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50 YAX GAASBEEK-CH.\17L"'.\IOOGR \. OlL. Yol. XYIII. The indoor occupations that should be provided might include carpentry, wood carving, metal work and cement work and, "-here facilities are afforded, printing, bookbinding. electric wiring, and cigaret making. The outdoor occupations should include farminO' ()'ardenin<Y car"' el e ,,.. "' of stock, building operations, wood chopping. These outdoor occupations become productiYe occupations if the patient is permitted to utilize the results of his labor by selling his product after purely business arrangements have been made with the hospital for the raw material used, or for rent of land occupied in gardening, farming, or raising stock. Care must be taken to prevent any given occupation from be- coming humdrum. Neither should it ever be below the patient's ability. The time is past when theater parties, motor rides. and basebalI games accomplish anything for our ·psycho-neurotic cases. These patients should not be allowed to substitute time-passin<Y pleasures for therapeutic occupations. They must be made to feel that they are merely sojourning temporarily in the hospital that thev are simply being overhauled for full duty later. ' · A REPORT ON THE USE OF CHAULHOOGRA OIL DERIVATIVES IN LEPROSY. By c. B. VAN GAASBEEK, Lieutenant, Medical Corps, United States Navy. r·In. this report ?f the results of the treatment of leprosy in the \ irgm Islands with the ethyl ester derivatives of chaulmooO'rn oil ~o claim is made for originality. All credit for the results obtained IS due to Doctors McDonald and Dean and their coworkers in Hawaii, who first instituted this method of treatment at the Kalihi Hospital in Honolulu, and whose preparation of the oil we used and whose technic we :followed. It is our purpose to show the effect of the ethyl esters of chaulmoogra oil upon the rnrious clinical mani- festat~ons of the. disease as compared with the same clinical symp- toms m some p~tients who did not take the treatment. At our leper colony on th~ ISiand of St. Croix, Virgin Islands, :for the period covered ~y tlus report there were 72 patients, 37 of whom requested and received treatment, while 35 refused treatment. Those who refused .tr:atme~t ?id so :for religious reasons. They belonged to the Christian M1ss10n Church and believed only in divine healinO" and refused all manner of treatment, except plain water dressing~ for their ulcers. O:f those that received the treatment there were 27 of the anesthetic type, 2 of the nodular, and 8 of the combined nodular-anesthetic ='O· 1. Y.\X GAASBEEK-CHAUL~IOOGRA OIL. 51 cvpe. Of those that refused treatment there were 23 of the anes- tlietic type: none of the nodular, and 12 of the mixed type. Treatment was started on February 8, 1921, with the ethyl ester dcrinitiYes of the fatty acids of clia11lmoogra oil receiv.ed from Hawaii under the arbitrary title of HI. Since our supply of the oil was lim- ited, we administered it only to those requesting it. \Ye gaxe 1 c. c. the fir~t week intramuscularly into the buttocks; 2 c. c. for the next three weeks; 3 c. c. :for the following six weeks, at which time, April i:3. 19:H, our supply was exhausted and we were forced to discontinue the treatment until September 7, 1921, when, with a new and large supply of the oil on hand, we were able to begin again. EYen ·with the relatively low number of injections and the smnll dosage given :rnd the long period of five months in which there was no medica- tion, the results obtained are deemed worthy of note. During the period of injections the patients received tonics, the best food obtain- able, plenty of exercise, recreation, and rest and small amounts of chaulmoogra oil in capsule by mouth. It was :found that the ma- jority of the patients could not take much oil by mouth and it was difficult to continue the oil in greater doses than one-sixth gramme three times a day. In a large number of cases even this small dosage had to be frequently discontinued :for variable intervals and in some to be stopped altogether. ln our series the nasal smear was positive. for Bacillus leprae in 23 of those who received the treatment. Under treatment the nasal ~mear became negative in every case. Of those who refused treat- ment there also were positive nasal smears in 23 patients. Of these latter, 15 have become negative without treatment and 8 are still positi' e. The effect o:f the treatment upon the nodules was truly remarkable. There were 10 patients who had nodules in which the disease had exi~ted from 1 to 9 years. The more marked changes were noticed in thoy.;e patients having leprosy under 6 years' duration. In 2 of the paticnb the nodules entirely disappeared; in 5 patients most of the nodules were gone, but a few remained "·hich were comparatively tiny; in the remaining 3 patients the nodules were smaller in size and much softer in consistency. In every case there was evidence of marked improvement. Although the nodules were not directly in- jected. they could be seen getting smaller week by week. Of the 12 patients that had nodules ancl refused treatment there wa<: no change for the better in any of them. In eight there was no apprl'<'iable change. In four the nodules were more numerous. harcler- in eonsistency, and the skin infiltrated to a far gr enter extent. In 01w patient the nodules became so large and numerous that they ronl<l not be accurately recorded on the outline fi~nre chart. 