NODULAR LEPROSY.
Nodular Leprosy (_Lepra tuberosa, L. tuberculosa_) is usually easily
diagnosed by its characteristic skin affection.
The leprous nodes or nodular Lepromata are of different size and
colour; their consistence is at first firm and hard; they are but
slightly compressible, and show little elasticity. Their form is
usually semi-spherical, but they are often oblong. The smallest
nodule that we have seen was not more than 1-2 mm. in diameter, and
its appearance was so little characteristic, that we had to confirm
the diagnosis by excision and microscopical examination. The larger
the nodules, the more characteristic is their appearance. As they are
almost always seated in the cutis, the epidermis over them is stretched
and shiny; it is occasionally normal in colour, but usually at first
reddish, later becoming yellow. _The localisation of the nodules is
usually characteristic._ They are generally first evident on the face,
on the backs of the hands, and on the dorsal surfaces of the wrists,
and next on the extensor surfaces of the limbs. They are more rarely
seen on the back and nates; on the flexor surfaces of the extremities,
on the breast, abdomen, scrotum, and penis, they are quite exceptional;
and we have never seen them on the glans penis, the palms or soles, or
on the hairy scalp. Leloir has described a leprous affection of the
palms of the hands, of which he himself says that it closely resembled
a syphilide in that situation. Since Danielssen, with his enormous
experience, never saw a leprous affection of the palm of the hand, we
incline to believe that the affection which Leloir observed, not only
resembled, but actually was, a syphilide.
Here in Norway where the people often go barefoot, wading in streams,
marshes and rivers, the backs of the feet and the under part of the
calves are frequently the seat of the first leprous eruption, not so
often in the form of nodules, as of a dense, regular infiltration.
Now since, as we have noted above, the face and back of the hands are
the usual seats of predilection for the earliest appearance of the
eruption, it appears not improbable that this has its explanation in
the climatic influences on these parts, possibly influenced by the
structure of the skin, especially the cutaneous vessels. That there
are peculiarities in the structure of the tissues, which determine the
localisation of the poison, one may conclude; for certain organs are
never affected with leprosy, in spite of the fact that the poison has
evidently at some time circulated in the blood.
The face is usually especially characteristic, as the eyebrows are
almost always the seat of nodules. The nodules are sometimes isolated
though close together, sometimes there are only one or two, though
usually several, and sometimes there are no distinct nodules, but the
eyebrow is infiltrated both in length and breadth, and of a reddish
colour. Even if the infiltration is not so great that the brow appears
thickened, the reddish colour and the shadow over the eyes give to the
face a characteristic expression, and one can feel the infiltration,
if the brow is gripped between the thumb and forefinger. In these
cases the hairs persist; in more severe infiltration, and where
nodules are formed, they drop out. The forehead and cheeks usually
present a diffuse or spotty redness and burnish, and with the finger
one recognises the infiltration as an increased resistance. This
discolouration is most evident on changes of temperature, as when a
patient comes from the outside cold into a warm room. Not infrequently
the suspicion of Leprosy is aroused by this change of colour, and by
the shadows over the eyebrows, even years before more definite symptoms
appear. But in most cases one finds distinct nodules in the eyebrows
and over the countenance generally. When the nodules are numerous and
large, so that the eyebrows project far over the eyes; when the cheeks
and chin are beset with large rounded or flat nodules pressing on each
other, so as to cause deep furrows between them; when the point of
the nose, the alæ nasi, and the lips are infiltrated throughout their
whole thickness; the countenance is frightfully deformed, and there is
developed the so-called _Facies Leonina_. The lobules of the ears are
almost always infiltrated, and become red, thick and elongated. _Plate
I_ is a case of tuberous leprosy of two years’ duration, the hands
being swollen with leprous infiltration.
[Illustration: PLATE I.]
