LEPROSY REVIEW The Quarterly Publication of THE BRITISH LEPROSY RELIEF ASSOCIATION VOL. xxx. No. 4 OCTOBER 1959 Principal Contents Editorial Two Years' Experience of Ciba 1906 in the Treatment of Leprosy The Multipuncture Depot Lepromin Test with Different Antigens Intramuscular Injection of Sulphones Circulation in the Feet of Leprosy Patients The Etiology of Plantar Ulcers A Tension Equaliser in the Operation for Claw Hands A Modified Technique for Staining Leprosy Bacilli Letters to the Editor Abstracts Report Review 8 PORTMAN STREET, LONDON, W.l Price: Three Shillings and Sixpence, plus postage Annual Subscription: Fifteen Shillings, including postage LEPROSY REVIEW VOL. xxx, No. 4 OCTOBER, 1959 CONTENTS PAGE EDITORIAL A Further Report on the Diphenylthiourea, Ciba 1906 208 Comparative Clinical Trial of I njection Therapy 208 The Multipuncture Type Lepromin Test 209 Two Years' Experience with Diphenylthiourea (OPT or Ciba 1906) in the Treatment of Leprosy, J. M. B. GARROD 210 The Multipuncture Depot Lepromin Test ; Investigations with Different Antigens, J. A. KINNEAR BROWN and M. M. STONE 215 Short and Long Acting Sulphones by Intramuscular Injection, G. CURRIE 220 Circulation in the Feet of Leprosy Patients, with and without Ulcers, B. B. GOKHALE, S. M. VABLE, and SUMAN MODAK 234 Studies in Plantar Ulcers in Leprosy : IV The Etiology of Plantar Ulcers, E. W. PRICE 242 Use of a Tension Equaliser in the Many Tailed Operation for Claw Hands, R. H. THANGARAJ . 249 A Modified Technique for Staining Leprosy Bacilli in Sme-drs, R. RHODES- fuNB HI Letter to the Editor on press report of 2nd WHO Expert Committee on Leprosy,H. W. WADE 252 Letter to the Editor on "blue-black macules", BASIL NICHOLSON 254 Abstracts 255 Report 268 Review 269 Edited by DR. J. Ross INNES, Medical Secretary of the British Leprosy Relief Association, 8 Portman Street, London, W.l, to whom all communications should be sent. The Association does not accept any responsibility for views expressed by writers. Contributors of original articles will receive 25 loose reprints free, but more formal bound reprints must be ordered at time of submitting the article, and the cost reimbursed later. 208 LEPROSY REVIEW EDITORIAL A Further Report on the DiphenyIthiourea, Ciba J906 Dr. Garrod of the East African Lepros y Research Centre gives in this issue (p. 210) his experiences withCiba 1906, which follow up the earlier reports of Ross Innes et all from the same Centre, and the earliest and later reports by Davey and Currie2 and Davey). Garrod's results are a general confirmation of the previous work. He draws attention more to the great reduction in the incidence of reactions during administration of Ciba 1906 for long periods, and reports that this drug has been fo und to be useful in cases resistant to the stan­ dard treatment by DDS; also it has been free from toxic effects, and as regards the fa ll in bacterial index as compared with standard treatment, in the first 12 months the advantage lies with Ciba 1906. ft seems that the advantages of this drug are very solid ones, and either alone or in combination it is emerging as a valuable standard treatment of leprosy. Much is sometimes made of the somewhat greater cost of this drug, but fo rtunately for the patient most physicians find an irresistible attraction in using a drug which is the more efficient, in spite of greater price, as in that way lies true economy in the end. Comparative Clinical Trial of Injection Therapy In this issue Dr. Gordon Currie gives a very useful and careful study of the important differences in behaviour of the various injections of DDS (p. 220). Against a control group on oral DDS he tried DDS suspended in ethyl esters of hydnocarpus oil, DDS in an aqueous suspension, and DDS in the form of a special soluble sul­ phone. He evaluated these by records of the improvement in bacillary index and the evidence of degenerative changes in the bacilli, and objective and subjective clinical improvement, as well as occurrence of the reaction ENL. He usefully distinguishes between side effects and true leprosy reactions, and it is important that he also made a note of the incidence of pain as a result of the injection, and investi­ gated the occurrence of anaemia in the different methods. While there was little to choose between the therapeutic effectiveness of the sulphones, whether given by mouth or injected, there were distinct differences in other directions� There was no significant lessening of the incidence of ENL by the parenteral methods, but there was a great diminution of unpleasant and depressive side effects. There was an increased incidence of ENL with the oily suspension group, and the cause of this remains obscure. The oily suspension was undoubtedly difficult to inject, and quite painful, whereas