Chapter II.NODULAR LEPROSY.
Nodular Leprosy (Lepra tuberosa, L. tuberculosa) is usually easily diagnosed by its characteristic skin affection.
The leprous nodes or nodular Lepromata are of different size and colour; their consistence is at first firm and hard; they are but slightly compressible, and show little elasticity. Their form is usually semi-spherical, but they are often oblong. The smallest nodule that we have seen was not more than 1-2 mm. in diameter, and its appearance was so little characteristic, that we had to confirm the diagnosis by excision and microscopical examination. The larger the nodules, the more characteristic is their appearance. As they are almost always seated in the cutis, the epidermis over them is stretched and shiny; it is occasionally normal in colour, but usually at first reddish, later becoming yellow.The localisation of the nodules is usually characteristic.They are generally first evident on the face, on the backs of the hands, and on the dorsal surfaces of the wrists, and next on the extensor surfaces of the limbs. They are morerarely seen on the back and nates; on the flexor surfaces of the extremities, on the breast, abdomen, scrotum, and penis, they are quite exceptional; and we have never seen them on the glans penis, the palms or soles, or on the hairy scalp. Leloir has described a leprous affection of the palms of the hands, of which he himself says that it closely resembled a syphilide in that situation. 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. Now since, as we have noted above, the face and back of the hands are the usual seats of predilection for the earliest appearance of the eruption, it appears not improbable that this has its explanation in the climatic influences on these parts, possibly influenced by the structure of the skin, especially the cutaneous vessels. That there are peculiarities in the structure of the tissues, which determine the localisation of the poison, one may conclude; for certain organs are never affectedwith leprosy, in spite of the fact that the poison has evidently at some time circulated in the blood.
The face is usually especially characteristic, as the eyebrows are almost always the seat of nodules. The nodules are sometimes isolated though close together, sometimes there are only one or two, though usually several, and sometimes there are no distinct nodules, but the eyebrow is infiltrated both in length and breadth, and of a reddish colour. Even if the infiltration is not so great that the brow appears thickened, the reddish colour and the shadow over the eyes give to the face a characteristic expression, and one can feel the infiltration, if the brow is gripped between the thumb and forefinger. In these cases the hairs persist; in more severe infiltration, and where nodules are formed, they drop out. The forehead and cheeks usually present a diffuse or spotty redness and burnish, and with the finger one recognises the infiltration as an increased resistance. This discolouration is most evident on changes of temperature, as when a patient comes from the outside cold into a warm room. Not infrequently the suspicion of Leprosy is aroused by this change of colour, and by the shadows over the eyebrows, even years before more definite symptoms appear. But in most cases one finds distinct nodules in the eyebrowsand over the countenance generally. When the nodules are numerous and large, so that the eyebrows project far over the eyes; when the cheeks and chin are beset with large rounded or flat nodules pressing on each other, so as to cause deep furrows between them; when the point of the nose, the alæ nasi, and the lips are infiltrated throughout their whole thickness; the countenance is frightfully deformed, and there is developed the so-calledFacies Leonina. The lobules of the ears are almost always infiltrated, and become red, thick and elongated.Plate Iis a case of tuberous leprosy of two years’ duration, the hands being swollen with leprous infiltration.
PLATE I.Clinical Photo
PLATE I.
PLATE I.
