Bullous eruptions occur chiefly on the extremities and often develop suddenly with or without sensations. They are of a variable size filled with a yellowish serum and rupture in a few hours leaving an excoriated surface. Rapid healing is the rule with pigmentation or scars as the evidence. It must here be noted that slight frictions and moderate heat may produce in leprous subjects blisters and ulcerations which in other people would not be caused by similar irritations.
Nerve changes are those of a multiple neuritis. The complex sensations of the skin may not all be lost at once. Thus the tactile sense may be present after those of temperature and pain are abolished or vice versa; or the sensation of cold lost or the opposite. However, in the more advanced cases all sensory functions disappear. Sweat and oil glands fail to produce, the hair turns white or falls out, the surface becomes dry and atrophic and hence secondary cutaneous lesions are often developed because of lowered vitality. As long as only the sensory nerves are affected, even though extensive, the disease may not affect the general health. Neuralgic pains, often paroxysmal in character and other annoying symptoms need not necessarily awaken suspicion of their grave character and the terrible results of further insidious nerve involvement may not show for many years. In advanced cases of leprosy, the nerves of the face and extremities are particularly attacked. The ulnar and peroneal nerves seem especially prone to involvement. Regular or interrupted thickenings of the ulnar nerve may sometimes be felt behind the olecranon in the earlier stages of this form of leprosy.
Complex nerve degeneration manifests itself as partial or complete paralysis, atrophy and deformity. Contractions are often noted in the hand where the first phalanx is so extended and the middle and terminal phalanges are so flexed from atrophy of the muscles and tendonous contraction as to produce the “leper claw.” Total loss of the sensory and trophic functions lead to other deformities and mutilations. Blebs appear over the phalangeal joints, ulcers destroy the deeper parts, gangrene may cause spontaneous amputation, or absorption of the bone may ensue so that one after another, the fingers are lost without ulceration or gangrene. The feet may undergo similar mutilation and deep plantar ulcers are not uncommon in those who go barefooted.
Fig. 200 – Leprosy of the anesthetic variety, showing characteristic deformities of the hands and wrists.
As the disease progresses the muscles of the extremities may become successively affected, those of the upper extremities much more so than those of the feet and legs. When the nerve supply of the face is attacked, patients may be unable to close the eyes from the paralysis of the orbicularis, the lachrymal secretion may cease causing irritation of the eyeball, the lids may become everted, the lips and cheeks may be flaccid, and partial or complete paralysis be evidenced by drooping of the muscles. When the sensory supply of the throat is affected, the functions of swallowing is so interfered with that regurgitation through the nose may be noted but, as a rule, the mucous membranes are fairly healthy in the case of pure anesthetic leprosy. The victims of this form of leprosy usually die from an intercurrent disease or from gastrointestinal disorders.
The eruptive stage of mixed leprosy usually includes lesions of both the tubercular and anesthetic forms, one or the other predominating. This variety is apt to be characterized by chronicity and severity from the combined presence of the features of both forms. This mixed type is more common in the United States than either of the pure varieties.
The duration of leprosy varies widely. Inasmuch as the tubercular form prevails most in a new country or among a virgin population, and the anesthetic in greater relative frequency with its continued prevalence in after years, it follows that the average duration may vary considerably in different countries or regions with the prevailing form of the disease. Roughly speaking it may be said that the average duration of tubercular leprosy is from five to six years, anesthetic from twelve to fifteen and mixed leprosy about ten years.
Fig. 201. Leprosy, mixed variety in a Chinaman, showing a gangrenous and ulcerative condition of the nose and right cheek, amounting to actual mutilation.
Etiology and Pathology – The bacillus leprae, discovered by Hansen in 1874, is the efficient cause but the method by which it grains access is not known. Observation would indicate that the mucous membrane of the nose and probably the mouth also was the common source of infection but it is possible that any abrasion of the skin could readily be the point of entrance. This latter fact is well shown because in tropical countries where people are prone to go barefooted, the first lesions are found on the feet in over half the cases. The anesthetic type is not as contagious as the tubercular. In fact the disease is only feeble contagious and is probably not directly contagious or inoculable from man to man. An intermediary host, such as has been observed in the causation of malaria, might explain many of the contradictory features of leprosy. Males are more subject to this disease than females in a proportion of two to one. It is rarely noted in childhood and never occurs in infancy. It is not hereditary, although a predisposition to it has been observed. Certain influences attributed to climate, race and sex may predispose to leprosy, but collective or personal habits of living, which include excesses of all kinds, bad hygiene, insufficient food and lack of cleanliness, appear to be the most important factors. Although leprosy exists in cold as well as hot climates, and moist, damp regions seem to favor its spread, the temperate climate of most of the United States and Europe is unfavorable to its development.
Fig. 202 – Leprosy, showing the results of complex nerve degeneration in the shape of spontaneous digital amputations, atrophic areas and pronounced dermatitis.
The causal bacilli resemble the tubercle bacilli closely but are found in groups, are more readily stained than the latter and are much more numerous in the surface lesions. After staining with fuchsin they appear as pink rods in length about one-half the diameter of a red blood corpuscle, in width about one- fifth their length. They may always be found in the tubercular nodules but are relatively absent in the anesthetic form. Whether it is the living bacilli or their toxins which produce the mischief is not known, but they have been found in the kidney, liver, spleen, sebaceous glands, hair-follicles and secretions of the mucous membranes when these parts have been attacked. The tubercular lesions are produced by deposits of cells in the corium and subcutaneous tissue, similar to the condition found in lupus and syphilis. They are diffuse granulomatous growths characterized by their limitation to the connective tissue elements, especially to the lymphatic system of the skin, and by their enormous number of organisms. In the anesthetic type, it is believed that the nerve changes are limited to the peripheral structures but recently central nerve involvement has been noticed.
Diagnosis – Advanced typical cases of leprosy are easily recognized in a leprous country or in those that have lived in such a country, but atypical sporadic cases may present some difficulty because their prodromata are not peculiar to leprosy.
Syphilitic macules are smaller, less colored, less permanent and do not seek the face. The nodules of syphilis are smaller, more grouped, of a deep red color, ulcerate more readily and are indiscriminate in their choice of location. It is well to remember that syphilis and leprosy may coexist.
Lupus vulgaris nodules are softer, smaller, more circumscribed, grouped in patches interspersed with the scar tissue, and do not produce the thickening of the eyebrows and ears found in leprosy.
Mycosis fungoides presents patches that are more red and eczematous than leprosy and its fungating, ulcerating growths develop upon the same patches at a later period of the disease.
Lupus erythematosus lacks the anesthesia and other neurotic symptoms of macular leprosy and is less apt to show multiple lesions.
Erythema multiforme usually manifests itself in smaller areas, does not become nodular, is acute in its evolution and presents successive gradations of color.
Tinea versicolor presents a fine scaliness of its patches without any sensory changes and the microscope will reveal its causal fungus.
Vitiligo spots are irregular in outline, whiter and more sharply defined by a pigmented border, and are normal in texture and sensibility.
Morphea may always be distinguished by its hard, lardaceous, waxy-white surface and its violaceous border.
Syringomyelia presents a loss of the heat and pain sensations without loss of the tactile sense and the facial muscles are not involved.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war