The changes in the nails are a part of the trophic disturbance; they become thickened, brittle and cleft, and sometimes thin and diminished in size, as one finds them, as we shall see later, in the terminal stages. The secretion of sweat is affected, being diminished over the anæsthetic areas, and the hairs there are altered and fall out.
We regard the pemphigoid bullæ as a trophic symptom; they may appear at the very commencement of the disease, along with the macular eruption; but they usually appear late when the anæsthesia has become extensive; in this we agree with Danielssen. Neisser and Leloir give prominence to the early appearance of pemphigoid bullæ, Neisser believing that the irritation of the commencing interstitial neuritis causes this trophic symptom. Our reason for regarding them as trophic symptoms is that we have never been able to find bacilli in the bullæ we have examined, not even in those which appeared at the same time as the maculæ, and their marked symmetry is also in favour of their nervous origin. The bullous eruptions usually appear suddenly. The patients will discover on awaking, one or more blisters which may be already burst; some have pain and fever for hours or days before their appearance; (Leloir). They vary in size—they may be small, from the size of a pea to that of a bean, or as large as the palm of the hand.
Their contents are serous, but if the bullæ persist, they become purulent. They usually rupture early and heal, leaving behind them violet-coloured scars, which after some time become pale. If irritant factors are added, if the bullæ last long and become purulent, there develops after rupture deep ulceration, most frequent on the hands and feet.
Bullous eruptions of the mucous membranes, which Leloir has noted, we have never been fortunate enough to see.
We regard also as tropho-neurotic vaso-motor symptoms the acute rheumatoid affections of the joints, which are not infrequent in our hospital. The joints, especially the small ones of the fingers and hands, and also those of the knee and ankle, become painful and tender, and on palpation, a collection of fluid can usually be recognised. The affection is always symmetrical.
These affections of the joints, which belong to the earlier stages of the disease, usually appear simultaneously with the macular eruption, and disappear with it, but they may appear later; and after one, or it may be only after several attacks, thickening of the ends of the bones and ligaments, with stiffening of the limbs, is developed. Leprous affections of the tendon sheaths, which Wolff refers to, we have never seen. The contracture of the fingers and toes is not tendogenous, so far as we can decide from clinical and anatomical investigation; it is myogenous, the leprous paralyses, which we shall immediately describe, being the cause.
Hillis claims to have recognised a motor weakness in the prodromal stage of the disease, and considers that the nerves are already affected with the leprous virus. Such a weakness referable to a neuritis of the motor nerves we have not noted previous to the macular eruption and the onset of the anæsthesia. If there are, in the prodromal stage, muscular weaknesses, we are inclined to regard these as symptoms of the general weakness; according to our view, the skin affection is the first definite symptom of the disease. The muscular affection may always be definitely recognised as a secondary symptom by the atrophy, and the altered electrical reactions. Different degrees and varied extent of the muscular affection may be noted; trivial paresis with only very slight atrophy, which, along with the anæsthesia, may completely disappear, if the neuritis passes off without destroying the nerve fibres; and almost complete paralysis with great atrophy of the muscles.
Paralysis with atrophy is most marked on the hands and forearms, feet and calves, and on the face.
PLATE V.
