LEPROSY:
IN ITS
CLINICAL AND PATHOLOGICAL ASPECTS.
LEPROSY:
IN ITS
CLINICAL & PATHOLOGICAL ASPECTS.
BY
DR. G. ARMAUER HANSEN,
_Inspector-General of Leprosy in Norway_,
AND
DR. CARL LOOFT,
_Formerly Asst. Phys. to the Lungegaards Hospital_.
TRANSLATED BY
NORMAN WALKER, M.D., F.R.C.P. ED.
_Asst. Phys. for Dermatology, Edinburgh Royal Infirmary_.
WITH NUMEROUS PHOTOGRAPHS AND COLOURED PLATES.
BRISTOL: JOHN WRIGHT & CO.
LONDON: SIMPKIN, MARSHALL, HAMILTON, KENT & CO., LTD.
HIRSCHFELD BROS., 82, HIGH HOLBORN.
1895.
JOHN WRIGHT AND CO.,
PRINTERS AND PUBLISHERS, BRISTOL.
AUTHORS’ PREFACE.
As it is evident in the numerous recent publications on Leprosy that
our first work on the disease, which was published in Norwegian,
is unknown to many investigators, and as there appear in their
publications many statements, to our thinking, premature and founded
on insufficient knowledge, we think it desirable to present a
comprehensive statement of the result of our studies of this disease,
so interesting in itself and so instructive in other directions.
Since one of us has been for more than twenty years occupied in dealing
with the disease, we hope to be able to lay before experts a thorough,
complete and instructive demonstration, the more, as we do not base our
views, as has been frequently and unfortunately done, on any single or
scattered observations.
TRANSLATOR’S PREFACE.
In the translation of this little work I have, of course, made absolute
accuracy of meaning my first aim. It presents the views of one who in
his knowledge and experience of the disease is probably second to none.
There are, of course, certain points on which there is much difference
of opinion. For example, Hansen’s view, which is very widely held, of
the position of the bacilli in the cells, is very strongly opposed by
Unna. Then as to the occurrence of nodules on the palms and soles which
Hansen denies, Unna remarks that it is quite exceptional, while Hillis
seems to consider it by no means rare. The chapter on Treatment has
been wholly re-written for this edition, and is practically a summary
of the late Dr. Danielssen’s views. The photographs are a further
addition to the original German edition. It has been pointed out to me
that Dr. Hansen does not refer to the recent Indian Commission. His
views on it may be found in the _Lancet_, of October, 1893.
In conclusion, I have to thank my friends, Dr. Colcott Fox for a
general reading of the proofs, and Drs. George Mackay and Stockman for
their revision of those parts relating to the affections of the eye and
to the drugs used in treatment.
NORMAN WALKER.
EDINBURGH, _May, 1895_.
CONTENTS.
_CHAPTER I._
PAGE
INTRODUCTION AND NOMENCLATURE 1
_CHAPTER II._
NODULAR LEPROSY 5
Seat, 5; Localisation, 5; Affection of the Eyes, 8; Affection
of the Extremities, 10; Affection of the Mucous Membrane,
11; Affection of the Lymphatic Glands, 13; Subcutaneous
Nodules, 13; Affection of Nerves in this Form, 14; Fate of
the Nodules, 15; Commencement of the Disease, 16; Duration
of the Eruptions, 19; Fate of the Patient, 19; Combination
with Tuberculosis, 22; Comparison with that Disease, 23;
Affection of the Lungs, 26; Cultivation of the Bacilli, 27,
Miliary Leprosy, 28; Mental Symptoms, 29.
_CHAPTER III._
STRUCTURE OF THE LEPROMA 31
Movement of the Bacilli, 31; Nature of the Cells, 32;
Nature of the Blood Vessels, 32; Softening of the Nodule, 34;
“Brown Elements,” 34; “Globi,” 35; Position of the Bacilli
in the Cells, 37; Position of the Bacilli in the Blood Vessels,
38; Effect of Measles, 40; Digestion of the Bacilli by the
Cells, 41; Structure of the Bacilli, 41; Bacilli in the Sweat
Glands, 43; Affection of the Testicle, 45; Affection of the
Liver, 47; Affection of the Spleen, 47; Affection of the
Glands, 48; Affection of the Nerves, 50.
