LEPROSY. 
By ISADORE DYER, Ph. B„ M D. 
Dermatologist to Charity Hospital; Professor of Dermatology, Neto Orleans Polyclinic 
Lecturer and Clinical Instructor on Dermatology, Medical Department, 
Tulane University, etc., New Orleans, La. 
Reprinted from the May, 1S94, number of the Texas Medical Journal. 
GRAHAM & SON, LTD., NEW ORLEANS. LEPROSY. 
By ISADORE DYER, M. D., 
Professor of Dermatology in the New Orleans Polyclinic; Lecturer 
and Clinical Instructor in Skin Diseases, Medical Department, 
Tulane University, Etc., New Orleans, Louisiana. 
Leprosy is an endemic, malignant, constitutional disease, 
characterized by alterations of the cutaneous, nerve and bone 
structures, resulting in anaesthesia, ulceration, necrosis, general 
atrophy, and deformity. Leprosy is a well defined affection, 
due to the development in the economy of a special bacillus, 
called the bacillus leprae, or the bacillus of Hansen. This 
bacillus is rod-shaped, with conical ends, or rounded, resem- 
bling the bacillus of tuberculosis, but shorter, pointed, and 
more of a cylinder than the latter. The bacillus of Hansen is 
very tenacious of life, and resists to a remarkable degree the 
action of time and atmospheric agents. In its development in 
the tissues, the micro-organism causes the formation of neo- 
plasms, or new growths. These neoplasms formed in the skin 
or the mucous membranes give rise to the tubercular type, 
while, attacking the nerves especially, they develop the anaes- 
thetic, or the tropho-neurotic variety of leprosy. When these 
two forms are intercurrent, the type then present is called the 
"mixed," or "complete" variety. Often the one, especially 
the tubercular type, disappears, giving place to the other as a 
sequel. Another form of leprosy is sometimes described, the 
macular. This seems to be only a stage in the development of 
either of those already mentioned. 
Leprosy is ushered in by certain prodromic manifestations, 
to which has been given the name; period of invasion. This 
stage of the disease is marked by fevers, irregular in period 
and in type. Malaise, anorexia, dyspepsia, epistaxis, dryness 
of the nasal passages and of the respiratory tract, vertigo, 
headaches, exaggeration of the functions of the fat glands, are 
some of the notable symptoms. There may be pruritus or 
hyperaesthesia of the skin, and neuralgic pains in all locations. 
There is often a premonitory eruption, of the bullous type, re- 
sembling pemphigus. It differs, however, in this, the erup- 
tion seems to affect the extremities chiefly, comes in rapidly 
successive crops of vesicles, or bullae, which, breaking, often 
heal as ulcers. As introductory, now the macular eruption 2 
appears. At various parts of the body, spots appear, red at 
first, then brownish; the borders become white, and occasion- 
ally thickened. These fade, often shortly after their appear- 
ance; at times, some are fading while others are developing. 
After a lapse of time, months, or years even, the symptoms of 
confirmed leprosy appear. These may be characteristic at 
the start. At once leprosy may appear in small tubercles. 
Oftenest, however, the first eruption to appear consists of 
spots, or patches, varying in size, but averaging the size of 
the palm. These are hyperaemic or erythematous, a pale red 
or wine color, at times violaceous, livid or brown, yellow or 
even plainly pigmented, or almost black. 
These spots sometimes disappear completely even quite 
rapidly, and without leaving any traces. The centre is some- 
times darker than the margin, sometimes depressed and free 
from color, the patch being formed by the ring of its periphery. 
It is frequent, at this stage, to see nodosities scattered over the 
skin, resembling the nodular erythema, accompanied likewise 
by rise of temperature, and being transitory and leaving 
abruptly at times. All such symptoms may be absent, and the 
lepra tubercle be evident from the beginning. This is a sort 
of rounded, hemispherical nodosity, varying in size from a 
pin's head to a hazel nut, hard and elastic to the touch, pale 
red or brown in color, at times copper colored, smooth and 
telangiectic. These tumors are isolated and form distinct, 
discrete nodosities, or they may be confluent, forming irregular 
shaped, rounded, oblong masses. They may develop on the 
patches referred to above. In that case the patches become 
thickened at certain points, and here the nodosities are formed. 