The eyes are, in the nodular form, almost always affected; nodules are
frequently present in the eyelids, the upper as well as the lower, and
are usually situated close to their margin. The earliest affection of
the eye itself, which we have observed, is a faint clouding of the
upper part of the cornea, which often appears as a very fine dotting
of the corneal surface, only noticeable when one can compare the upper
part of the cornea with the black pupil, and often requiring for its
recognition the use of a lens. A slight infiltration of the limbus
conjunctivæ is always combined with this clouding of the cornea, but it
is at this early stage so slight that it cannot be noted clinically.
Later on it increases, and gradually attacks the whole of the
outer margin of the cornea. When this infiltration becomes greater it
appears yellow, as seen through the conjunctiva running intact over
it, and this gives to the eye a peculiar woe-begone aspect. It is
quite exceptional for this infiltration to extend completely round
the cornea, for that part of the limbus directed towards the nose
is almost always free. As time goes on the infiltration increases,
and a low rampart is formed around the cornea. Sooner or later the
infiltration and nodule formation attack the cornea itself, in one of
three different ways: first, quite superficially, immediately under the
epithelium. The nodule in this case is always elevated, usually grows
very rapidly till it finally covers the whole cornea, and may by its
height prevent the closure of the lids. That part of the cornea lying
below or behind the nodule is quite clear. Secondly, the infiltration
may attack the cornea in the form of a wedge, and form a node which
is not so much elevated as in the previous instance; and thirdly, the
infiltration may penetrate the cornea close in front of Descemet’s
membrane. The result, complete blindness, is the same in all cases
when the nodule covers the pupil. A frequent accompaniment of this
form of the disease is iritis, or, as anatomical investigation shows,
irido-cyclitis. These forms of iritis run a chronic or sub-acute
course, sometimes so stealthy and painless that it is observed by
neither doctor nor patient, until adhesions have formed between the
pupillary border and the capsule of the lens. Blindness may sometimes
be caused by exudation into the pupil. _Plate II_ shows a typical case
of tuberous leprosy of six years’ duration. The hairs have completely
disappeared from the eyebrows; on the chin a few can still be seen
between the tuberosities. In the right eye is a nodule, growing from
the _Limbus conjunctivæ_ into the cornea. Nodules may also be present
in the iris, and usually arise in the outer and under margin, in the
angle between the cornea and the iris; they may completely fill the
corresponding part of the anterior chamber, are of a yellow colour,
and sometimes look exactly like an obliquely-placed hypopion, as they
have an inner or upper straight, or slightly concave margin. We once
did an iridectomy directly through a small early nodule, and put a
stop to its further growth. On anatomical examination we also find a
leprous affection of the anterior part of the retina over the ciliary
body, which appears as a fine white spotting of the retina; the ciliary
nerves are always for a considerable distance backwards infiltrated
with leprosy, as are the _membrana supra choroidea_ and the choroid
itself.
[Illustration: PLATE II.]
On the extremities the nodules always appear singly, but when
closely set may run together to form large plaques. On the backs of
the hands and fingers nodules are very frequently, and on the extensor
surfaces of the thighs and the front of the legs almost always, found.
The calves are often also infiltrated as a whole, especially on the
fibular side close above the ankle, and this infiltration reaches as
high as the middle of the leg; the skin is tense and shiny, reddish
blue in colour, and in this infiltrated part ulcers resembling varicose
ulcers readily appear, which are as difficult, if not more so, to heal.
They are surrounded by thick elevated walls, may last for years, and
occasionally completely surround the leg.
