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may clear up in the centre and form circinate le- sions, or gyrate figures from a coalescence of sev- eral such rings. The serpiginous tendency is chief- Iv noted on the lower extremities. The centres of ISC 01 iii.inii.Tr leprosy siinwinR circinalc patclR-s. l*:ilicnt presented hy B. Parounagian before the New York Academy of Medicine, December 29, 1910. 714 fOX: SYMPTUMATOLOGy OF LEPROSY. [New York Medical Journ.^ the macules may present a loss of pigmentation, while their borders are superpigmented, and some- times upon the leprous patch a vitiligo develops in the shape crystal waters free slot machine of white and depressed discs. The macules may be hyperresthetic or itchy at the outset. Sooner or later they become anaesthetic, the anaes- thesia being most marked in the centre of the patches, while the superpigmented border is often, for a time at least, hyperaesthetic. The macules are roughly symmetrical, the symmetry being more marked in crystal waters online free the anaesthetic type. The sites of predi- lection are the face, extensor aspects of the ex- tremities, the buttocks, and the back. The lesions are very rare upon the palms and soles and are al- most never seen upon the scalp. There is generally noticeable absence of sweating over the macules, and after considerable time there may be crystal waters slots free slight branny desquamation. While the macules may ex- ist unchanged for many years they are usually f: al- lowed sooner or later by the symptoms of tuber- cular or anaesthetic leprosy or a combination of b th types. The first appearance of tubercles and indeed the various crops of tubercles are often ushered in by leprosy showing large serpiginous patch, (-asc of Henry Vox. febrile symptoms. In some cases they appear in- sidiously without such general manifestations. They may appear in the form of diffuse flat infiltrations or as circumscribed nodules, varying from a small pea to a cherry or pigeon's egg in size. They are generally situated within the skin, although at times they may be beneath the skin, as in the shotlike nodules that may occur in the lobule of the ear. The tubercles may be engrafted upon or appear be- tween the already existing macules. Their color varies from a light red, violaceous, or yellowish hue to a play crystal water slot free dark brown or reddish brown color. The surface of the ttibercles is generally greasy from an excessive sebaceous secretion ; it may be hyperaes- thetic or moderately anaesthetic, and shows as a rule an absence of hairs. Indeed the falling of the eye- brows due to tubercular infiltration constitutes one of the earliest symptoms of nodular leprosy. The tubercles are found in the greatest number upon the face and the extensor aspect of the extremities. Upon the face they are chiefly noted upon the fore- head, nose, chin, and ears, and their presence im- parts a peculiar frowning or leonine expression to this form of the disease, which when once seen, can never be forgotten. For some un- known reason the scalp seems to enjoy a remarkable immunity to the ravages of leprosy, as it is never invaded by tuber- cles, and only in the rarest instances by macules. The palms and the soles are also very rarely the seat of tubercular in- filtration. The tubercles are abundant ui)on the backs of the hands, elbows, knees, and about the ankles. As the last phalanx of the hand play crystal waters slots is spared for a time the infiltration of the first two phalanges gi\es the fingers a peculiar fusiform ap- pearance. Upon the feet and ankles it is impossible to distinguish individual nodules, as the skin of this region is often the seat of a diffuse, hard oedema, presenting the picture of true elephantia- sis. The nails, especially of the fingers, are often spared for a considerable time. During the exacerbations of leprosy • which are of frequent occurrence it is often noticed that the tubercles become reddened, swollen, and tender. At the end of these attacks some of the lesions are found to have decreased in size while new tubercles will have formed in other localities. The usual evolution of the tuliercles is to slowly disappear by ab- sorption, leaving a deep stain or a slight cicatrix, or to soften and ulcerate. In a few cases they undergo a fibrous trans- formation. Ulceration of crystal waters slot machine the nodules oc- curs more frequently in tropical countries- and among the more ignorant and un- cleanly class of patients. The ulcerations- o'i\er large areas at times and encircle ,111 entire limb. They eventually heal and leave apigmented scars that may be somewhat anaesthetic and crystal waters slot game are generally surrounded by a superpigmented border. The pharynx, palate, uvula, epiglottis, dorsum of the tongue and less often the- FOX: SYMPTOMATOLOGY OF LEPROSY online crystal waters 715 mucous membrane of the mcuth are sooner or later attacked by diffuse nodular infiltrations. These may persist for a time or become absorbed, ulcerate, or cicatrize. As a result of ulceration there is fre- quently distortion of the epiglottis or uvula. Per- foration of the palate is very unusual. Later the interior of the larynx and even the trachea may be invaded by the leprous deposits. A peculiar pallor is shown by the mucous membrane of the larynx and pharynx. One of the earliest symptoms of lep- rosy is a change in the voice, which may at first be slightly hoarse and later becomes harsh, sibilant, or whispering, and often interrupted by attacks of . dyspnoea. The visual, apparatus is frequently involved in crystal waters slots tubercular leprosy. The lesions involve the ante- rior segment of the globe, especially the sclerocor- neal junction and the ciliary region. There may be a keratitis which gradually invades the entire cor- nea, or a tubercle may form at the limbus and pen- etrate into the anterior chamber and destroy vision. Iritis is also common and is most frequently of plas- tic type. The inguinal glands and less often the axillary and cervical glands are enlarged in tubercular lep- rosy and increase in size during the exacerbations of the disease. They are not as firm as the glands of syphilis and do not suppurate in the latest stages of the disease. The urine often contains albu-

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