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. A slight infiltration of the limbus conjunctivæ is always combined with this clouding of the cornea, but it is at this early stage so slight that it cannot be noted clinically. Later on it increases, and gradually attacks the whole of the outermargin of the cornea. When this infiltration becomes greater it appears yellow, as seen through the conjunctiva running intact over it, and this gives to the eye a peculiar woe-begone aspect. It is quite exceptional for this infiltration to extend completely round the cornea, for that part of the limbus directed towards the nose is almost always free. As time goes on the infiltration increases, and a low rampart is formed around the cornea. Sooner or later the infiltration and nodule formation attack the cornea itself, in one of three different ways: first, quite superficially, immediately under the epithelium. The nodule in this case is always elevated, usually grows very rapidly till it finally covers the whole cornea, and may by its height prevent the closure of the lids. That part of the cornea lying below or behind the nodule is quite clear. Secondly, the infiltration may attack the cornea in the form of a wedge, and form a node which is not so much elevated as in the previous instance; and thirdly, the infiltration may penetrate the cornea close in front of Descemet’s membrane. The result, complete blindness, is the same in all cases when the nodule covers the pupil. A frequent accompaniment of this form of the disease is iritis, or, as anatomical investigation shows, irido-cyclitis. These forms of iritis run a chronic or sub-acutecourse, sometimes so stealthy and painless that it is observed by neither doctor nor patient, until adhesions have formed between the pupillary border and the capsule of the lens. Blindness may sometimes be caused by exudation into the pupil.Plate IIshows a typical case of tuberous leprosy of six years’ duration. The hairs have completely disappeared from the eyebrows; on the chin a few can still be seen between the tuberosities. In the right eye is a nodule, growing from theLimbus conjunctivæinto the cornea. Nodules may also be present in the iris, and usually arise in the outer and under margin, in the angle between the cornea and the iris; they may completely fill the corresponding part of the anterior chamber, are of a yellow colour, and sometimes look exactly like an obliquely-placed hypopion, as they have an inner or upper straight, or slightly concave margin. We once did an iridectomy directly through a small early nodule, and put a stop to its further growth. On anatomical examination we also find a leprous affection of the anterior part of the retina over the ciliary body, which appears as a fine white spotting of the retina; the ciliary nerves are always for a considerable distance backwards infiltrated with leprosy, as are themembrana supra choroideaand the choroid itself.
PLATE II.Clinical Photo
PLATE II.
PLATE II.
On the extremities the nodules always appear singly, but when closely set may run together toform large plaques. On the backs of the hands and fingers nodules are very frequently, and on the extensor surfaces of the thighs and the front of the legs almost always, found. The calves are often also infiltrated as a whole, especially on the fibular side close above the ankle, and this infiltration reaches as high as the middle of the leg; the skin is tense and shiny, reddish blue in colour, and in this infiltrated part ulcers resembling varicose ulcers readily appear, which are as difficult, if not more so, to heal. They are surrounded by thick elevated walls, may last for years, and occasionally completely surround the leg.
Of the mucous membranes, those of the nose, mouth, larynx and pharynx are affected. The nasal mucous membrane is affected only in its anterior part along with the alæ nasi and the anterior part of the septum. If a general infiltration takes place in this situation, the softening and ulceration which may ensue lead eventually to the disappearance of all the soft parts of the nose; the bones are never affected. (SeePlate III, a case in which the leprosy developed in 1848, and was of the tuberous variety. The tubers disappeared partly by suppuration. In 1857 he entered an asylum and then presented the same appearances as in the photograph. He was thenanæsthetic. There were cicatrices in the face due to the disappearance of the nodules, the point of the nose was gone, but the nasal bones were intact, thus differing from syphilis. He died in 1885.) In the mouth, the mucous membrane of the lips, of course, shares in the process when these are completely infiltrated, and even on the mucous membrane of the cheeks one occasionally sees and feels thickening and infiltration. The tongue is often the seat of nodules, which in all respects correspond to those of the skin. The gums, the velum, and the uvula may be either infiltrated or dotted with nodules. The rest of the mucous membrane of the pharynx is more frequently infiltrated than beset with nodules, and the same is true of the epiglottis, which sometimes becomes quite stiff and almost immoveable. In the larynx, the true and false cords are more frequently the seat of infiltration than of nodules; the voice is rough and hoarse, the rima glottidis is often so narrowed that respiration is rendered difficult; excessive narrowing of the rima is only present in the late stages, and is proportionately rare. When the mucous membrane ulcerates the cords grow together, both anteriorly and posteriorly, and when the infiltration disappears there remains a scar tissue, which, by its contraction, reduces the rima to a small slit, a few millimètres wide. In such cases a very little mucus is sufficient almostor completely to close the opening, and the patient may perish from suffocation. Usually an emetic suffices to open up the hole at once; but tracheotomy is often necessary to supply air to the patient, the attacks of suffocation are so frequent, and since he is already voiceless, he loses nothing by the operation.