Most frequently the tubercles occur in the corium, then, 
secondarily, they invade the adjacent tissues. They may be 
entirely underneath the skin, but though not seen, they can be 
readily felt. The most frequent locations of this, the tuber- 
cular, type of leprosy, are the face, the hands, the forearms 
and the lower limbs. Attacking the face, the forehead, eye- 
lids, nose, lips, chin and cheeks suffer most. The nose is 
flattened, enlarged and infiltrated. The cheeks are bunched. 
The ears, lobules »particularly, are thickened, pedunculated 
and leathery; tubercles as large as hazel nuts often develop 
here. The scalp is rarely affected. Once developed, the 
tubercles do not remain stationary. They may continue to 
grow, become confluent, form enormous bunches; they may 
exfoliate, or become complicated with oedema. Spontaneous 
retrogression sometimes occurs. The lesions soften, grow 
pale, sink into the skin, shrivel up and finally disappear, leav- 
ing behind a spot with a yellow-white centre and a pigmented 3 
periphery. They may become inflamed, suppurate, open on 
the surface, and slough in part or entire. They may simply 
ulcerate, without destruction of tissue, remain small, superfi- 
cial ulcers, covered with greenish or brown crusts, destroying, 
by degrees, the adjacent tissues underneath, the tendons, liga- 
ments and the bones. 
Tubercles developing on the mucous membranes tend to 
ulcerate and produce destruction or functional disturbances of 
the parts involved. From the beginning there are disturb- 
ances of the various senses. In certain cases the tubercular 
eruption develops very rapidly, and may reach a fatal termina- 
tion in a few months; more often, however, it takes years to 
complete its course. There are periods of latency and activ- 
ity, but death comes finally from exhaustion, from marasmus, 
or is hastened by some intercurrent malady, of which tuber- 
culosis, syphilis and nephritis are the most frequent. 
The anaesthetic, or the tropho-neurotic form of leprosy, or, 
as Leloir calls it, the systematic nervous leprosy, presents the 
same period of invasion as the tubercular form. The bullous 
eruption usually appears in single lesions, which are incessantly 
reformed, leaving behind a scar, or at least a pigmentation. 
Here, too, the bullse may come on the ends of the fingers or 
toes, and leave very obstinate sores. Usually this form comes 
as a skin eruption, erythematous or hyperaemic at first, then 
colored or not. It may be pigmented at the start, with subse- 
quent atrophy of the pigment in whole or in part. The spots 
of most importance, and usually looked upon as characteristic 
of the macular stage of anaesthetic leprosy, are patches, smooth 
and shining, with well defined periphery, free from color, atro- 
phied in the centre, resembling somewhat the lesions of mor- 
phoea and vitiligo. The edges are colored red, brown, or 
brownish yellow, and may or may not be prominent or elevated. 
These patches are often serpiginous, but in such cases the re- 
sult of confluence. These patches are the seat of frequent 
disturbances of sensation. The discolored parts are always 
anaesthetic, and those most colored are the most anaesthetic. 
In exceptional cases, the reverse is the case; namely, instead 
of anaesthesia, these patches are markedly hyperaesthetic. The 
anaesthesia of this form of leprosy may occur at points free from 
patches or spots, or apparently free from a lesion. In such 
event, the seat of the anaesthesia is on the forgotten site of an 
injury, bruise, or burn. 
Gradually the nervous system is involved. Leloir speaks of 
two divisions of the leprous nerve effect (Traite de la lepre, 
1886): 1. The period of invasion. This corresponds to the period 
of the cutaneous manifestations, when hyperaesthesia is common, 4 
when paroxysms of neuralgic pains occur, rheumatic, or 
arthritic pains, and it is possible to observe marked thickening 
of certain nerves. 