52 Y.\X GAASBEEK-Cl I AUL:\fOOGRA OIL. Yo!. XVIII. The effect of the treatment upon the macules was no less striking. Of those patients taking treatment there "·ere macules present on either the face, body. or extremities in 29. Even after the limited tr<:'atment given these disappeared entirely in 12 patients. In 8 patients th~y became smaller, faded, and approached the normal color of the skin. In 5 patients some of the macules had disappeared while the remaining ones were faded. In 4 patients there was no appreciable change. In 1 patient, at the beginning of the treatment, there were 29 areas of disturbed pigmentation; in January, 1922. there were only 4 areas, and these were small and much faded. In om· experience the duration of the disease had no effect upon the disappearance of the macules under treatment. They disappeared in patients who had had leprosy 2, 10. and 12 years, and remained unchanged in patients having had leprosy 2, 3, 6, and 8 years. In one patient the macules, which had begun to fade, became more evi- dent when she became pregnant. In no patient, however, did the blotchy condition of the skin become worse under treatment. In the patients who refused treatment there were macules present in 25. During the period of this report they disappeared in 2; remained the same in 16; and became more marked and numerous in 7. Upon the leprous ulcerations the results were not so striking. This was probably due to the fact that in most of the ulcers there was a secondary invasion by pyogenic organisms upon which the chaul- moogra oil had seemingly no effect. There were ulcers present in eight patients receiving treatment. In four of these the ulcers promptly healed; in one patient the large perforating plantar ulcers became smaller and granulating; while in three patients there was no change. The duration of the disease did not seem to have any effect upon the healing of the ulcers. Healing seemed to depend rather upon the duration of the ulcer and the extent of the anesthesia. In cases where the ulcers were comparatively recent and the anesthesia slight, there was prompt healing when treatment was instituted. In cases where the ulcers were of long standing and involved bone, and the anesthesia was total, there was no change or, at the most, only slight improvement. In the patients who refused treatment. ulcers were present in 18. Withont treatment 1 healed. 4 remained the same, and the ulcera- tions in the 13 remaining patients became progressively worse. The effect of this method of treatmeqt upon disturbed sensation was marked. At the beginning of the treatment there was anesthe- sia, either slight, marked, or total, in 35 patients. In 6 patients the anesth<:'sia C'leared up entirely; in 20 patients there was improvement: while in the remaining 9 there was no change. In those who im- proYecl. the areas of total or marked anesthesia became slight, or the :'\o. l . VAX GAASBEEK-CHAUL:\IOOGRA OIL. 53 areas of slight anesthesia disappeared. The patients who showed no change or very little improvement were those that had had leprosy for a long period of time, such as for 13, 18, and 25 years. ;\fost improvement was seen in patients ha.Ying leprosy less than ,i y('ars. but, improvement was quite marked in those having leprosy le~ than 10 years. Our records show slight improvement in one patient having had leprosy for 35 years. In no case did the sensory disturbance become worse under treatment. In the patients that refused treatment anesthesia was present in all 35 cnses. Of these, 19 remained the same, while in the remaining t 6 the condition became worse either by extension of the areas of anesthesia or by the anesthesia becoming more marked in the areas already present. In no case was there improvement. Since this treatment was instituted there have been four patients paroled. Two of these patients were entirely free from symptoms, while the other two still had small areas of slight anesthesia. In two of the patients the duration of the leprosy was 3 years. in one 6 wars, and in the other 9 years. · ~one of the patients that have refused treatment haYe improved ~o as to be paroled. The rules that regulate the paroling of the patients provide that tlw:v must have at least three successive negative nasal smears and none positive for leper bacilli within the last 6 months; one smear to he taken