Of the mucous membranes, those of the nose, mouth, larynx and pharynx
are affected. The nasal mucous membrane is affected only in its
anterior part along with the alæ nasi and the anterior part of the
septum. If a general infiltration takes place in this situation,
the softening and ulceration which may ensue lead eventually to the
disappearance of all the soft parts of the nose; the bones are never
affected. (See _Plate III_, a case in which the leprosy developed in
1848, and was of the tuberous variety. The tubers disappeared partly
by suppuration. In 1857 he entered an asylum and then presented the
same appearances as in the photograph. He was then anæsthetic. There
were cicatrices in the face due to the disappearance of the nodules,
the point of the nose was gone, but the nasal bones were intact, thus
differing from syphilis. He died in 1885.) In the mouth, the mucous
membrane of the lips, of course, shares in the process when these are
completely infiltrated, and even on the mucous membrane of the cheeks
one occasionally sees and feels thickening and infiltration. The tongue
is often the seat of nodules, which in all respects correspond to
those of the skin. The gums, the velum, and the uvula may be either
infiltrated or dotted with nodules. The rest of the mucous membrane of
the pharynx is more frequently infiltrated than beset with nodules, and
the same is true of the epiglottis, which sometimes becomes quite stiff
and almost immoveable. In the larynx, the true and false cords are more
frequently the seat of infiltration than of nodules; the voice is rough
and hoarse, the rima glottidis is often so narrowed that respiration is
rendered difficult; excessive narrowing of the rima is only present in
the late stages, and is proportionately rare. When the mucous membrane
ulcerates the cords grow together, both anteriorly and posteriorly,
and when the infiltration disappears there remains a scar tissue,
which, by its contraction, reduces the rima to a small slit, a few
millimètres wide. In such cases a very little mucus is sufficient
almost or completely to close the opening, and the patient may perish
from suffocation. Usually an emetic suffices to open up the hole at
once; but tracheotomy is often necessary to supply air to the patient,
the attacks of suffocation are so frequent, and since he is already
voiceless, he loses nothing by the operation.
[Illustration: PLATE III.]
The lymphatic glands (cervical, axillary and inguinal) in relation
to the affected skin and mucous membrane are always swollen: this
leprous swelling is always indolent, and never goes on to suppuration.
Sometimes the glandular swelling may aid in the diagnosis, if the skin
affection is not absolutely characteristic, though this is most rarely
the case.
The nodules are almost always seated in the cutis, but they may, though
rarely, be placed deeper in the subcutaneous connective tissue; they
form then no projections, but the skin over them is almost always
somewhat hyperæmic and bluish-red, and, if the finger is passed over
the place, the thickening or the nodule may be felt in the deeper
parts. It is in our experience that a patient who had only this form of
nodules was regarded by a colleague, well acquainted with the disease,
as free from Leprosy, probably because he did not use his fingers.
From the symptoms described above, the diagnosis is almost always very
easy, and we ourselves know of no disease of the skin which can be
confounded with nodular leprosy. If necessary a piece of skin may be
removed and examined for the presence of bacilli, which, at least in
the nodular form of the disease, are never absent. This, we have once
had occasion to do.
In addition to the skin the nerves are also affected, not always at the
commencement, but always in the later stages. Whether all peripheral
nerves are affected we cannot say--certainly the facial, radial,
ulnar, median and peroneal are always diseased. According to our
investigation the nerves of the extremities are affected throughout
their whole length, but the affection is severe only at certain places,
viz., where the nerves run superficially over bones or joints, as the
median at the wrist, the ulnar at the elbow, and the peroneal where
it crosses the fibula. As a result of this nerve affection we have
pain followed by anæsthesia. The pains in the arms, hands, feet and
calves are sometimes very severe and persistent. The affection at first
causes pain, by pressure on the nerves, and later--when the pressure
has led to atrophy--anæsthesia. Now since, as we shall later clearly
demonstrate, leprous affections tend to heal, it is not infrequently
the case that nerve affections, when slight, pass off without having
specially injured the nerves, and these nerves may be the seat of
fresh infections, and thus the patient suffers from repeated painful
attacks through a course of years. This is particularly the case where
there is general infiltration of the legs, and is either the result of
repeated attacks of the same, or of the implication of different nerve
branches. The nodules are often painful when first developed, but later
on sensation is deadened.
Of internal organs, the testicle, liver, and spleen, are always
affected in this form, but we shall consider them later in the
description of the pathological anatomy.
