“As the malady proceeds, the tubercles begin to crack, and at length to ulcerate: Ulcerations also appear in the throat, and in the nose, which sometimes destroy the palate, and the cartilaginous septum; the nose falls, and the breath is intolerably offensive. The thickened and tuberculated skin of the extremities becomes divided by fissures, and ulcerates, or is corroded under dry sordid scabs, so that the fingers and toes gangrene, and separate, joint after joint.”
The description of the course and symptoms of the disease, as given by Schedel, is more minute and detailed.
“Lepra tuberculosa, or Greek elephantiasis, is” (he observes),[146] “characterised by the eruption of fawn-coloured or yellowish-brown tubercles, various in size, irregular in shape, somewhat shining, and soft and smooth to the touch. These tubercles are preceded by erythematous patches, in which the sensibility of the skin is diminished: slightly elevated at their outset, they become afterwards more projecting, whilst the sensibility of the parts is usually quite lost, although they are sometimes painful when touched. They more frequently occur upon the face, the nose, the ears, the lips, etc.; and being accompanied with a thickened and rugose state of the skin, they cause a most hideous distortion of the features, and frightful deformity.
“The evolution of the leprous tubercles is usually preceded by that of slight erythematous patches of a tawny red hue in whites, and blacker than the surrounding integuments in negroes. These patches are worthy of attention, since they announce the dreadful disease which is about to appear. When they are of some duration, the skin in these points already begins to lose its sensibility. Sooner or later, in some cases quickly in others very slowly, small soft, livid red tumours appear, varying in size from that of a pea to that of a walnut, or even larger. When these tubercles come out, the erythematous patches, on which the sensibility of the integument had become lessened, sometimes become painful; so much so, that we have heard patients declare that the pain produced by the handling of the small tumours at this period was similar to that felt when the cubital nerve receives a blow at the elbow. When they appear on the face, they are generally accompanied by a puffy swelling of the surrounding parts.
“Sometimes only small surfaces are attacked. We have seen the nose and ears alone affected, and much swollen and enlarged. When the disease occurs on the lower extremities only, it is found on the inferior part of the thigh, and around the ankles.
“After remaining stationary for a longer or shorter time, the disorder increases: instead of a few tubercles to be met with here and there, the whole face is covered with large dusky red lumps, separated by deep furrows; the features are horribly distorted; the alæ of the nose are thickened and swollen; the nostrils dilated; the eyebrows tuberculated and overhanging; the lips enormously thickened; the skin of the forehead and cheeks is thick, uneven, and tumid; the chin much increased in size, and the whole of the affected surfaces appear as if smeared with oil, and of a dusky livid red; the external ears, especially the lobes, are much enlarged and thickened, and beset with tubercles; the eyebrows and eyelashes and beard fall off; the sense of smell becomes impaired or totally lost; that of touch is often strangely affected; the voice grows husky, and is frequently lost; the eyesight is greatly weakened; the unfortunate patient is dejected; and the muscular powers depressed in a singular manner. With regard to the libido inexplicabilis, so much spoken of, our observations do not coincide with those of Dr. Adams, who mentions actual wasting of the generative organs. In the cases which have come under our notice we have witnessed quite the reverse, and yet several were young men in whom the disease was not too far advanced.
“At a still later period the symptoms are even more dreadful; the tubercles become the seat of ulceration, and sores of an unhealthy character succeed, and discharge an ichorous fluid, which, on concreting, form dark adherent scabs of various extent and thickness; these incrustations are sometimes followed by cicatrices, but this is unfortunately a rare occurrence. On the extremities the thick and tuberculated skin becomes divided by fissures, and ulcerates or is corroded under the dry scabs, so that the fingers and toes mortify and separate, joint after joint, the miserable patient surviving these horrid mutilations. Those individuals whom we have seen perish from this disease were carried off by enteritis; large ulcerations were found in the ilium, cæcum, and colon, excepting in one case, in which death was caused by tubercular phthisis.”
In studying the phenomena of this, as of any other disease, it will simplify our recollection of its more leading and more constant characters, if we have the principal symptoms of it embodied in a concise nosological definition, instead of being spread through a long and detailed description. Two of our last and best British nosologists give the following definition of tubercular leprosy or Greek elephantiasis (for I use these terms here and elsewhere as words perfectly synonymous).
“Elephantiasis” (says Dr. Cullen), “is a contagious disease, with (1) the face deformed with tubercles; (2) the skin thick, wrinkled, rough, unctuous, and divested of hair; (3) loss of feeling in the extreme joints; and (4) the voice is hoarse and nasal.”[147]
In defining the genus elephantiasis, Dr. Good selects the second and third characters of Cullen as the most distinctive, and adds to these two others—viz. “(1) eyes fierce and staring; (2) perspiration highly offensive.” In defining the first species of this genus (or the Greek elephantiasis of other authors), he introduces as its three pathognomonic symptoms, the first and fourth characters of Cullen and a part of the second.[148]