement. The percentage of those worse has increased from 18 to 30 per cent.
TABLE I V . ANALYSIS OF CASES NOT UNDER TREATMENT, 3 YEARS LATER.
i
Progress of Patients
Total
C1
C2
N1
" Cured "
25
12
1
8
Improved
55
13
19
9
Quiescent
308
96
72
Arrested
407
165
83
8
Worse
i N2 --
C1N1
C1N2
4
--
2
8
--
43
40
21
118
48
18
16
6
27
C2N1
C2N2
--
--
2
2
9
15
12
30
10
11
4
5
5
.
7 12
-I TOTAL
878
294
226
114
87
67
24
33
!
33
Among the untreated cases, broadly speaking, only 10 per cent. get worse and 9 to 14 per cent. improve. The vast majority remain quiescent or arrested. It is noteworthy that the numbers of those brought to stages of quiescence or arrest under treatment has increased from 31 to 56 per cent. of the total. These latter percentages are of little significance among the untreated controls which are de facto in earlier stages, predominantly quiescent when first brought under observation. Table V refers to advanced segregated cases treated with methylene blue. They had, in nearly all cases, received previous treatment with sodium gyno~cardate. The results are very discouraging.
H . M. W O O D M A N .
637
Five out of thirty-six C2N2 cases show some improvement ; eight out of nine C3 cases are worse ; and none improved. Only thirteen out of thirty-two advanced types show improvement. Some nodular cases showed doubtful temporary benefit, relapsing quickly into their usual course of decline. Other workers such as FITZGERALD(1934), in the Federated Malay States, report that 6 weeks is the optimum length of course for dye injections. It is possible that, in future experimental treatment, better results will accrue from their use confined to periods of weeks rather than months.
TABLE V . ANALYSIS OF ADVANCED SEGREGATED LEPERS TREATED WITH METHYLENE BLUE.
Progress of Patients
Total
Improved
13
Quiescent
22
Worse
47
TOTAL
82
C2 --
C2N1
C3N1
N2
C1N2
C2N2
C3N2
2
1
1
4
5
1
4
3
1
2
I
8
7
3
2
5
21
1
9
13
7
4
11
36
-1
-1
--
C3 --
]
10~0
SUMMARY.
Definite evidence is given in favour of treatment with chaulmoogra derivatives over a period of 3 to 4 years (vide commentary on Tables I and II). After this period further treatment appears to be of little or no avail except in special cases. A big proportion of early cases become arrested without interference but are assisted to do so by treatment. No method of treatment so far employed holds out much prospect for the advanced C3 cases whose destiny, when they survive, is generally the maimed and disabled N2 stage. The settlements are effective in removing the chief loci of infection from the district and in centralizing and simplifying the control of cases. In spite of the great incidence of leprosy it is important to note that only 10 per cent. of cases are any danger to their neighbours, as far as can be at present judged in the absence of repeated and exhaustive laboratory examinations.
638
LEPROSY IN SOUTHERN SUDAN.
REFERENCES.
ATKEY,O. F . H . (1934). T h e distribution of leprosy in the Southern Sudan with reference to climate and diet. Internat. ft. Leprosy, ii, 193. • (1935). Leprosy control in the Southern Sudan. Ibid., iii, 73. BRAZIL CONFERENCE ON TREATMENT OF LEPROSY. (1935). Leprosy Rev., vii, 72. (Abstracted and translated by Dr. J. W. LINDSAY from Revista de Leprologia de Sao Paulo, June, 1935.) CRUICKSHANK, A. (1932)• Leprosy in Southern Bahr el Ghazal. Ibid., iii, 1. FITZGERALD, R . D . (1934)• Rep. reed. Dep. F.M.S., 1933. MONTEL, L. R. (1934)• Traitement de la 16pre par le bleu de m6thyl6ne en injections intraveineuses. Bull. Acad. Mdd., cxii, 208. RosE, F . G . (1934). Curability of leprosy. Leprosy Rev., v, 152. (1935). Ibid., vi, 19. • (1936). Ibid.,vii, ll. RYaIE, G . A . (1934). Use of fluorescein and phthallic acid in leprosy• Internat. J. Leprosy, ii, 139.
Vol. XXX.
No. 6.
April, 1937.