Before we more closely describe the course of the disease, we shall
first briefly discuss the fate of the nodules. These usually remain
for years unchanged, growing very little or not at all. The skin over
and around them, or rather its vascular supply, is very sensitive to
changes of temperature, so that the skin, as we have already indicated,
changes its colour with change of temperature from dilatation of the
blood vessels. The vessels evidently suffer from the invasion of
the leprous poison. New outbreaks have often the appearance of an
“erythema nodosum,” with great hyperæmia. We had once the opportunity
of examining a piece cut out of such an erythema-like eruption, and
found dilated vessels and round cells, and only after long search a few
bacilli. One must conjecture that there is deposited with the bacilli
a chemical poison which affects the vessels, or that the bacilli
produce the poison, and that this poison has its action only in its
immediate neighbourhood.
But occasionally the nodules grow so luxuriantly that the epidermis
develops furrows and clefts which may reach down to the nodules, and
then a bloody fluid comes out of them which dries up on the surface to
a reddish brown scab. Or it may happen that the upper horny layers of
epithelium disappear, and that only a few rows of cells of the rete
Malpighii remain. In this case the exuded fluid less often dries,
the surface is usually blood-red and moist, and appears like an
ulceration, though it is not really one. When this takes place on the
face, particularly on the lips, or on the backs of the fingers, the
sufferings of the patient are very much increased. After several years
the nodules usually soften about the middle of their base, and the
nodule may sink in over the softened part; or they burst, the softened
part is thrown off, and now is developed the true ulceration by which
the nodule may be completely eliminated and sunken stellate scars alone
remain.
The determination of the commencement of the disease is exceptionally
difficult, indeed impossible, for it must always be founded on the
statements of the patient, and the patients either observe themselves
insufficiently, as may frequently be noted, or they conceal many
facts. As a matter of fact we do not know the earliest symptoms of
the disease. According to Danielssen and Boeck, the patients often
suffer long and repeatedly, before the outbreak of the disease, from
weakness, with rheumatoid pains and fever. This the patients frequently
corroborate. But we are inclined to regard these attacks of fever as
indications of the already existing disease. It appears to us more
probable that the disease begins with some form of local affection
which is so indistinct that the patient himself does not notice it, or
at least lays no weight upon it, and that these local affections are
analogous to others with which we are familiar, namely, the nodules
which may last for years before new and such definite eruptions
appear, that the disease cannot any longer be ignored or kept secret.
We believe therefore, that the patients do not really know when they
commence to be ill, and that they date the beginning of the disease
from a later eruption. If at the commencement only the extremities
are affected the patients may conceal their condition for years, and
through this concealment become so accustomed to lie, that later it is
impossible to receive from them correct information.
The cases are very frequent in which the patients have for several
years only scattered nodules, and then suddenly a fresh outbreak
of numerous nodules. The disease always advances by outbreaks of
eruptions which repeat themselves at longer or shorter intervals. It
is very often the case that the older nodules soften during a fresh
outbreak, and completely or partly disappear; and these outbreaks are
always accompanied by fever, the temperature rising to 39° or 40°
Cent. Now we know that the nodules, if the patient is affected by
another febrile disease, may disappear. It is, therefore, difficult to
decide whether the disappearance of the nodules is the cause or the
result of the eruptive fever. But we possess certain observations in
which the disappearance of the nodules has begun before the onset of
the fever, and in which, therefore, the fever and the later eruption
appear to be caused by the softening of the nodules. Supported by these
observations we regard the eruptions as auto-infections, in which
bacilli (or poison) from the older lepromata pass into the blood, and
thus new areas of the skin or other organs are affected. We have often
observed that an irido-cyclitis, or an affection of the throat, arises
during an eruption, and also that the nerves beneath the nodules become
swollen and painful, and once we have seen the testicle become swollen
and painful during an eruption. As to the affections of the liver
and spleen we have no clinical observations; they appear to cause
no clinical symptoms, or at all events, such indefinite ones that,
although our attention has been directed to them, they have escaped
observation.
