G. Armauer Hansen

“ Along with the paralysis and atrophy of the muscles, there appear also, as the result of the destruction of the nerve trunks, trophic affections of the bones and of the skin. The changes in the skin have been already described; when the anæsthesia is advanced, there always appear ulcerations under the heel and the ball of the foot. Most of these owe their origin simply to pressure; the weight of the body is too much for the atrophic skin. They are always callous, heal with great difficulty, and so long as the patient goes about, not at all. ”

“ We have occasionally a complete subject with vigour and good health, but usually only a miserable rudiment of a human being, with more or less paralysed and deformed hands and feet, with unclosable eyes, of which the lower part of the cornea is opaque, and from which the tears run down over the cheeks, and with paralysed facial muscles unable to close the mouth, so that the saliva constantly dribbles from it. Such cases may, however, live long and reach great ages, if under such circumstances this can be looked upon as any advantage. They die usually from some intercurrent disease. ”

“ There is hardly anything on earth, or between it and heaven, which has not been regarded as the cause of Leprosy; and this is but natural since the less one knows, the more actively does his imagination work. And since all that was known of Leprosy was that it was a loathsome disease, search was made everywhere for a cause. We will not linger over the older literature of Leprosy. That may be found fully dealt with in Danielssen and Boeck’s Traité de la Spedalskhed and in Hirsch’s Geographical Pathology. ”

“ And looked at thus, we know of no specific disease which can be called hereditary. The conditions which are hereditary are all anatomical and physiological peculiarities of the organism. A bacillus which is living in the organism cannot be regarded as one of its anatomical or physiological peculiarities; it is a parasite. ”

“ 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. ”

“ Even in such preparations there are many places where one cannot definitely distinguish the position of the bacilli; but as one always finds bacilli in the cells where the preparations are sufficiently clear, we may safely conclude that the bacilli lie everywhere in the cells. In the connective tissue spaces one often sees bacilli in and round the nuclei of the connective tissue cells (Plate X, Fig. 8) , and although the body of the cell is not visible, we may conclude that the bacilli lie in the cell body, and not free in the lymph spaces. ”

“ 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. ”

“ If one examines, microscopically, sections or teased preparations of fresh nodules, one sees little else but cells, with distinct nuclei, usually of the size of a white blood corpuscle, or rather larger. There are also a few larger so-called epithelioid cells, with larger nuclei, and among the cells, fragments of connective tissue and of blood vessels. With a higher power, one sees in the fluid of the preparation small straight rods, which are not destroyed by addition of potash. These are the lepra bacilli, and thus were they first discovered in the year 1871. ”

“ 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 question as to heredity now is, Can the lepra bacillus be conveyed by heredity. This is Baumgarten’s view; he holds that both Tuberculosis and Leprosy are thus spread, that the bacilli of both diseases may be transferred to the children and there remain dormant, but that they can thence be conveyed to another generation, and from it to a fourth, fifth, etc. generation, and then in the third, fourth, etc. generation become once more active and cause the disease. ”

“ 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. ”

“ 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. ”

“ Since one of us has been for more than twenty years occupied in dealing with the disease, we hope to be able to lay before experts a thorough, complete and instructive demonstration, the more, as we do not base our views, as has been frequently and unfortunately done, on any single or scattered observations. ”

“ But amongst the people where leprosy prevails, it is almost impossible to get sufficient cleanliness thoroughly enforced. We think, therefore, that the best measures are those which have been taken in Norway, where the lepers are isolated at their own request, and where the communities can get rid of the disease, if they will, since the sanitary authorities have the power to order the leper to live sufficiently isolated from his family, and, if he cannot or will not assent to this, can compel him to enter an asylum. ”

“ With great patience and moderate pressure one can succeed in artificially injecting the lymphatics without causing extravasation. It may even be the case that only one, or at most one or two ampullæ are affected. Microscopically the ampullæ and trabeculæ are found more or less filled with brown bodies or globi. These are evidently lymph cells which have become filled with bacilli and their degenerative products—granules.
One could hardly have a better demonstration of the functions of the lymphatic glands, as filters, than in these leprous glands. The circulation through them is not arrested ”

“ We have seen a case of maculo-anæsthetic leprosy, which probably arose by inoculation from a very severe case of nodular leprosy, since the patient some years before the outbreak of the disease had for a long time shared the bed of a nodular leper. In this case the virulence of the bacilli must have been at once diminished on their inoculation on another organism. And since it also happens that a maculo-anæsthetic case may on a fresh eruption become nodular, the bacilli must be able by cultivation in the organism to re-acquire their power. ”

“ The anæsthesia relates to the different qualities of sensation, and is not only present in the patches, but progresses gradually from the periphery toward the centre, so that at last the whole extremity, and often also parts of the trunk, become anæsthetic; the face is always more or less anæsthetic. We have often found thermal anæsthesia present alone, or accompanied by anæsthesia or analgesia. The anæsthesia may become more and more extensive, or it may very gradually disappear, indicating that the neuritis of the affected nerve has disappeared. ”

“ We consider it superfluous to point out further [Page 102] how the isolation of the patients has caused the decrease of Leprosy in Norway. It is not possible to explain the action of isolation by the elimination of heredity; the time is too short for that. The only one possible solution is that which we have given, and therefore we regard this decrease of Leprosy in Norway following on isolation as the best proof of the contagiousness of Leprosy. Leprosy is, then, according to our view, a contagious disease, and only contagious, not hereditary. ”

“ 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 [Page 25] 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. ”

“ But even if leprosy be a contagious disease, one can easily understand how it should spread little, or not at all, in North America, when one compares the social condition and especially the cleanliness there with that in Norway, and probably especially with that of the districts in which leprosy is most prevalent. In North America the dwelling houses are roomy, so that the lepers whom we saw there had usually their own room, or at least their own bed ”

“ Iodine has been used as iodide of potassium, and externally as tincture of iodine and iodine ointment. At the beginning of his studies in leprosy Dr. Danielssen had great confidence in iodine, but he soon learned what a very dangerous remedy it was in this disease. Even small doses of iodine produce new eruptions of leprous tubers or patches, and Dr. Danielssen therefore ultimately used it as a test in cases of apparent cure. When a patient was considered cured, he gave him iodide of potassium, and if no new eruption developed, the cure was considered complete. ”

“ That leprosy is really contagious is primarily evident from its nature as a bacillary disease. No one has been able to demonstrate the presence of the bacillus outside the human body, so that we may abandon the idea of a miasmatic origin.
Unfortunately, all attempts to inoculate animals have failed. The now old experiments of Neisser and Damsch, as well as our own, we may pass over. We dealt with them in our Copenhagen communication. Since then Melcher and Ortmann believe that they have communicated the disease to rabbits. ”