2. A period of nerve degeneration, marked clinically by 
anaesthesia, paralyses, atrophies and tropic disturbances. With 
the anaesthesia, there appears a muscle atrophy, which attacks, 
first of all, the muscles of the hand (causing contraction), the 
extensorand flexor muscles of theforearm, and the characteristic 
".grzj/i?," or " claw hand," follows. There is loss of power, 
sense of touch, etc., in these parts. The muscles of the foot 
and leg are likewise similarly affected. At times the muscles 
of the face and the trunk are affected. Then comes the atro- 
phy of the skin, the shortening of the muscles, shrinking of 
the skin, and a general senile aspect. There are a variety of 
tropic disturbances, shedding of the nails, falling of the hair, 
loss of the teeth, ulceration of the nasal passages, and ulcera- 
tion of the gums. There may be perforating ulcers of the feet 
and hands-ulcers, painless, anaesthetic, beginning over the 
joints, gradually deepening, and ending by extending to the 
articulation, causing the phalanges of the fingers or the toes to 
fall. Dry gangrene, necrosis, with abscesses, occur; absorption 
of the bone, and a final deformity of the patient results. Now 
the tropho-neurotic leprosy has reached its last stage. Maras- 
mus begins, with general listlessness, and the patient dies from 
pure exhaustion, or death is hastened by an almost necessary 
septicaemia. Often a complication with pneumonia, pleurisy, 
albuminuria, or a persistent diarrhoea carries the patient off. 
The mixed, or complete form of leprosy, is the really 
typical form. Here there is a combination of the tubercular 
and the anaesthetic varieties. It may begin as the mixed, or, 
starting as the tubercular leprosy, it may assume the anaesthetic 
form, the two being intercurrent. It then, of course, assumes 
the symptoms of both varieties, and the history and the end is 
the same. 
These three forms may vary so as to deceive, and a part 
only of the symptoms be present. In this, leprosy does not 
differ from other diseases, but if the mental photograph of a 
type is always ready, the disease is not hard to diagnose, even 
in its exceptions. 
The bacillus of leprosy is contained often in the lymphatic* 
cells and tissues, but is most frequently found in the leprous 
tissues themselves. Leprous tissue is granulation tissue, made 
up of spheroidal cells, massed so as to infiltrate the corium, 
and breaking up the connective tissue fibres. These cells are 
grouped around the vessels, these hypertrophy, become varicose, 
and are themselves much thickened. Ultimately the whole or 5 
part of this leprous tissue is re-absorbed or eliminated, and the 
site is marked by a cicatrix. 
From syphilis, leprosy is diagnosed by the color of the 
lesions, their course of development, the anaesthesia, the de- 
formity, and finally the microscopic finding of the Hansen 
bacillus. 
It is diagnosed from morphoea and circumscribed sclero- 
derma by the location, general distribution of the lesions, and 
the ulceration. Further, the lesions of leprosy are usually 
anaesthetic, while those of these affections are exceptionally so. 
Finally, leprosy can be isolated from other affections if 
you are mindful of these points: 
i. Habitat. 2. History of contact. 3. Anaesthesia. 4. 
Trophic disturbances. 5. Eruptions of bullae in successive 
crops, or single one recurring. 6. Perforating ulcers. 7. 
Muscle atrophy. 8. The claw hand. 9. Clubbed fingers. 
10. Discolored and blunted nails. 11. Characteristic anaes- 
thesia of the little finger an early sign. 12. The leonine face. 
13. The leathery ears. 14. Ectropion. 15. Deformity and 
loss of phalanges of fingers and toes. 
The cause of leprosy is the bacillus leprae or the bacillus 
of Flansen, sometimes called the bacillus of Niessler. The 
disease is contagious and by inoculation. The bacillus is 
brought in contact with a broken surface, accepted by the cir- 
culation, and is in time spread generally over the body. The 
disease may be congenital, but has not yet been proven hered- 
itary. 
There are numerous contributing causes, chief among 
which are poverty and bad hygienic conditions. Improper 
diet and exposure are also factors. It is probable that the 
disease is more common along the seaboard than in the in- 
terior counties, but climatic conditions are only of secondary 
importance. 
Many authors look upon fish diet as productive of the dis- 
ease, but the disease has been found prevalent in sections 
where fish diet was not possible. 
