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Toua laa autraa axampiairaa originaux aont fiim4a an comman^nt par la pramlAra paga qui comporta una amprainta d'Impraaaion ou d'lHuatration at an tarmlnant par la darnlAra paga qui comporta una talla amprainta. Un daa symboiaa aulvanta apparattra sur la damiira imaga da chaqua microficha. salon la caa: la symboia -^ signifia "A SUIVRE". la symbola ▼ algnifia "FIN". Laa cartaa. planchaa. tableaux, ate. pauvant Atra fllmAa i daa taux da reduction diffArants. Loraqua la document est trop grand pour Atre reprodult en un soul clich*. 11 est film* i partir da Tangle aupArlaur gauche, do gauche i drolte. et do haut en bee. en prenent le nombre d'Imagea nicaaaalra. Lea diagrammea aulvanta lliuatrent la mAthode. 32X 1 2 3 1 ' 2 3 4 5 6 l^ THREE CASES ILLUSTRATING THE VALUE OF THE BACTERIOLOGIUAL DIAGNOSIS OF LEPROSY FOR PUBLIC HEALTH PURPOSES. BY WYATT JOHNSTON, M.D, Lecturer on Bacteriology and Medico-Legal Path-ij^y, McGill University ; Pathologist to the Montreal General Hospital. AND W. H. JAMIESON, M.D., Demonstrator in Pathology, McGill University : Assistont Pathologist to the Mont- real General Hospital. i! (Reprinted from the Montreal Medical Journal, January, 1897.) tl n tl , I THREE CASES ILLUSTRATING THE VALUE OF THE BAG TERIOLOGICAL DIAGNOSIS OF LEPROSY FOR PUBLIC HEALTH PURPOSES.' BY Wyatt Johnston, M.D., Lecturer on B^teriology and Medico-Legal PatholoKy. McGill University ; Pathologist to the Montreal General Hospital. AND W, H. Jamieson, M.D., Demonstrator in Pathology. McGill University : Assistant Pathologist to the Mont- real General Hospital. (From the Laboratories of the Boaxti of Health of the Province of Quebec and the Montreal General Hospital.) The case which ^e wish to bring before the Society to-night is that ot a Chinaman aged 27, who was brought to the Montreal General Hospital in a dying condition, and died a few hours after admission. The man had been a little over a year in the country and was not known to be suffering from any serious illness pe^lrmed '"'P'"°''' ""^ '^^°''"* ''"^^^ ^^^^^' ^ ««r«°er's autopsy was External examination of the body showed a gangrenous, ulcerated area, 2 inches in diameter, involving the skin over the right elbow surrounding which the tissues were thickened, firm and nodular' JNumerous firm nodules were seen on the skin over the face, ex- tremities, back and genitals ; over the surface of the glans these were especially well marked. The nodules on excision showed no signs of necrosis or suppuration and appeared to be chronic. The cellular tissue of the right upper arm was cedematous, with ecchymosis in the course of the lymphatics and during the autopsy numerous ecchymosed areas, varying from' 2 to 6 inches in extent, were found in regions which excluded the Idea of their being the result of contusions. The most marked ecchymosis was beneath the right iliac and psoas muscles Bacterial examination of these ecchymoses showed a few short, thick bacilli (Proteus) staining by Gram's method ; no micrococci. Ihe nerves showed no changes and in particular no nodules in the nerve sheaths. The lungs were deeply congested, no consolidation, no tuberc es, or other nodular deposits. In the left epididymis there were several firm, whtish nodules the size of peas. Cut surface firm and 1 Read before the Montreal Medico-Chirurgical Society, Nov. 9, 1806. )'■ .1 2 smooth. The other organs showed nothing of special note. Nutrition was good. The gangrene of the skin over the elbow and the evident condition of septicaemia present appeared to explain death. The general nodular skin eruption did not correspond with either syphilis, lupus, glanders, variola, nor with any of the forms of skin diseases ordinarily met with. It was only towards the close of the autopsy that the idea of the eruption being due to leprosy occurred to us. A cover slip was then prepared by smearing it with a drop of the juice obtained by scraping one of the nodules. On stainitig this with carbol fuchsin and decolourizing with sulphuric acid and methylene blue (Gabbett's fluid), innumerable, slender, red rods were seen, many of them arranged in the peculiar clumps designated as lepra cells. Examination of the nodules in the testicle showed also the presence of numerous lepra bacilla, and sections of the skin showed large numbers in the deeper layers. Cultures from the smaller nodules of the skin on Loeffler's serum and glycerine remained sterile. Inocu- lation of a small nodule into the anterior chamber of a rabbit's eye, shows at the end of three months a nodular exudate over the anterior surface of the iris. No signs of tuberculosis appeared in the animal, the general condition being good and its weight not diminished. The examination of cover slips thus established the nature of this case with certainty in a few minutes, whereas without this neither the post-mortem nor the clinical examination by the house phj sician or the physician in attendance had led to the discovery of its real nature. The bacteriological method appears to be thus eminently adapted for the examination of any doubtful case of skin disease which may be leprosy, as the Vjacilli are certain to be found in large numbers in cover slips prepared from the material obtained on scraping the nodules of the skin. The microscopic resemblance between the leprosy and tubercle bacilli should not form a serious source of error, as in tuberculous lesions of the skin the bacilli are always very scanty, and usually only a few are found in the entire cover slip, while in lepra each microscopic field shows enormous numbers of them. The lepra bacilli also readily stain by the simple aniline dyes, while tubercle bacilli do not. The ease and certainty by which the diagnosis of leprosy can be made was also shown in a case which one of us (Johnston) examined for Dr. Shepherd six years ago. This patient, a West Indian mulatto, had a good position as waiter in a Montreal hotel, and to avoid losing 8 his position, allowed himself to be treatad for three years for syphilis without any improvement resulting. He then visited Dr. Shepherd's skin clinic, where a diagnosis was made at once from the appear- ance of the skin eruption and the presence of anaesthetic areas, this diagnosis being confirmed by the microscopic examination. Recently a case has come under our notice where a Chinese laundry- man in Three Rivers, supposed to be a leper, was kept under obser- vation and isolated while a scraping from one of the skin lesions was forwarded for bacteriological examination to the Laboratory of the Board of Health of the Province of Quebec. No leprosy bacilli were found. Subsequently our personal exami- nation of the case showed it to be one of psoriasis, and a repetition of the bacterial tests again gave negative results. While authorities differ as to whether leprosy under certain condi- tions is actually contagious, there can be no doubt as to the advantages of the bacteriological niethod of diagnosis for public health purposes, since by this means an obscure case can he made out in the course of a few minutes, and if the suspected pers:)n is situated at a distance from any laboratory, the samples scraped from a nodule of the skin may be sent by mail enclosed in an envelope addressed to the bac- teriologist. In choosing a nodule from which to take the specimen, it is perhaps better to select one in an early stage, before much scar- ring has taken place, by pricking or scraping off the top of a nodule, and collecting the fluid which exudes on pressure. When dried on an ivory vaccine point or a glass slide samples may be more readily sent by post. Manson has recommended rendering the nodule anaemic by clamp- ing the base with forceps before taking the sample, but in our experience this is not necessary, as the blood does not interfere with the examination. We have reported these cases because in spite of the dread with which leprosy is regarded by the public, this simple means af diagnosis does not seem to have been as frequently made use of as it should be by the sanitary authorities. ''