E. Graham Little

Acute Nodular Leprosy Originating in this Country and Cured by Vaccine Treatment.

MR. X., a Chiinesestudent, aged 36, whohad been six months in this country, was brought to me oni May 14th by Dr. Sherwill Dawe, with the following remarkable history: The patient had been under his care for some weeks, suffering from severe pain in the left arm from the axilla to the wrist. Local applications, but nomedicine, were given until three weeks later, when an eruption of nodules came out quite suddenly upon the face, and later upon the body. These gave rise to no subjective symptoms; there was no itching or pain. Under the impression that the eruption was an urticaria, calcium lactate was given by the mouth, and no other medicine had been taken by the patient. The eruption spread rapidly over the trunk and hands, and a patch of infiltrated skin, approximately four inches by two inches, appeared near the wrist, and a similar patch of induration upon the back a little later. He was brought to seeme ten days after the first onset of the rash. The photograph (Fig. 1) gives a very fair impression of the state of the face when I saw him on May 14th. The skin over tlhe forehead anid cheeks was studded with granulomatous nodules; the face was generally swollen, especially over the forehead and nose. A large number of granulomatous nodules and plaques of inidurated reddened skin were also found upon the back and front of the trunk. Upon the left forearm there was a very prominent induration of the skin, with a typical dusky flush;thle ulnar nerve upon this side was greatly swollen and tender. The patient was obviously acutely ill, but no rise of temiiperature had been noted. The glands were generally enlarged. I told Dr. Sherwill Dawe that I regarded the eruption as a lepride, and I obtained his permission to show the patient at the meeting of the Dermatological Section of the Royal Society of Medicine on May 20th. My diagnosis was confirmed by the unanimous opinion of the members present. In the discussion which followed, Dr. Seiueira mentioned a case with an acute outbreak-the only one in his experieence-in a woman who came from South Africa. Dr. Macleod gave an instance under his care of a boy in whom an acute outbreak of nodules, practically covering the body within forty-eight hours, had occurred, but the patient had had a previous attack of leprosy two years before. Dr. Whitfield mentioned a case under Dr. Pringle in whom an acute leprous swelling of the face had -iome on within a few hours of an attack of malaria. Dr. Adamson pointed out the analogy between these cases and post-exanthematous lupus, which occurred after measles or other fevers in children who suffered from tuberculous glands. The rarity of such acute cases may be gauged from the fact that four medical men, with vast experience of skin disease, could each cite only one instance within their individual observation. Further discussion ensued upon the measures to be taklen, and it was again the unanimous opinion of the meeting that the prognosis was so desperate that the patient should be urged to take immediate steps to return to his home in China, if arrangements could be made for his transit. Leprosy is not a notifiable disease in this country, and there is no adequate provision for the reception of such cases. Somiie years ago one of the members of the Section was confronted with an extremnely difficult position, in which he sought the advice and assistance af his colleagues. A man suffering from leprosy had been living in lodgings in London. A lawsuit for damages, brought by the landlord, appeared probable, and this lesson of the very serious plight of a patient suffering from leprosy in England added to the urgency of the advice which I gave to Dr. Dawe, that the patienit should leave England as speedily as possible, before his condition would prevent him from doing so. Now comes the remarkable sequel. Mr. X. had1 the good fortuniie to come under the observation andl treatlment of Dr. James Hasson, whose very -extensive experience of leprosy in Egypt enabled himiit6 give a much more pro-