Leprosy may get well spontaneously. The disease, how- 
ever, is generally considered incurable. The treatment of 
leprosy is tonic. A change of climate is advisable, and the 
plainest possible diet. Regular tonic baths, cold douches, 
showers, and alkaline. Numerous remedies have been sug- 
gested, but most of them are only palliative, excepting in a 
very few cases. Of the remedies used, Chaulmoogra oil is the 
most popular. It is given internally, beginning with five drops 
three times a day after eating, and gradually increasing. It is 
best given in capsule, or in cold tea, or in milk. 6 
Hoang Nan is a remedy much used in South America. It 
is given in pill form in doses of three grains three times a day 
after meals. Arsenious acid, sulphate of strychnine in tonic 
doses, and long continued, are given. Salicylate of soda, 
quinine, salol, iodide and bromide of potassium are also given. 
Unna, of Hamburg, has succeeded in two cases with the use of 
ichthyol internally and externally. Internally he gave the drug 
in increasing doses to a point of tolerance, beginning with five 
drops three times a day. Externally it was used in ointments 
and plasters, alone and combined with resorcin, with pyrogal- 
lic acid, etc. 
The external treatment of leprosy should be based on two 
essential principles. First, the removal of the lesions with 
caustics or cautery; and second, promotion of the absorption 
of the lesions with suitable applications. For the tubercles in 
their early stage, iodine, nitrate of silver, blisters, mercurial 
ointments, electro-cautery, etc., may be used. 
Balsam of Peru ointment, iodide of lead ointment, sali- 
cylic acid ointment, gurgun oil, etc., may be rubbed into the 
lesions. 
When there is ulceration, ordinary antiseptic methods 
should be applied. Iodoform, salol, boric acid, aristol, etc , 
may be dusted on after thorough cleansing with antiseptic so- 
lutions. 
Where the lesions of anaesthetic leprosy are conveniently 
confined to one member it is advisable to stretch the principal 
nerve or even to make an exsection of the nerve. 
The prognosis of leprosy is always bad. The disease 
may be arrested, temporarily relieved, but cures are rare. 
The disappearance of all evidences of the disease may be fol- 
lowed years later by a new manifestation and with manifold 
energy. 
The tubercular is more rapidly fatal than the other form. 
According to Hillis (Ziemssen), 38 per cent, die of leprosy 
and its direct consequences. The rest of the fatal cases die of 
nephritis, pneumonia, diarrhoea, anaemia, fevers, peritonitis-in 
the order named. 
In the prophylaxis of leprosy, the patient should be made 
to take regular baths, and to use individual utensils, towels, 
etc. Excesses of all kinds should be avoided. An occupa- 
tion should be followed which would not endanger family or 
friends. 
For the protection of the public, lepers should be isolated, 
should be prohibited from marrying, even among themselves. 
The disease is insidious, and the consensus of the best 
medical opinion favors absolute quarantine, with complete 
isolation, as the only means of entirely suppressing the disease. 7 
A. word as to the history. At the time of Christ, leprosy was 
still prevalent in the east. It existed, probably confined, in the 
early history of the world, to Egypt and the Orient. In the 
first century invading Greece, it spread over Southern Europe. 
In the (eleventh and twelfth centuries, during the Crusades, it 
spread all over Europe,reaching then the acme of its force,finally 
materially disappearing from the fifteenth to the seventeenth 
century. During this time, it was estimated that there were 
19,000 lepers in Europe, 2000 of them In France alone. At 
the present time, the disease is endemic in Northern and East- 
ern Africa, Madagascar, Arabia, Persia, India, China, Japan, 
Liberia and the islands of the Pacific and Indian oceans. In 
Europe, leprosy is still active in Norway, Southern Russia, 
points along the Mediterranean, and in Brittany, in France. In 
North America, it is found in Canada and in the United States. 
It is endemic in Louisiana, where it was introduced in 1758, 
by the Acadians. Various attempts have been made at colo- 
nization here, but with hardly enough spirit to assure success. 
This has been successfully accomplished in Minnesota, where 
leprosy occurs among the Norwegian settlers. In 1859, eP' 
rosy was introduced into the Sandwich Islands, by two Chinese 
immigrants. In 1885, there were 4500 cases in the Sandwich 
Islands. Leprosy has existed in Mexico since Cortez' time. 
There seems in this country a certain apathy in the matter 
of the care of our lepers. With such an example as the Sand- 
wich Islands afford, and in a climate far superior to our own, 
it seems a foolhardy indifference which exposes all to the com- 
mon risk. Suitable legislation should be demanded and its 
enforcement compelled.