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.
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.
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.
PLATE III.