_The eruptions are of the most varied duration._ Some last only a
few days and cause so little fever that the patients experience no
particular disturbance to health; they only know that a few new nodules
appear, or that they are sore about the throat. Others last for
weeks, indeed, months, with remittent fever, the temperature rising
to 40°. Quinine has no effect. During such eruptions the strength
of the patients is of course distinctly diminished, but when the
eruption is over they recover rapidly and feel themselves all right
again; only they are more leprous than before, or at least have more
leprous manifestations. The number of eruptions varies greatly in
different cases. Sometimes the patient has, for several years, several
eruptions every year; in other cases the eruptions appear only very
rarely--one or two in the whole course of the disease, and they may be
very slight. It appears as if the bacilli in different cases were of
varying virulence, or possibly the structural conditions are different
in different individuals, so that in some the bacilli (or the poison)
reach the blood more easily than in others.
Therefore the _fate of the patient is very different_. If the
eruptions are frequent the growth of the nodules is usually luxuriant,
and those nodules with diminished epithelial covering, and therefore
moist, are very frequent. If then, the whole countenance and part
of the extremities are covered with such nodules; if the eyes are
blinded by the formation of nodules in the cornea; if the tongue and
the pharynx are, through formation of nodules and infiltration, half
ulcerated and sore; if respiration is made more difficult by the
narrowing of the rima, and the voice inaudible; then the condition is
as miserable as is possible to conceive.
If there is added to this, amyloid degeneration of the kidneys, liver,
spleen and intestine, with diarrhœa, it can only be desired that death
shall put an end to such a condition, and that usually takes place
soon, although occasionally the patient may linger for months. Whether
leprosy alone is responsible for the end is, we think, doubtful; as
remarked above, the affections of the liver and spleen appear to be
without much significance.
The biliary secretion is never influenced, and there is according to
our observations no special leprous anæmia. The patients are indeed
often anæmic, or become so during the disease, but we have not been
able to convince ourselves that this is a direct result of the leprosy.
In many examinations of the blood, which were indeed undertaken for
other purposes, we have never noticed anything remarkable in relation
to the number or form of the blood corpuscles.
As in almost all cases of nodular leprosy nephritis is present, we
are inclined to regard this nephritis as a frequent cause of the
marasmus which ensues. Tuberculosis was formerly a frequent occurrence
in our hospitals, where our observations have chiefly been made. The
relationship between this and leprosy we will discuss later.
The prognosis in the case of patients in whom the eruptions appear
less frequently is more favourable, and they may live many years.
Either they die from an intercurrent disease or as a result of their
nephritis, or they become in time anæsthetic, that is, according to our
view, they recover. When the nodules become stationary they ultimately
soften, as described above, and may be absorbed without opening, though
this is rare and usually occurs only with single nodules; or they burst
and ulcerate; in either case they leave scars. If this takes place in
all the nodules and the patient is attacked by no fresh eruptions, then
anæsthesia gradually develops as the result of the affection of the
nerves; in the nerves, too, the specific leprous affection disappears,
and there remains only scar tissue, which by compression destroys
the nerve fibres and thus causes anæsthesia. Then gradually all
specific leprous affections disappear, and the patient is healed from
his leprosy, and may live many years in perfect health, having lost
practically nothing of his power of work. Such cases are unfortunately
not very frequent; but we have had the opportunity of examining some
after death and have not been able to discover in them any specific
leprous affection.
Thus one is struck with the fact, how little leprosy of itself
influences the health of the patient, and if nodular leprosy usually
shortens life, that takes place probably because in this form the
frequent ulceration leads to amyloid degeneration of the internal
organs, or that the nephritis is a sequel of the leprosy. The nephritis
appears either as the so-called parenchymatous or as the interstitial;
according to our examinations it is never bacillary. Further, as
nephritis is very much rarer in the maculo-anæsthetic form of the
disease, it must be assumed that nodular leprosy in some way causes
nephritis. The same is true of amyloid degeneration. The duration of
life of a patient with the nodular form of leprosy is in general eight
to nine years after the definite outbreak of the disease.
The most frequent complication which we have seen in our institutions
is tuberculosis, particularly some years ago, for then the
institutions were over-crowded, and consequently the sanitary
conditions were in many respects unsatisfactory.
In order to give an idea of the frequency of this complication, we
have placed in tabular form at the end of this work the results of
eighty-nine autopsies (see TABLE I, page 128).