following a coryza incited by iodides. There must be no open lesions. There must be some improvement in the sensory condi- tion. Nodnles must have entirely disappeared. Patients considered ready to be paroled are examined by two physicians who must find them free from any active manifestations of the disease that would . onstitute a menace to the community should they be released. rn<ler these conditions patients are paroled for two years, during which time they are kept under observation. There are now seven patients ready to be paroled and one patient who will be ready to be paroled within a few months. Unless there are urgent reasons for paroling patients sooner, it has been considered better to keep them a reasonable length of time so that the maximum improvement might be observed. Besides the 4 paroled patients and the 8 that can be paroled, im- pro>ement was noted in 18 of those receiving treatment. No improve- ment was found in 7. On the whole more marked improvement was observed in patients having leprosy less than 5 years, although considerable improvement was found in those of 5-10 years' duration. Those that showed no improvement had had leprosy 6, 8, 13, 18, and 25 years, respectively. Xone of the patients refusing treatment improved. Twenty-two r<:'mainecl the same and 13 have become progressively worse. / 54 VA2I GAASBEEK-CHA"C"LMOOGRA OIL. Vol. <XYIIL A few case histories are given to show the effect of the chaulmoogra oil derivatives upon nodules, ulcers, macules, a,nd sensation. Case 1. H. R. ; male ; age, 18. Admitted to leper colony March 26. 1915. Three years before admission he noticed nodules on bis legs and later on his. face and ears, and his hands became swollen. Nasal smears were constantly positive for B. leprae. Treatment was started. on February 15, 1921. At this. time examination showed an ad•anced condition. His upper eyelids were- thickened, his nose enlarged with large nodules on both alae. Part of cartilagi- nous nnd bony septum was absorbed. His upper lip was thickened and ul- cerated on the inner surface, lower lip was thickened. Tongue was thickened and covered with nodules. Ears were large, thickened, and nodular. Skin ove1· forehead, cheeks, chin, and face generally thickened and gave a leontine ap- pearance. Neck was slightly thickened and covered with nodules. Chest: Upper anterior part thickened and nodular; posteriorly, nodules and blotches present. Abdomen covered with small nodules. Uppe1· extremities: Very nodula1· throughout, ulcers oyer both olecranons. all fingers enlarged, ulcer present on dorsum of right hand. Lower extremities: :\oclular, skin generally thickened, feet enlarged and show scars of former ulcers. Sensation: Complete anesthesia of feet and legs as far as kuees; slight anesthesia of hands and forearms. Examination in January, 1922, after treatment. showed the following: Small nodules present on forehead, nose, both ears, lips, noel chin; rest of body shows slightly thickened skin where nodules had become absorbed. The leontiue expression had gone, ulcers had healed, macules bacl disappearecl, and hml(ls were slightly swollen. Sensation: Slight anesthesia of face, hands and forearms, feet aucl leJ!s. Case 2. J. S.; male; age, 14; admitted to leper colony on Octobe1· 21. 1919. Nasal smear positive for B. leprae. Several months before admission patient noticed macules above right eye. These blotches became larger and patient was sent to this institution. Examination at beginning of treatment on Febru- ary 15, 1921, showed general discoloration of face with normal skin at irregular intervals. Neck showed 40-50 light patches. Chest, abdomen, and back showed many irregular macules. All extt·emities showed many macules which were· slightly anesthetic. In .January, 1922, there were present instead of a couple hundred blotches, only seventeen. and these were so faint that they could be· made out with difficult~'. His face bad entirely cleared up and the nasal smear was negati\·e for B. levrae. Case 3. A. 1\l.; female; age. 40; ndmittecl to tile leper colony on Octobt>r 18, 1818. Treatment was started on Febnrnry 15, 1921. At this time she bail an ulcer on the inner side of her right great toe and a few light-colored nreas- on th<> face that merged into one another. );'asal smear was positive for H. leprae. Scn~at:on: Slight anesthesis of hands, more on ulnar s!de and areas on forearms; moderate anesthesia of both feet and of lower half of left leg anteriorly ; slight anesthesia of entire right leg and of upper half of left leg nnteriorly ancl entire left leg posteriorly. In Januar~· . 1922, examination showed the following: Nasal smears were negative for B. leprae; there were no blotches -011 fnce, and the ulcer ha<l healed. Sensation: There was slight anesthesia of botll hands, a patch of slight nnesthesia on right leg anteriorly, slight anesthesia of both legs poste- riorly. On 1\lay 6, 1922, there were no ulcers, blotches, or anesthesia anf1 the- patient was paroled. Case 4. W. R.; boy; age, 31 years; admitted to leper colony on May 24. 