SOME R E S U L T S OF T R E A T M E N T OF LEPROSY IN T H E S O U T H E R N SUDAN. BY
H. M. WOODMAN, M.B., B.CH.,* Sudan iVIedicalService.
The following data apply to the biggest leper settlement in Africa. An analysis is given of some 3,500 cases. A term of 6 years has been allowed to elapse before publication of observations and results, and it is felt that this should be long enough to assess the findings as of some definite value, and, as far as Central African leprosy is concerned, be a definite contribution to the advocacy or otherwise of treatment. The area in question has been described by CRUICKSHANK(1932). Country.--The frontiers of the Bahr el Ghazal area of the Sudan and the Belgian Congo, between latitudes 4 ° and 6 ° N., open savannah forest, with a rainfall of approximately 51 in., an altitude of 2,000 ft., and a temperature range from 54 ° to 100 ° F., covers some 15,000 square miles and carries a population of over 120,000. Ra ce.- -The people are entirely of the mesaticephalic Azande tribe, or its partially absorbed subordinates numbering nearly ten ethnologically related peoples. * .'~Iy thanks are due to D r . E. D. PRIDIE, Service, for p e r m i s s i o n to publish this paper.
D.S.O., O.B.E.,
Director, S u d a n M e d i c a l F*
632
LEPROSY IN SOUTHERN SUDAN.
Mode of L~fe.--They are purely agricultural, living on a carbohydrate diet based upon eleusine, manioc, maize, groundnuts, bananas, beans, and forest roots and herbs. They have no meat except in the short hunting season, and are completely deprived of milk. HistoricaL--There is no written record of these people earlier than the eighteen forties. The earliest reliable writers hardly mention the existence of leprosy. I cannot recall any reference to it at all by SCHWEINFURTH,YUNKER, CASATI, EMIN and GESSI. It is not, however, regarded as a new endemic disease by the people themselves. THE CAMPAIGN. A complete leprosy survey of the area was carried out in 1929-30. Patients were convened into three settlements, the biggest with 2,000 patients. The three main principles were :-(1) To register and segregate every advanced case, i.e., C2-3 or active N2, and " mixed " advanced cases. (2) To register and admit all others, from the earliest N1, who were willing to come in. (3) To register and inspect, but not admit, tile remainder and observe them as controls. The following analysis refers to Li Rangu which is the largest of the settlements. Up to date, 2,689 lepers have been admitted to the settlement, of whom 204 are segregated. There are 809 controls outside, not admitted or treated. Throughout the population there is a leprosy incidence of 2.8 per cent. as an average, and 7 per cent. as a maximum (by chiefs). Segregation, being carried out rather differently in different parts of the continent, is mentioned in more detail. This particular method, though by no means ideal, has been found, as far as it goes, to meet the conditions. Standard native mud and grass huts are built at 30 metre intervals, standing back 20 metres from an especially isolated road. Each leper has a hut to himself. If an uninfected wife, husband or child elects to remain with the patient, they will live in the adjoining separate hut. Each hut has its own plantation but extra rations are supplied bi-weekly, supplemented by 6 oz. palm oil, simsim, lulu oil or animal fat (when obtainable). If a leper is so disabled that he cannot help himself at all he has a subchief who is responsible for seeing that a next-door neighbour looks after his cultivation. Other relations are not allowed to sojourn, but no attempt is made to prevent them visiting the patient. Two watchmen are employed to check this. The tendency is for an uninfected wife or husband to desert. On these conditions there is not much difficulty in getting patients to stay.
H. M. WOODMAN.
633
Treatment.
(1) From the opening of the settlement until 1932 alepol was the standard treatment. Given at first intramuscularly and then intravenously with or without analgesics such as carbolic, courses were continued on standard lines until the weekly injection reached a maximum of 7 c.c. of 4 per cent. solution. These courses were later varied in combination with sodium hydnocarpate and gynocardate. At the same time macular and nodular areas were treated with 50 per cent. trichloracetic acid. Those cases which tended to improve reacted more favourably to sodium gynocardate. There was less complaint of pain and less chance of abscess formation. Accordingly : - (2) 1933 et seq.--sodium gynocardate became the standard treatment. The dosage and length of courses varied in certain individual cases and groups of cases but the general procedure adopted was on the following lines : Weekly injections of 3 c.c. of 3 per cent. were given for 3 months, followed by 2 weeks rest. Then 4 c.c. of 3 per cent. for 3 months, followed by 2 weeks rest. Then 5 c.c. of 3 per cent. for 3 months, followed by 4 weeks rest. A second similar course of weekly injections of 3 per cent. solution of sodium gynocardate was given, beginning with 4 c.c. and ending with 6 c.c. and with the same intervals of rest. This course was repeated after the final 4 weeks rest. Further treatment then commenced with weekly injections of 2 c.c. of 4 per cent. for one month and 3 c.c. for 2 months, followed by 2 weeks rest. Then 4 c.c. for 3 months and 2 weeks rest up to 5 c.c. of 4 per cent. for 3 months and a final 4 weeks rest. Cases subsequently continuing on sodium gynocardate injections commence with 3 c.c. of 4 per cent. but do not exceed 5 c.c. of 4 per cent. Iodine was tried for broken-down nodules. Ulcers were dressed with hydnocarpus oil or iodoform. Hydnestyle employed intradermally on nodular cases with some success was found impracticable through shortage of staff. (3) 1935 et seq. Methylene blue was used for selected segregated cases. Courses are given intravenously commencing with weekly injections of 2 c.c. of 0.5 per cent. solution, working up to 10 c.c. of 2 per cent. solution over a period of 12 months, allowing 2 weeks interval of rest every 2 months. At the end of 18 months a maximum of 5 c.c. of 5 per cent. solution was being given. Such a procedure did not give rise to the toxic symptoms (headache, backache, giddiness or syncope), found if the drug is pushed too liberally. (4) 1936. Four groups of advanced cases are now being observed and compared while undergoing treatment respectively by (i) trypan blue, (ii) fluorescein and sod. bicarb., (iii) methylene blue in higher concentrations, (iv) sodium gynocardate.
