[Reprinted from The Tri-State Medical Journal and Practitioner, St. Louis, March, 1897.] 
LEPROSY.* 
By A. H. Ohmann-Dumesnil, 
Professor of Dermatology and Syphilology in the Marion-Sims/College 'of 
St. Louis. (j 
THERE is perhaps no disease which has been more spoken of with less 
knowledge on the part of the general public, and of a great proportion 
of the medical profession, than leprosy. Nor is there one which has 
been so much subjected to misinterpretation or which has produced so much 
fear and terror in the popular mind. The latter is no doubt due to the 
Biblical influence induced by unconscious misinterpretation on the part of 
translators and commentators. For, it is a well-known fact that in many 
oriental countries but little attention is paid or importance attached to 
lepers, they intermarrying with the healthy, coming in daily personal con- 
tact with the unaffected, and being treated without any difference from 
others not leprous. It may possibly be that the writer of the book of 
Leviticus had but a restricted knowledge of the disease itself, as we find 
psoriasis called leprosy-and in comparatively modern times, lepra alphos. 
Aaron himself had leprosy (psoriasis) and was admitted within the Holy 
of Holies, an act which would not have been permitted had he been suffer- 
ing from true lepra. On the other hand, the Jew who had leprosy was 
declared "unclean" and pronounced a pariah. From this arose the popular 
idea that the disease was contagious; and, it may be stated as a matter of 
fact, that the Semitic race in the Orient presents more leprous subjects 
than any other, so far as they have been observed in Palestine, Syria, 
Turkey, the Mediterranean Islands and in that neighborhood. 
To-day the disease may be said to practically exist all over the world, 
the smallest numbers being found in Europe and in the United States. 
India is estimated to harbor over 300,000 lepers. China is also known to 
contain large numbers. The countries mentioned above continue to furnish 
their quota. The Sandwich Islands are notorious for the number of lepers 
found there. Mexico and the South American countries also present many 
cases of the disease, and the list might be continued almost indefinitely. 
The burning question connected with leprosy is whether it is a contagious 
malady or not. As we have already stated, the Ancient Hebrews regarded 
it as such, and this opinion was intensified in Europe during the Middle 
Ages, but more especially after the first return of the Crusaders from the 
Holy Land. Such a large number returned afflicted with "leprosy" and 
transmitted their disease that it was not long before severe means were 
adopted to prevent its spread. The dissemination of the trouble finally be- 
came so great that the unfortunate victims were kept incarcerated in special 
buildings; and it is estimated that at one time there existed no less than 
thirty thousand leper houses in Europe. A critical examination of the 
accounts and descriptions of the disease, as it then occurred, will demonstrate 
to an impartial reader that the trouble was in reality syphilis. This 
readily explains its rapid dissemination and its ready contagion. Treat- 
ment being ignorantly applied, the patients neglected and abhorred, also 
* Read before the St. Louis Academy of Medical and Surgical Sciences. 2 
easily explains the ravages which it made and the rapid deaths which fol- 
lowed in its wake. Those not syphilitic suffered, in a certain proportion, 
from the bubonic plague, and a very few were probably leprous. 
On the other hand, we have the curious history of the spread of the 
disease in the Sandwich Islands. It is not so many years ago that leprosy 
Fig. i. Tubercular leprosy, (Mexican Woman.) 
was unknown in the islands. A Chinaman affected with leprosy, so the 
account goes, was the original focus, and from him it spread to the natives, 
and from one to the other with such frightful rapidity that it might be said 
with propriety that these islands "are naught but one vast leper colony. 
Father Damien, the Belgian priest who lived among them for years, finally 3 
contracted leprosy and succumbed to the disease. In the case of the Sand- 
wich Islands there is no doubt of the certainty that the disease is leprosy, 
and it would seem, at first glance, to be an irrefutable argument in favor of 
the contagiousness of the disease. Careful study and inoculations by 
competent investigators have failed to show that leprosy is contagious, but 
it is inoculable with the greatest difficulty and only under special circum- 
stances. Pure cultures of the lepra bacillus have failed to bring on the 
trouble, and perhaps the only method which has been found to be successful 
in transmitting the disease is by vaccination from the visicle of a leper. 
This is certain to transmit the disease in nearly every case. The entire 
question still remains sub judice; and in many experimental cases nothing 
definite can be stated, as the disease is one having a long period of incuba- 
tion, being itself a very chronic process, patients with the disease living as 
long as sixty or seventy years after its first manifestation declares itself. 
Fig. 2. Tubercular Leprosy. (Chinaman.) 
No attempt will be made to give a complete description of the'disease, 
as a mere outline would fill a volume. A description of one or two typical 
cases may, perhaps, give a faint idea of the more prominent characteristics 
of the trouble. One of the commoner forms is the tubercular. Good 
pictures of this form are given in Figures 1 and 2. Figure 1 is a picture 
of a Mexican woman, spinster, about 53 years of age, who applied to me 
for treatment. She was employed as a nurse in a family of Mexicans, 
taking care of an infant and a small girl, neither of whom contracted the 
disease, and whose parents laughed at the suggestion of such a possibility. 
