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LEPRA MACULOSA.—This form is more common in tropical countries and is distinguished chiefly by its macular (spotty) lesions. In size they vary from a small coin to areas as large as a platter. They are diffused or circumscribed, roundish or shaped irregularly, yellowish, brownish or bronzed in color, often shiny or glazed. They may be infiltrated and may be elevated, or on a level with the adjacent tissues. The patches are usually at first very sensitive, but they finally become insensitive, so that a knife can be thrust deeply into them without being felt. The regions chiefly affected by this type are the back, exposed parts, the backs of the hands and wrists, the forehead, the cheeks, ears, back of the feet, and ankles. The eruptions may be scanty or general; conspicuous or insignificant. The eruptive symptoms are associated commonly, early or late, with the serious phenomena described below.
LEPRA ANAESTHETICA. (Nerve Leprosy. Atrophic Leprosy. Lepra Trophoneurotica).—Before the development of this form of leprosy there may be one or two years of ill-health. Usually the skin at this time becomes in localized patches over-sensitive, sometimes there is over-sensitiveness and special nerves, because of their enlargement, become accessible to the touch. Those named later become tender, and the seat of lancinating or shooting pains. This clinical variety may be commingled in its symptoms with each of the other types. With or without such commingling, however, there commonly is noted, after exposure to cold or after being subject to chills first an eruption, red (erythematous) patches, or of "bullae," size of a bean on cheeks, ears, back of the feet, and ankles. The eruption may be outer skin covering (epidermis) and filled with a clear tinted or blood-mixed serum, and usually occurring upon the extremities. The scars that follow are shrunken (atrophic) patches, each often greater in extent than the base of the original trouble, color whitish, shiny, glazed, or better described as a tint suggesting the hue of mica; their outline is circular and form also the dumb-bell figure by running (coalescing) together, or juxtaposition. These scars are always without sensitiveness (anaesthetic), and they may exist together with spotted and non-sensitive patches upon the trunk or other parts such as the face, hands, feet, ankles, thighs, but rarely on the palms and soles. Neither those of the one class nor of the other, however, are disposed over the surface of the body in lines, bands or curves, corresponding with the distribution of the skin (cutaneous) nerves. Sometimes the ulnar and other nerves (median, posterior tibial, peroneal, facial and radial) that are accessible to the touch are swollen, tender, insensitive or as rigid as hardened cords. Reddish-gray swellings may be recognized by the eye along the nerve tract. General shrinking skin symptoms follow. The skin becomes dry and harsh; there is little or no sebaceous product and the skin of the face seems tightly drawn over the bones. As a consequence of deforming shrinking (atrophy) of the eyelids, a persistent overflow of tears, consequent eye changes follow, and a constant flow of saliva escapes from the parted lips. The fingers are half drawn into the palm of the hands; the nails are distorted and ulceration occurs later. These ulcers are irregular, oval, roundish or linear in form covered with thin blackish, flattened, tenacious crusts with soft bases, and their floors covered with a soft debris mixed with blood, the whole insensitive to every foreign body, and external application. At last the symptoms of mutilating lepra (leprosy) may occur, digits or portions of the wrist, part of hand (meta carpus) or corresponding portions of the foot may be detached from the body. Death may occur at any time during the course of the disease. In this form it is said to last from eighteen to twenty years and is thus not so rapidly fatal as the tubercular variety.
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Treatment.—The main treatment is the isolation and segregation of all lepers from contact with the well; wholesome laws are enforced in some countries where leprosy prevails, and provision is made not only for the isolation and segregation, but also for their care. On account of its relative variety America has not yet awakened and legislation only forbids the entry of infected persons. At Molokai, in the Hawaiian Islands, provision is made for the care of lepers. Many of the public hospitals for the care of the sick poor refuse to receive lepers. The child of a leprous woman should be removed from the mother after birth and not nursed by another woman. No medicines are known to have any curative effect. An immediate change of residence and climate should be made if the patient happens to live in a district where the disease prevails. A highly nutritious diet should be taken.
The outlook.—The future is in general dark for the leper. It is often of a malignant character, and a fatal result is the rule. A change of climate and conditions may help. Scandinavian lepers who have removed to the United States have been greatly benefited by the change, but there is no known cure. The isolation should be as effective as that for tuberculosis. It is not contagious but infectious.
HYDROPHOBIA.—Rabies and hydrophobia are two different terms, meaning the same disease, the former meaning to rage or become mad. This term applies more especially to the disease as it exists in the maniacal form in the lower animals, while hydrophobia comes from the Greek, meaning "dread of water." As we occasionally find this dread of water only in the human subject, the term is properly used in such a case. The lower animals frequently attempt to drink water even though the act brings on a spasmodic contraction of the swallowing (deglutitory) muscles. Hydrophobia is an acute infectious disease communicated to man by the bite of an animal suffering from rabies. It is due to a definite specific virus which is transmitted through the saliva by the bite of a rabid animal. Its natural habitat (location) is the nervous system, and it does not retain its virulence when introduced into any other system of organs. It is essentially a nervous disease and transmitted by the saliva of rabid animals. When inoculated into a wound this virus must come in contact with a broken nerve trunk in order to survive and reproduce itself. If by accident it attacks the end of the broken nerve trunk, it slowly and gradually extends to the higher nerve centers and eventually produces the disease.
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The incubation, or the time it takes for the disease to develop, varies, but usually is from three to six months. There is a recorded case where the person began to show symptoms of the disease thirteen days after having received a severe wound on the head. The incubation period is seldom longer than six months. The symptoms of the disease in the human being vary within narrow limits. There are three classic symptoms usually encountered, and these are fear, apprehension or excitement, together with deglutitory (swallowing) spasms, terminating in general paralysis. The patient remains conscious of his agony to the end, but the period of illness is of short duration, lasting from one to three days.
The bites of rabid dogs cause ninety per cent of the cases in man and animals. The cat is the next important factor in spreading the disease and about six per cent of the cases are caused by this animal. For other cases four per cent come from bites of horses, wolves, foxes, etc. The wolf in Russia, or other animals like it, may be the chief cause there; but dogs cause ninety per cent, taking all the cases found. Man, dog, cat, horse, cattle, sheep, goat, hog, deer, etc., are subject to the disease either naturally or experimentally. The disease is confined commonly to dogs, because the dog naturally attacks animals of his own species and thus keeps the disease limited mainly to his own kind. Naturally the dog follows this rule, but on the other hand, in the latter stages of the disease he usually goes to the other extreme and even attacks his own master, etc. The dogs that are the most dangerous and do the greatest damage are of the vicious breeds.