From the statistics there given it is evident that we have had ample
opportunity of examining the combination of tuberculosis and leprosy.
Most of these examinations were indeed made in the pre-bacillary era;
but we are satisfied that the _differentiation_ of tuberculosis and
leprosy without an examination for bacilli is by no means difficult.
As Danielssen and Boeck had described a leprous affection of the
intestine, we gave great attention to this point, and as we were at
the same time engaged in an investigation on the pathological anatomy
of the lymphatic glands, we lost no opportunity of carefully examining
these organs. It was during this investigation that we discovered the
characteristic leprous affection of lymph glands, and had our attention
first directed to the leprous affection of the liver and spleen, which
affections are, macroscopically, so little evident, that we at first
overlooked them.
The leprous and tuberculous affections of the lymph glands are
macroscopically so very different, that it is impossible to confuse
them, and the microscopical differences are still more evident. Both
fresh and hardened preparations were always examined. And since the
lymph glands are always affected with leprosy, if the organs which
drain into them are affected, even if this affection is very slightly
developed, we conclude from the fact that we have never seen a leprous
bronchial or mesenteric gland, that there is no leprous affection of
the lungs or of the intestine, and later examination of certain special
preparations have only confirmed us in this view. But more of this
later, and we will first treat of the differences between tuberculosis
and leprosy.
In organs affected with tubercle one always finds, as is well known,
giant cells and caseous degeneration; in the many, we can truthfully
say, thousands of preparations of leprous affections, which we have
had under the microscope, we have never seen either a typical giant
cell with marginal nuclei or caseous degeneration. There are indeed
multinuclear cells in the lepromata, but never giant cells like those
of tubercle.
What may be the reason for this striking difference in the action of
the very similar bacilli of tubercle and leprosy, we have no idea; we
simply state the fact and assert that, if one finds giant cells, he
is dealing with tuberculosis and not with leprosy. This alone would
be sufficient to cause us to separate the two neoplasms, but there
are many other distinctions. Tubercle is avascular; the leproma is
rich in vessels; tubercle undergoes caseous degeneration, the leproma
never. Anatomically therefore, we are justified in maintaining a sharp
distinction between the two diseases.
So far as concerns the resemblance between the tubercle and lepra
bacilli, we must not omit to mention that one almost always finds
among tubercle bacilli some which are pretty long and somewhat bent;
this is never the case among lepra bacilli. Baumgarten has indicated
as a distinction between them, the fact that the latter is more easily
stained; according to our experience this distinction can scarcely
be regarded as sufficient. But the distribution of the bacilli in
the tuberculous and leprous tissue is usually so very different, the
tubercle bacilli being usually arranged singly, the lepra bacilli
always in large quantities in masses and clumps, that a confusion of
the two diseases anatomically can only be possible in exceptional
cases. Danielssen has repeatedly stated in his triennial report of
the Lungegaards Hospital that tuberculosis and leprosy are such
nearly allied diseases that the one (leprosy) may pass into the other
(tuberculosis) by a modification of the bacilli, and that thus the
frequent combination of the two diseases is to be explained. This
view we cannot, in view of the above demonstration, support. If an
organ is attacked at the same time by tuberculosis and leprosy, one can
anatomically very readily separate the two diseases. We would rather
seek the explanation of the frequent combination of the two diseases in
our institutions in the great over-crowding and consequently insanitary
conditions to which they were formerly subjected. Tuberculosis
once introduced, we find a ready explanation in the bad habits of
the patients in regard to expectoration, why it was difficult or
impossible to root it out. In later years, when the institutions are
no longer full and the sanitary conditions consequently much improved,
tuberculosis has much decreased. Whether tuberculosis was as frequent
a combination in the country as in our institutions we do not know.
The duration of life of patients in the country is about a year longer
than in our institutions, and possibly this depends on the absence of
tuberculosis.
Doutrelepont has recently described in the transactions of the German
Dermatological Society, _On the Pathology and Therapeutics of Leprosy_,
a lung affection, probably developed by tuberculine treatment, which
he diagnosed from the examination of the sputum. But the patient had a
leprous affection of the larynx, and his account by no means excludes
the possibility that the bacilli in the sputum came from a ruptured
nodule in the larynx, possibly softened by the tuberculine treatment.