the aqueous suspension was easy and relatively painless. Dr. Currie discusses the psycpological factors in regard to the pain of the injection and the reverence of certain African peoples for the EDITORIAL 209 "healing power of the needle", andjnfers that this might be an advan­ tage. However, it might be safer to be more cautious about this and look to the long term effect of a painful injection which often has to be repeated at intervals of a fortnight or more, often over a long period of time. In spite of the reported reverence of the African for such things, we beg to express some doubt whether in the long term a painful injection will ensure a high attendance rate ; there is more to human nature than a reverence for magic. Though the soluble preparation apparently can only produce high peak levels at fortnightly intervals, Dr. Currie found no loss of efficiency. He found that the Avlosulfone aqueous suspension was the preparation of choice on the grounds of freedom from pain, absence of side effects, ease of injection, economy in the total quantity of suI phone needed, and efficiency. The Multipuncture Type Lepromin Test Dr. Kinnear Brown reports on his further studies with this test (p. 215) and points out that any response to lepromin by this route can be independent of any normal tissue element it contains. He used antigen made from normal skin and from tuberculoid skin, and studied the effect of BCG vaccination on the depot lepromin. All the lepromin negatives became positive, and there was an enhance­ ment in the degree of positivity. His continued experience with the multipuncture test has convinced him of its simplicity, economy, and effectiveness. As regards the general use of multipuncture BCG vaccination, recently A. H. Griffith4has reported on his experiments to compare the multi puncture and intradermal routes. He found a falling off in conversion rate with the multipuncture route compared with the intradermal vaccination, and suggests that the general use of multi­ puncture should be delayed until the method has been improved and standardised. Kinnear Brown's work therefore has much practical importance, as supporting the efficiency of the multipuncture method. References I. INNES, J. Ross et al. E. Afr. Med. J., 1957,34, p. 395. 2. DAVEY, T. F. and CURRIE, G. Lep. Rev., 1956,27, p. 94. 3. DAVEY, T. F. et al. Lep. Rev., 1958,29, p. 25. 4. GRIFFITH, A. H. Lancet, ], 7084, 6th June, 1959, pp. 1170- 1172. (See Abstract p. 264 or this issue.) 210 LEPROSY REVIEW TWO YEARS EXPERiENCE WITH DIPHENYLTHIOUREA (DPT or CIBA 1906) IN THE TREATMENT OF LEPROSY B.A.O., H. by J. M. B. GARROD, M. B. , B.ch., D.T.M. & Director, East African Leprosy Research Centre, A/upe, Kenya Introduction One of the drawbacks to the use of the sui phones in leprosy is that reactions are increased in number and severity. At the best these are troublesome and interrupt treatment. They can cause serious constitutional disturbances and are hardly beneficial to the patient if the more severe types develop. Severe cases may only be kept in tolerable comfort by continuous administration of corticosteroids. Diphenylthiourea (OPT) was reported to be active in leprosy by Davey and Curriel ( 1956) and by Ross rnnes et af.2 (1957). A further report by Davey et a/.3 (l958) confirmed the earlier report, and drew attention to the lesser incidence of reactions among patients treated with DPT. Further experience here with some of the patients reported by Ross Innes and some additional patients up to April 1959 is recorded here. Patients All were inpatients of whom four had had substantial previous treatment with DDS. All others denied previous treatment, or admitted to receiving only a few tablets of DDS beforehand at outpatient dispensaries and health centres where oral DDS is generally available. Forty patients were studied and their numbers and types are shewn in Table I. The distribution of cases bears no relation to the general incidence but is more an indication of the types seeking inpatient treatment. TABLE r Tuberculoid Lepromatous Borderline Indeterm. Male Adult 10 II 2 0 Female Adult 3 5 0 Male under 18 3 0 I Female under 18 0 17 18 2 3 Lepromin tests were done on all patients before starting treatment. The lepromin used was a crude Mitsuda-Hayashi type prepared here. The lepromatous cases except three had negative Mitsuda tests. The three had doubtful tests with reactions less than 3 mm. in diameter. Biopsies were taken before starting treatment. Histologic­ ally not all might have been accepted as lepromatous but they were Two YEARS' EXPERIENCE WITH OIPHENYLTHIOUREA 21 1 what is known as frank lepromatous cases in Africa. Nodules were generally present, and bacilli were found easily in globi and in masses. The tuberculoid cases had positive Mitsuda tests.