The patient stated that she had had the disease for years, and had never 
suffered any particular discomfort from it, with one possible exception. 
This was a complete anaesthesia of the integument of the limbs and of the 
face and head. She could not feel the prick of a needle, nor was she aware 
of the fact when a piece of her skin was excised. This symptom, which 4 
is quite the most prominent one in the anaesthetic form of leprosy, is one 
observed in more than eighty per cent of the cases of the disease which 
are examined in reference to this special symptom. It is a particularly im- 
portant point to establish, from the fact that it is far from rare to observe 
mutilating ulcerations of the fingers and toes follow it. Although these 
heal spontaneously, they leave mutilations which are, in many instances, 
hideous, and only less so than the deformity of the nose occasioned by 
the necrosis and caries of the bones, and ulceration of the soft lining 
structures. 
As in all cases of leprosy of the tubercular and anesthetic forms, there 
existed in this case the peculiar velvety feel of the skin. It also had the 
doughy consistence so characteristic of the condition; the tubercles were 
also softisli to the touch, and there was present a great looseness of the 
integument. This was most marked on the arms, the skin hanging from 
the upper portions of the arms like the dewlap from a bull's neck. Since 
observing it in this case, I have noted its presence in every leper I have had 
occasion to observe; and, whilst it is not particularly mentioned by leprol- 
ogists, it would certainly be instructive to learn whether it is a constant 
symptom or not. To resume the description of the case: On the dorsal 
aspects of the hands and feet, as also upon the fore-arms and legs, large, 
soft tubercles, darker in color than the surrounding skin, presented them- 
selves. The face (as may be seen from Figure 1) was a typical one, and 
gave the characteristic leonine expression of tubercular leprosy. The 
tubercles were disseminated over the entire countenance, the nose having 
the characteristic broadening, the superciliary eminences accentuated, the 
lips thickened, and the cheeks hanging down in flabby folds. Along the 
edges of the nares small split-pea sized tubercles were present, and these 
were excised without producing any pain. As is the case in all operations 
on lepers, be they trivial or serious ones, healing occurred very rapidly and 
without extensive scars. The ears were large, soft and velvety, being 
thickened to quite a considerable degree. So far as the general condition 
of the patient was concerned, all the functions seemed to be properly per- 
formed, menstruation being still present and regular. The patient's appe- 
tite was fair, and sleep good. No particular pains were complained of, 
and the woman seemed to be always in a cheerful and contented mood. 
She was not irritable, and was unusually patient with her charges. 
This case is not so well marked as the one shown in Figure 2. Here 
we are presented with one occurring in a Chinaman. In this case the 
tubercles are much more marked, and the folds are thick and furrows deep. 
The neck is traversed by folds, and the expression of the face has a fierce- 
ness lent to it not due to any disposition of the kind. The Chinese always 
present a more hideous appearance than any other race. This is no doubt 
due to the peculiar conformation of the features in the Mongolian. 
The anaesthetic form of leprosy is not frequently met in its pure form. 
In fact, nearly all forms are mixed. In the anaesthetic, the macular form 
is seen; the anaesthetic is mixed with the tubercular, etc. One peculiar 
phase of the anaesthetic form which has elicited a great deal of comment 
and discussion, is a certain atrophy of the interossei muscles of the backs 
of the hands. A very marked case of this is shown in Figure 3, delineat- 
ing a case in a Chinaman. He was cheerful, despite his segregation, and 5 
felt in good physical condition. A feature connected with the particular 
muscular atrophy shown, was a weakness in the grasp of each hand. This 
peculiar atrophy has an interest for both neurologists and leprologists, from 
the fact that it is so suggestive of syrringo-myelia; and, when the trouble 
has progressed, or when anesthesia is marked, we may have typical 
examples of Morvan's disease, so far as appearance and general symptoms 
are concerned. The first question which arises is as to whether the atrophy 
is due to leprosy alone, or is there a true syrringo-myelia present, produced 
by the action of the leprous process on the spinal cord. In regard to 
Morvan's disease, some have expressed great doubt that it is a disease perse. 
Zambaco Pasha has even gone so far as to assert that all cases of Morvan's 
disease are in reality leprous, and that the latter disease can always be 
demonstrated by tracing back the history of the individual and his prede- 
cessors. These questions cannot be considered here, and it will suffice to 
say that the presence of the atrophic form is prognostic of grave nerve 
complications, Morvan's disease being an incurable affection and accom- 
panied by varying degrees of imbecility. The whole question is one 
which has awakened the liveliest interest, and is still being investigated by 
some of the most competent authorities living. 
Fig. 3. Anesthetic Leprosy. ( Chinaman.) 