We cannot, therefore, recognise this observation as infallible evidence
of the presence of a leprous lung affection, any more than that case
of leprosy of the lungs described by Bonome in _Virchow’s Archiv_,
Bd. C. That author himself draws attention to the great resemblance
of the affection to tuberculosis, and as it is quite evident from
his description of the bronchial lymphatic glands that they were not
leprous, and he notes the presence of giant cells in the pathological
products, we cannot doubt that it was really a case of tuberculosis.
In the same case there was found an affection of the spinal cord, from
which Bordoni-Uffreduzzi cultivated on glycerine agar an organism which
he recognised as the lepra bacillus. Here we may remark in the first
place that we have never seen a leprous affection of the spinal cord,
and have never found bacilli in it. We must indeed admit that we have
only examined the spinal cord in a few cases, because there appeared
to be no indication for such an examination, since clinical symptoms
do not point to an affection of that organ, and as in the profusely
nodular cases, affections easily recognised appear everywhere, except
in the liver and spleen, it was to be expected that an affection of the
spinal cord would have been recognisable. In necrotic bones, which
we have often examined, nothing leprous is found. This necrosis is
therefore no specific leprous affection, but a secondary one. Secondly,
we must remark that in spite of many attempts we have never succeeded
in cultivating lepra bacilli on glycerine agar. We therefore believe
that Bordoni-Uffreduzzi has cultivated tubercle bacilli instead of
lepra bacilli. The only thing which speaks for the leprous nature of
the lung affection and the cultivated bacilli, is the circumstance that
the author did not succeed in inoculating guinea pigs and rabbits with
tuberculosis. But, according to all investigations on tuberculosis,
it appears to us not incredible that the tubercle bacilli may, under
circumstances, become so weakened that they are no longer pathogenic.
Arning has described a miliary leprosy, and found in the products of
this disease giant cells, and also leprous ulcers in the intestines.
Dr. Arning has kindly sent us some preparations of this miliary
leprosy, in which we find evidence everywhere that the case is one of
tuberculosis, both because giant cells are found everywhere, and the
bacilli are only present singly, and scattered. They are never present
in the excessive numbers, and have not the arrangement, which they
usually have in leprous products. In connection with the presence of
giant cells in leprous products, we may note that we have received
from two foreign colleagues preparations in which they believed giant
cells to be present. But we have found, on careful examination of
the preparations, that they were cross and oblique sections of blood
vessels, which with their endothelial nuclei gave the impression of
giant cells. Without the use of a homogeneous immersion lens it was not
possible to make a definite distinction.
According to our observation there exists a sharp anatomical
distinction between leprosy and tuberculosis, and there is no such
thing as leprosy of the lungs and intestines, the bones and the
kidneys. In order to establish a differential diagnosis in doubtful
cases, we recommend in the case of the lungs and the intestines a
thorough examination of the bronchial and mesenteric glands. We
ourselves have never sought in vain, in cases of these affections, for
tuberculous or caseous degeneration in the glands, and we have seen in
no single case anything resembling leprous affection of the glands.
So far as concerns the central nervous system, Danielssen noted that
he had several times seen acute hydrocephalus in leprosy. We once saw
severe cerebral symptoms with maniacal attacks. The patient, who was
taken into a lunatic asylum, left this later, cured. Other indications
of an affection of the central nervous system in leprosy are unknown
to us. Anatomically, we have not been able to recognise in the nervous
system any traces of leprosy. In connection with this, we may note that
we have several times seen pain and swelling of the knee joints during
eruptions, which at their conclusion disappear. In these cases there is
nothing to be made out anatomically. When we reflect that, as indicated
in describing the eruptions, the bacilli and (or) their toxines most
probably circulate for some time in the blood, it is remarkable that
the organs above referred to are not affected by leprosy. We can give
no reason for this; connective tissue, which is especially liable to be
affected, is present everywhere.