¢ 
21,3 Gomez et al.: Early Lesions of Leprosy 243 
filtration of the ears or of parts that are frequently subject 
to friction and traumatism, such as the elbows and knees, may 
be the first manifestation of the disease. 
In some of the older children we were able to elicit a history 
of paresthesia, hypesthesia, and anesthesia as the first and, 
frequently, only manifestation of leprosy. Such disturbances 
were frequently noticed first on the peroneal side of the leg 
and the ulnar side of the forearm or on the external maleolus 
and the back of the elbow joint; and, occasionally, on close 
examination one can notice also isolated patches of anesthesia 
in other parts of the body. 
We were not able to see or obtain a clear history of bulle 
formation, which is one of the first manifestations of leprosy, 
pointed out by Dyer(3) and by Gwyther. (4) 
Hopkins(5) has already noted that the macular lesion is the 
most constant of the early manifestations in all types of skin 
leprosy and that such a macule is usually unaccompanied by 
symptoms, such as pain or itching, that would likely attract the 
attention of the patient. We cannot state that all the white 
patches that we noticed in children are leprous, in the absence 
of other functional nervous disturbances and other definite 
leprous lesions. It is significant, however, that such blemishes 
are so prevalent among the children of lepers, about one-fourth 
of whom, as noted in Table 5, show this type of lesion with or 
without concomitant functional nervous changes. On the other 
hand, we have seen definite evidences of progressive changes 
in these whitish patches; that is, in the course of time they 
became reddish, infiltrated, and bacteriologically positive, as 
shown in Plate 5, figs. 1, 2, and 3. We have also found some 
white patches (Plate 2, figs. 2 and 3), which were bacteriolog- 
ically positive, and which on their physical appearance could 
not be distinguished from bacteriologically negative patches 
(Plate 1, figs. 1, 2, and 3; and Plate 2, fig. 1). 
DEVELOPMENT OF THE DISEASE 
After the first lesions, such as white areas, anzsthesia, flushed 
legs, and infiltrations, the disease progresses by the aggravation 
of the preceding conditions. The white areas increase in num- 
ber, may remain white or may acquire reddish edges (Plate 4, 
fig. 1; and Plate 5, fig. 3) or centers (Plate 5, figs. 1 and 2), 
may become more or less elevated, and previously bacteriologi- 
cally negative patches may become positive. The infiltrations 
become more accentuated, and nodules appear on the ear, the 