No special attempt will be made in this place to discuss the matter, 
that of the therapeusis of recognized cases being perhaps of more impor- 
tance. Up to within late years nearly every author regarded leprosy as an 
incurable disease. Various attempts were made in the way of medica- 
tion, but no satisfactory or adequate results were obtained. Unna, on the 
other hand, looks upon the disease as a perfectly curable one, and he claims 
to have obtained successful results. In view of the results which have been 
obtained by nearly all those who have attempted to treat the disease, very 
little encouragement can be held out for' an ultimate cure, although im- 
provement can be safely promised and obtained in a comparatively short 
time. The treatment of Unna, which he has well spoken of, was based 
upon the researches and findings of a pathologic and of a therapeutic 6 
nature. To begin with, the researches first made by Hensen, and after- 
wards pursued by other investigators, have proven, with as great a cer- 
tainty as in the case of tuberculosis, that leprosy is a bacillary disease due 
to a specific bacillus having peculiarities in its methods of staining, bleach- 
ing and cultivating. The bacillus resembles very closely that of tubercu- 
losis in its morphological characteristics, but differs materially frcm that 
organism in the fact that cultures can be made only with the greatest diffi- 
culty and upon special media. Furthermore, it is aerobic. It is this last 
quality-this greediness for oxygen-which causes it to assume a particular 
locality in the tissues. The bacilli hug closely the walls of the arterioles 
and of the lymphatic vessels. It is this fact which has led to the conclu- 
sion that the best treatment is such an one as will rob the organism of the 
oxygen which it seeks. In order to accomplish this, reducing agents are 
clearly indicated. Their external and internal use combined should cer- 
tainly accomplish the desired purpose, if anything can. Good resultshave 
been reported as following the use of this method, but, unfortunately, no 
cure has as yet been accomplished. 
The fact that, among our strongest reducing agents, ichthyol holds a 
foremost place led me to the employment of that agent, both internally and 
externally, in the case shown in Figure 1. The dosage was carefully and 
gradually increased, and the patient grew steadily better. She began by 
taking fifteen grains of ichthyol three times a day, and applied a twenty per 
cent ichthyol ointment, having a base of equal parts of lanoline and cold 
cream, twice daily. The internal dose was increased up to one drachm 
three times a day, at which she remained and continued for quite sometime. 
The ointment was increased to a strength of sixty per cent. A strange 
circumstance in connection with these high doses of ichthyol was the fact 
that, far from producing nausea, as might be reasonably expected, the drug 
seemed to increase the appetite, and the patient declared that she felt much 
better in every respect. It became occasionally necessary, in the course of 
the treatment, to suspend the internal administration of the drug, this being 
done whenever the ichthyolic fetor of the breath became markedly pro- 
nounced. 
Among the phenomena which were noted in this case, and which were 
of a most gratifying nature, may be mentioned the return of the sensibility 
of the skin. The cutaneous anaesthesia, which was complete, disappeared 
entirely, and the slightest touch of any external body was instantly per- 
ceived and recognized. In addition to this, it was noted that the tubercles 
diminished perceptibly in size, and the face no longer presented the charac- 
teristics of the leonine countenance to the same marked degree as it did 
before the inception of the treatment. After this much improvement had 
been procured in a comparatively few months' time, the patient passed from 
under my observation, and I learned later that she had returned to Mexico 
with the family employing her. This was, of course, quite a disappoint- 
ment, in view of the progress which had been made, but one which I have 
experienced in every case of leprosy which I have had occasion to treat. 
One of the oldest and, it is claimed, one of the best methods of treatment 
for this disease is the internal administration of chaulmoogra oil in grad- 
ually increasing doses. Many cases of marked improvement have been 
noted as due to its action, but no undoubted cure has yet been demonstrated. 7 
A remarkable case of improvement, observed in Paris, is reported and 
figured in the Atlas of Skin Diseases of the Hospital St. Louis, which is 
still going through the press. There is no doubt that the improvement is 
remarkable, but the time which has been necessary to accomplish this seems 
to be almost out of proportion to the result achieved. Another agent which 
has found many supporters, and which is highly lauded is gurjun oil. It 
is used very much in oriental countries, as chaulmoogra oil is, both being 
also quite popular in the Western Hemisphere. We do not see any but en- 
couraging reports; and absolute and undisputed cures have not been brought 
forward up to the present. 
The latest method which might prove successful is that which has been 
recently brought forward. It is simply the application of sero-therapy to 
the treatment of the disease. I suggested over a year ago the injection of 
serum of goat's blood, the animal having been inoculated previously, in the 
manner employed in other methods of serum injections. All animals being 
immune to leprosy, a curative as well as preventive serum should certainly 
be obtainable. Within the past two or three months indefinite reports of 
successes obtained with goat serum in cases of leprosy have been published. 
However, so far as an ultimate cure is concerned, but small hope can be 
held out yet. I have seen two reported cases of cure, but the tubercles had 
returned and the cases were again suffering from the former symptoms. 
The structural changes which become established in a case of several-or 
many years' standing are such as to be practically beyond the reach of all 
treatment. That there is a possibility of preventing the evolution of the 
disease, when taken at its inception, is most probable. The method of doing 
this has, so far, not been satisfactorily demonstrated; and leprosy still re- 
mains an odium medicines, and bids fair to remain so until some effective 
means of eradicating it is discovered. Whether this will lie in the direc- 
tion of sero-therapy or of some means as yet undiscovered, must be left for 
the future. At present, we must, perforce, remain content with the methods 
at our disposal.