_CHAPTER IV._
LEPRA MACULO-ANÆSTHETICA 52
Prodromal Stage, 53; Development of Bullæ, 53; The
Macular Eruption, 54; Symmetry, 55; Neuritis, 56; Trophic
Disturbances, 57; Affections of the Joints, 59; Motor Weakness,
60; Atrophy of the Interossei, 61; Paralysis of the Orbicularis
oris et palpebrarum, 61; Trophic Affections of the
Bones and Skin, 62; Sensation, 64; Loss of Smell and Taste,
66; Duration, 66; Cause of Death, 66; Recovery, 67.
_CHAPTER V._
PATHOLOGICAL ANATOMY OF THE MACULO-ANÆSTHETIC
FORM 68
Comparison of Recent and Old Macuoles, 68; Alterations
in the Nerves, 70; Bacilli in the Nerves, 70; The Spinal
Cord, 71; Lymphatic Glands, 72; Muscular Affections, 72;
Association with Tuberculosis, 73; Necrosis of Bones, 75;
Joint Affection, 76; Difference between the two Forms of the
Disease, 77; Influence of Climate, 79.
_CHAPTER VI._
DIAGNOSIS AND PROGNOSIS 82
Diagnosis from Psoriasis, 82; Diagnosis from Syphilis, 83;
Diagnosis from Syringo-myelia, 83; Leprosy in France, 83;
Morven’s Disease, 83; Prognosis, 84.
_CHAPTER VII._
ETIOLOGY 86
Humoral Pathology, 86; Heredity, 87; Miasma, 87; Contagion,
88; Baumgarten’s Dormant Heredity, 89; Nature of
Heredity, 90; Father Damien’s Case, 93; Leprosy among
Norwegians in North America, 94; Inoculation, 95; Hutchinson’s
Fish Theory, 96; Direct Proofs of Contagion, 97;
Hospital Experience in Norway, 99; Communication of the
Disease, 102; Greater Danger of Nodular Form, 102; Leprosy
and Vaccination, 103.
_CHAPTER VIII._
TREATMENT 105
Ancient Treatment, 105; Treatment in the Eighteenth
Century, 105; Specific Remedies--Madar 107, Cashew Oil 107,
Gurjun Oil 109, Chaul Moogra 111, Hoang-nan 113, Ussacou
113; Carbolic Acid, 114; Creasote, 114; Phosphorus, 115;
Arsenic, 115; Ichthyol, 115; Kreuznach, 115; Mercury, 116;
Iodine, 116; Tuberculin, 117; Chlorate of Potassium, 118;
Hydroxylamin, 118; Europhen, 119; Aristol, 120; Naphthol
and Salol, 120; Methyl Blue, 120; Nerve Stretching, 120;
Electricity, 121; Salicylate of Soda, 122; Importance of
Isolation, 124; Results in Norway, 125.
TABLES.
PAGE
_TABLE I._ 128
The Frequent Complication of Nodular Leprosy with
Tuberculosis.
_TABLE II._ 138
The Proportion of Tuberculosis in Maculo-Anæsthetic
Leprosy.
_TABLE III._ 144
The Proportions of the Two Forms of the Disease in
Different Districts.
_TABLE IV._ 145
The Results of Isolation in Norway.
LIST OF PLATES.
PAGE
PLATE I.--Tuberous Leprosy (the so-called Facies
Leonina) of two years’ duration 8
” II.--Tuberous Leprosy of six years’ duration 10
” III.--Tuberous Leprosy after breaking down of
the Nodules 12
” IV.--Maculo-Anæsthetic Leprosy of two years’
duration 55
” V.--Case of Maculo-Anæsthetic Leprosy after
Recovery 61
PLATES VI. to XIII.--Chromo-Lithographs 148
LEPROSY:
IN ITS
_CLINICAL AND PATHOLOGICAL ASPECTS_.