63'.[
LEPROSY IN SOUTHERN SUDAN.
An analysis is given (Table I) of 1,000 cases indicating progress by categories after 3 years of treatment. The eleven categories given have included the most advanced nervous types under " N2." An interesting table (Table II) is given of a series of early untreated cases for comparison.
TABLE I. ANALYSIS OF OVER 1 , 0 0 0 LEPER CASES UNDER TREATMENT.
Progress of Patients
Total
C1
C2
C3
N1
N2
C1N1
C1N2
LI RANGU.
C2N1
C2N2
C3N11 C3N2 i
Much improved
194
87
Improved
268
134
49
Quiescent
325
108
Worse
189
Cured" TOTAL
"
29 i --
35
6
20
1
10
5
1
34
]3
22
1
4
]5
4
2
87
1
33
20
28
6
13
14
5
10
18
25
6
ll
16
23
l0
25
23
11
11
62
36
1
21
1
1
--
--
--
--
i,038
383
191
134
56
94
18
52
20
24
-8
--
I 58
TABLE I I . ANALYSIS OF SOME LEPER CASES NOT UNDER TREATMENT.
Progress
of Patients
Total
C1
C2
Much improved
27
15
l1
0
1
Improved
14
6
4
2
1
Quiescent
180
100
34
12
18
Worse
25
15
4
1
4
" Cured "
27
9
5
2
6
273
145
48
17
30
TOTAL
C1N1
N1
1
635
H. M. "WOODMAN.
Commentary on Tables I and H .
It will be noted that spontaneous " cures " appear to number about 10 per cent. among the untreated. This is nearly double the percentage (6 per cent.) o f " cured " among the treated. But the cures among the untreated have occurred exclusively among the earliest cases, whereas the other group includes all categories. (By " cured " is meant cases in which no visible lesion is any longer apparent, a n d d o e s not refer to WADE'S definition--" arrested without deformity.")
TABLE I l I . ANALYSIS OF NON-SEGREGATED CASES UNDER TREATMENT~ 3 YEARS ~ATER.
P r o g r e s s of P a t i e n t s
Total
C1
C2
N1
C1N1
.
.
C1N2 .
.
C2N1
C2N2
" Cured "
1
Improved
18
2
5
3
1
2
1
2
2
Quiescent
66
12
12
5
8
6
5
9
9
Arrested
15
10
2
Worse
48
1
7
1
8
2
7
6
11
148
25
26
10
17
11
13
19
22
TOTAL
1
N2
.
2
" A r r e s t e d " b e i n g w h e r e the case has r e m a i n e d q u i e s c e n t over a p e r i o d of t h r e e y e a r s .
The improved (including both " much i m p r o v e d " and " improved ") constitute 44 per cent. of the treated compared with 15 per cent. of the untreated. The proportion of those worse among the untreated is twice as great as among the treated. The most disappointing results are with the advanced nodular and " mixed " cases, the majority of whom are worse. Generally speaking the results weigh clearly in favour of treatment. Conclusions based upon these analyses should be considered in the light of a similar review applied to the subsequent 3 years. Included in Tables III and IV are those cases contained in Tables I and II, with the exception of those segregated, who are referred to later. It would be misleading to compare Tables I I I and IV alone as an index to the efficacy of treatment, for Table III is made up largely of (a) cases who have,
636
LEPROSY IN SOUTHERN SUDAN.
continued treatment because of their persistent tendency to get worse and (b) contains more than 50 per cent. relatively advanced cases of the C2, N2, C1N2, C2N2 categories, though not so advanced as to be considered "infective" and therefore segregated.
