REVIEW — TEOPICAL MEDICINE, ETC. 103 



ulceration of the nasal mucous membrane may be found with abundant bacilli practically in Leprosy— 

 almost pure culture. coniinued 



Nasal obstruction is often the earliest symptom, though naturally its significance is 

 frequently unrecognised. Black admits that great difficulties surround the actual 

 circumstances of the communication of the disease from individuals, and, from the fact that 

 it seems almost impossible to reproduce the disease in animals, concludes that there is some 

 very special relation between seed and soil. He thinks that the agency of an intermediate 

 host, be it flea, bug, or acarus has not been proved, and mentions that if the nasal mucous 

 membrane is the primary seat of infection then the intermediate host theory, however 

 enticing, must go by the board. 



In a later paper, Black^ again deals with the question and advances a theory to account 

 for the marked clinical difference between maculo-anaBsthetic leprosy and nodular leprosy. 

 He believes that nodular and mixed leprosy are simply maculo-anaesthetie leprosy plus the 

 infiltration and cBdema of the subcutaneous tissue in various parts of the body, caused by 

 the active invasion of the Bacillus leprse. Continuing, he says : — 



In practically all cases of nodular leprosy anaesthetic and leucodermic patches can be found just as in maculo- 

 ani'esthetic leprosy. I also noticed that when a nose had fallen in, in some cases of nodular or mixed leprosy the type 

 of the disease in the individual seemed to change and he became practically, in course of time, a maculo-anaesthetie 

 case, the infiltrations being gradually absorbed. I further noticed that some cases of undoubted maculo-anfesthetic 

 leprosy were of an extremely mild character. A patient would have a few anaesthetic patches on his body with, 

 perhaps, a contraction of the small and ring fingers of one of his hands and would otherwise be in perfect health — 

 in which condition he would remain for years. I also found that practically all the active cases of mixed and 

 nodular leprosy suffered from rhinitis and were discharging bacilli with the nasal secretion in great numbers, 

 whereas, except in a few of the early cases, I found that the maculo-antesthetic patients had no bacilli in their 

 nasal secretion. The above considerations afforded me what I consider to be a solution of the problem. I think 

 that there can be hardly any doubt that leprosy in its early stages begins as a small ulcer on some part of the 

 extensive nasal mucous membrane. We know quite well, from our clinical experience of the disease, that leprous 

 ulcers in favourable circumstances tend to heal. There can, therefore, be little doubt that a person can suffer from 

 a leprous ulcer in the nose that may heal and pass entirely away. This is the explanation of the maculo- 

 antesthetic cases. They have had nasal ulceration which has passed away, in some cases leaving perhaps a 

 cicatricial shrinking of the nasal septum, but during the time the ulcer existed leucocytes or white connective 

 tissue corpuscles got detached from the ulcerating spot and, along with the bacilli which they were attempting to 

 devour, were carried by the blood stream and lodged in various situations in the peripheral nerves, where they got 

 entangled, and the bacilli then proceeded to grow, causing pressure on the fine nerve fibrils and consequently 

 setting up nutritive changes in the skin which these axis-cylinders supplied, thus causing the patches of 

 discoloration and anaesthesia. 



In the nodular and mixed cases the progress of the disease is quite different. Instead of the nasal ulcer 

 healing up it proceeds to grow apace, producing extensive destruction of the nasal mucous membrane, causing it 

 to swell up and iiltimatcly attacking the nasal bones themselves. We have something to guide us from what we 

 know of other diseases affecting the nose, such as fleshy growths from the nasal mucous membrane, and how, if 

 not treated, the nose becomes distended and the aspect of the patient altered. Also in the disease called post- 

 nasal adenoids in children, how from their intra-nasal pressure they cause the face to assume a heavy, puffy and 

 stupefied appearance. A similar condition takes place in nodular leprosy. The accumulating swelling of the 

 mucous membrane extending into the numerous interstices of the naso-pharyngeal cavity causes the face to 

 assume its characteristic appearance of this clinical variety of the disease, assisted of course by the leprotic 

 infiltration from the festering nasal ulcer. But the festering sore has other consequences. The enormous number 

 of leucocytes which are on the scene trying to overcome the invading bacilli get many of them translated to 

 other parts of the body. They carry with them bacilli which in leprosy seem to have the property, at any rate at 

 some part of their life-history, of growing within the white blood corpuscles and thus propagating the disease 

 through all the parts of the body. As in maculo-anaesthctic leprosy, they get entangled in the peripheral nerves 

 and cause anfesthesias and the discolorations of the skin and they also in nodular leprosy form large accumulations 

 in the liver, the spleen, and in certain situations in the subcutaneous tissues throughout the body, and the patient 

 becomes at last, if not properly treated, a mass of ulcerating sores. 



The course of the disease is, as is well-known, extremely protracted, and the cases which we see in our asylums 

 are in nearly every instance in a very late stage of the disease, even on admission. The very early stage of the 

 nasal ulceration, naturally not being recognised, is completely overlooked, even by the patients themselves. They 

 think that they arc perhaps merely suffering from a protracted nasal catarrh, to which they pay no attention and 

 which they forget all about when the graver symptoms of the disease make their appearance. But at these 

 extremely early stages of the disease, these people are sources of infection, and this fact affords a very clear and 

 simple explanation of those mystifying and apparently hopelessly inexplicable cases of leprosy which from time to 

 time occur. You ask one of these patients : " Has he ever been in contact with a person suffering fi'om leprosy ?" 

 And he vehemently and perfectly truthfully affirms that he has never been in such contact. But though he did 

 not know it, and though the communicator of the disease did not know it, he has been in contact with a person 

 suffering from the primary early rhinitis of leprosy. 



This view, as the author remarks, brings leprosy, as far as pathology and treatment 

 are concerned, into line with tuberculosis and diphtheria, and he makes the suggestion that 

 possibly the opsonic treatment of Wright might be applied with advantage. 



1 Black, R. S. (October 20th, 1906), " A New Aspect of the Pathology and Treatment of Leprosy." Lancet, 

 p. 1064, Vol. II. 