CHAPTER I.
INTRODUCTORY.
The Bacillus Lepræ has now been recognised in all leprous products,
and although the fact has not yet been experimentally demonstrated, we
may practically say with confidence that Leprosy is a chronic disease
caused by the Lepra bacillus.
Leprosy appears in two forms, which are clinically pretty sharply
distinguishable, and were named by Danielssen and Boeck “nodular”
and “anæsthetic.” This nomenclature, introduced by these authors in
their pioneer work, _Om Spedalskhed_, Christiania, 1847, _Traité de la
Spedalskhed_, Paris, 1848, is so far important as it characterizes the
common and most prominent symptoms of the two forms, viz., in the one,
the nodular eruption on the skin, in the other, the anæsthesia which
results from the widespread affection of the nerves. On the other hand,
regarded from a strictly scientific standpoint, the nomenclature is
scarcely the happiest: firstly, because the one form is named from the
eruption on the skin, and the other from the results of the affection
of another organ, the nerves; and secondly, because the nerves are
affected in the nodular as well as in the other form, though the result
of the affection, the anæsthesia, does not so dominate the appearance
of the disease.
As Danielssen and Boeck recognised, skin eruptions are present in both
forms, and since, as we shall later point out, the eruptions differ
both clinically, and also somewhat in their anatomical formation, it
would perhaps be more strictly correct to describe the two forms as
Lepra tuberosa (tuberculosa) and Lepra maculosa or lævis. But, in the
first place, it is of questionable advantage to change a universally
accepted nomenclature; and secondly, it is very frequently the case
that one sees the patient for the first time after the disappearance
of the macular eruption with anæsthesia only, so that the name Lepra
anæsthetica exactly describes the case. But in order to give to
the skin eruption in the anæsthetic form its proper place in the
nomenclature we will describe the two forms of the disease as _Lepra
tuberosa_ (tuberculosa), and _Lepra maculo-anæsthetica_. And thus we
hope to have done justice both to the founders of the scientific study
of Leprosy, and to the clinical appearances of the disease.
Danielssen and Boeck have also described a mixed form of the disease,
in which nodular Leprosy is combined with anæsthetic. Sometimes
the skin eruption disappears and the nodular form passes into the
anæsthetic, and sometimes, though much more rarely, the anæsthetic
into the nodular; and since, further, the two forms are so different
in their clinical appearances that they look almost like different
diseases, the recognition of a mixed form might appear to be justified.
But since every case of nodular Leprosy is accompanied by affection of
the nerves and anæsthesia; and the natural termination of every case
of nodular Leprosy is to pass into the anæsthetic form, if only, as
occasionally happens, the patient live long enough; and since the skin
eruptions of the maculo-anæsthetic form are characterized, just as
those of the nodular form, by the presence of the leprosy bacillus, we
regard the transformation of a case of maculo-anæsthetic into nodular
Leprosy only as a sign of the unity of the two forms, and we delete
altogether the name of mixed Leprosy. Otherwise every case of nodular
Leprosy must, at all events after some years of existence, properly be
called “mixed,” for in such cases anæsthesia is never absent.
It has been attempted to indicate as a special form of the disease
a Nervous Leprosy, in which no characteristic skin affection is
present.[1] In view of what we have noted above, that nerve Leprosy is
present in both forms of the disease, and that an eruption may be noted
at some period in all carefully observed cases of the disease, this
attempt to indicate a special nerve Leprosy is evidently wrong.
[1] See Neisser: Lepra in Ziemssen’s Handbook.
We will first of all discuss separately the two forms of the disease,
the nodular and the maculo-anæsthetic, and then proceed to demonstrate
the unity of the disease in spite of the differences in form.