Commentary on Tables I I I and I V .
Spontaneous " cures " have declined to 2.8 per cent. of the earliest cases. Under treatment only 12 per cent. show any further improvement. The percentage of those worse has increased from 18 to 30 per cent.
TABLE I V . ANALYSIS OF CASES NOT UNDER TREATMENT, 3 YEARS LATER.
i
Progress of Patients
Total
C1
C2
N1
" Cured "
25
12
1
8
Improved
55
13
19
9
Quiescent
308
96
72
Arrested
407
165
83
8
Worse
i N2 --
C1N1
C1N2
4
--
2
8
--
43
40
21
118
48
18
16
6
27
C2N1
C2N2
--
--
2
2
9
15
12
30
10
11
4
5
5
.
7 12
-I TOTAL
878
294
226
114
87
67
24
33
!
33
Among the untreated cases, broadly speaking, only 10 per cent. get worse and 9 to 14 per cent. improve. The vast majority remain quiescent or arrested. It is noteworthy that the numbers of those brought to stages of quiescence or arrest under treatment has increased from 31 to 56 per cent. of the total. These latter percentages are of little significance among the untreated controls which are de facto in earlier stages, predominantly quiescent when first brought under observation. Table V refers to advanced segregated cases treated with methylene blue. They had, in nearly all cases, received previous treatment with sodium gyno~cardate. The results are very discouraging.
H . M. W O O D M A N .
637
Five out of thirty-six C2N2 cases show some improvement ; eight out of nine C3 cases are worse ; and none improved. Only thirteen out of thirty-two advanced types show improvement. Some nodular cases showed doubtful temporary benefit, relapsing quickly into their usual course of decline. Other workers such as FITZGERALD(1934), in the Federated Malay States, report that 6 weeks is the optimum length of course for dye injections. It is possible that, in future experimental treatment, better results will accrue from their use confined to periods of weeks rather than months.
TABLE V . ANALYSIS OF ADVANCED SEGREGATED LEPERS TREATED WITH METHYLENE BLUE.
Progress of Patients
Total
Improved
13
Quiescent
22
Worse
47
TOTAL
82
C2 --
C2N1
C3N1
N2
C1N2
C2N2
C3N2
2
1
1
4
5
1
4
3
1
2
I
8
7
3
2
5
21
1
9
13
7
4
11
36
-1
-1
--
C3 --
]
10~0
SUMMARY.
Definite evidence is given in favour of treatment with chaulmoogra derivatives over a period of 3 to 4 years (vide commentary on Tables I and II). After this period further treatment appears to be of little or no avail except in special cases. A big proportion of early cases become arrested without interference but are assisted to do so by treatment. No method of treatment so far employed holds out much prospect for the advanced C3 cases whose destiny, when they survive, is generally the maimed and disabled N2 stage. The settlements are effective in removing the chief loci of infection from the district and in centralizing and simplifying the control of cases. In spite of the great incidence of leprosy it is important to note that only 10 per cent. of cases are any danger to their neighbours, as far as can be at present judged in the absence of repeated and exhaustive laboratory examinations.
638
LEPROSY IN SOUTHERN SUDAN.
REFERENCES.
ATKEY,O. F . H . (1934). T h e distribution of leprosy in the Southern Sudan with reference to climate and diet. Internat. ft. Leprosy, ii, 193. • (1935). Leprosy control in the Southern Sudan. Ibid., iii, 73. BRAZIL CONFERENCE ON TREATMENT OF LEPROSY. (1935). Leprosy Rev., vii, 72. (Abstracted and translated by Dr. J. W. LINDSAY from Revista de Leprologia de Sao Paulo, June, 1935.) CRUICKSHANK, A. (1932)• Leprosy in Southern Bahr el Ghazal. Ibid., iii, 1. FITZGERALD, R . D . (1934)• Rep. reed. Dep. F.M.S., 1933. MONTEL, L. R. (1934)• Traitement de la 16pre par le bleu de m6thyl6ne en injections intraveineuses. Bull. Acad. Mdd., cxii, 208. RosE, F . G . (1934). Curability of leprosy. Leprosy Rev., v, 152. (1935). Ibid., vi, 19. • (1936). Ibid.,vii, ll. RYaIE, G . A . (1934). Use of fluorescein and phthallic acid in leprosy• Internat. J. Leprosy, ii, 139.