1921. A short time before admission there had been noticed light spots on his ' :-;o. 1. VAN GAASBEEK-CHAULMOOGRA OIL. 55 (ace tlmt w<>rc .slightly anestlletic. Repeated nasal smears were negative. P,irnmiuntion showed well-flefiuecl blotches of lighter skin on face and upper and lower extremities. These spots "ere moderately anesthetic. Sensation: Moder- ate anestllesia of bands and forearms. slight anesthesia of arms, and slight anesthesia of entire lower extremities. Treatment was started on Sentember 7, l921 at which time he received one-half e. c. Because of his youth he never Ms ~eceived more than 3 c. c. Up to January, 1922, he had received, besides l!is initial dose of one 1 c. c., thirteen 2. c. c. doses and two 3 c. c. closes. Ex- nmilllltiou in .Jnnuary, 1922. sho\'l"ed the spots much smaller and so faint that tlley <'onld with difficulty be made out. There was no anesthesia. Cnse 5. L. C.; female; age, 15; admitted to the leper colony on .January 21, 1921. On admission examination showed. many irregular mncules on face, trunl,, and extremities. All of these areas \Yere slightl y nnesthetic. There wa~ loss fff eml of right middle finger and. tlexor contracture of the second, third, and fourth fingers of left hand. Treatment was started on February 15, 1921. Exnmination in January, 1922, showed that ,the contractures remain the snnw. but thl' macules had quite disappeared. Xnsal smears haYe never been posith'I'. In onlet· to show the contrast the following case, in which the patient refused all manner of treatment and did not receive the chaulmoogra-oil injections. is outlined. This is an advanced ca,se, but no worse than some 0£ our patients who haYe received treatment ~nd improYed under injections of chaulmoogra-oil derivities. The prog1·ess the disease made in one year without treatment is unusual. Case 6. L. JI.; male; age, 32; admitted to the leper colony ~larch 9, 1910. ()ne year hefore admission he noticed a light-colored spot on bis left cheek. In .JnntHH'~'. ]!)21. the nasal smear was positiYe for B. lepi·ae. Examination at tlrnt tirnf' showed nodules on upper eyelids. nose. ears, lips, cheeks, and neck, ehest, extremities, and genitalia. Sensation: Moderate anesthesia of hands nnd forearms. slight anesthesia of arms and shoulder. Examination i11 January, 1922, showed sarne nodular distribution but nodules were more numerous anfl larger. Ulcers were present on both feet and left hand. Sensation: That of upper extremity remained the same; slight .anesthl'sia of face and back; total anesthesia of both feet, nnd anterior sm·- fn<'I' of both legs ; marked anesthesia of right thigh and slight anesthesia of left thigh anteriorly. There \\'as marked anesthesia of both thighs and legs poste riori~· . SUMMARY. 1. P nder treatment with chaulmoogra oil derivatives, the nasal smear has become negative for B. leprae in eYcr3I case. 2. In eYerv case presenting nodules there was a marked improve- ment, and i1~ some cases there was a complete disappearance of the nodules. The Jess the duration of the leprosy the greater was the effect. 3. In 29 patients with macules there was a complete disappearance 0£ this lesion in 12 and improvement in 13 of the remaining 17. 'Only 4 did not. improve and in these cases the macules became no worse. 4. In 8 patients with ulcers, 4 healed, 1 improved, and 3 remained the same. 56 CHOISSEP.-LABORATORY 'IVORK IX HAITI. Yo!. X\"Ill. 5. In 35 patients in whom there was some degree of anesthesia, there was complete disappearance of this manifestation in () and in 20 there was improvement. In those who had leprosy of short duration the improvement was more marked. u. Even with our limited treatment 4 patients have been paroled or 10 per cent of those who received treatment. There are 8 patient::; to be paroled shortly, making a total of 32 per cent apparently cured. 7. Besides the patients paroled and those to be paroled. improve- ment was found in 18 others or over 48 per cent. making a total of 80 per cent of the patients under treatment apparently cured or im- proved. 8. Most marked improYement was noted in patients ha,·ing lepros ~­ less than 5 years, although improvement was marked in patients haY- . ing the disease 5 to 10 years. 9. ·without treatment, 22 patients remained the same, ancl rn be- came ''orrn. In no case was there any actual improvement. Our observations have led us to conclude that the ethyl ester derivatives of chaulnioogra oil ha1e a very definite place in the treat- ment of leprosy. It is believed that they will cure some cases, especially those of relatively short duration, and it is known that they "-ill bring about improvement in a majority of patients to such an extent as to permit their parole. Xo harmful effects have been ob- served from its administration.