PLATE III.Clinical Photo
PLATE III.
PLATE III.
The lymphatic glands (cervical, axillary and inguinal) in relation to the affected skin and mucous membrane are always swollen: this leprous swelling is always indolent, and never goes on to suppuration. Sometimes the glandular swelling may aid in the diagnosis, if the skin affection is not absolutely characteristic, though this is most rarely the case.
The nodules are almost always seated in the cutis, but they may, though rarely, be placed deeper in the subcutaneous connective tissue; they form then no projections, but the skin over them is almost always somewhat hyperæmic and bluish-red, and, if the finger is passed over the place, the thickening or the nodule may be felt in the deeper parts. It is in our experience that a patient who had only this form of nodules was regarded by a colleague, well acquainted with the disease, as free from Leprosy, probably because he did not use his fingers.
From the symptoms described above, thediagnosis is almost always very easy, and we ourselves know of no disease of the skin which can be confounded with nodular leprosy. If necessary a piece of skin may be removed and examined for the presence of bacilli, which, at least in the nodular form of the disease, are never absent. This, we have once had occasion to do.
In addition to the skin the nerves are also affected, not always at the commencement, but always in the later stages. Whether all peripheral nerves are affected we cannot say—certainly the facial, radial, ulnar, median and peroneal are always diseased. 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. Now since, as we shall later clearly demonstrate, leprous affections tend to heal, it is not infrequently the case that nerve affections, when slight, pass off without having speciallyinjured the nerves, and these nerves may be the seat of fresh infections, and thus the patient suffers from repeated painful attacks through a course of years. This is particularly the case where there is general infiltration of the legs, and is either the result of repeated attacks of the same, or of the implication of different nerve branches. The nodules are often painful when first developed, but later on sensation is deadened.
Of internal organs, the testicle, liver, and spleen, are always affected in this form, but we shall consider them later in the description of the pathological anatomy.
Before we more closely describe the course of the disease, we shall first briefly discuss the fate of the nodules. These usually remain for years unchanged, growing very little or not at all. The skin over and around them, or rather its vascular supply, is very sensitive to changes of temperature, so that the skin, as we have already indicated, changes its colour with change of temperature from dilatation of the blood vessels. The vessels evidently suffer from the invasion of the leprous poison. New outbreaks have often the appearance of an “erythema nodosum,” with great hyperæmia. We had once the opportunity of examining a piece cut out of such an erythema-like eruption, and found dilated vessels and round cells, and only after long search a few bacilli.One must conjecture that there is deposited with the bacilli a chemical poison which affects the vessels, or that the bacilli produce the poison, and that this poison has its action only in its immediate neighbourhood.
But occasionally the nodules grow so luxuriantly that the epidermis develops furrows and clefts which may reach down to the nodules, and then a bloody fluid comes out of them which dries up on the surface to a reddish brown scab. Or it may happen that the upper horny layers of epithelium disappear, and that only a few rows of cells of the rete Malpighii remain. In this case the exuded fluid less often dries, the surface is usually blood-red and moist, and appears like an ulceration, though it is not really one. When this takes place on the face, particularly on the lips, or on the backs of the fingers, the sufferings of the patient are very much increased. After several years the nodules usually soften about the middle of their base, and the nodule may sink in over the softened part; or they burst, the softened part is thrown off, and now is developed the true ulceration by which the nodule may be completely eliminated and sunken stellate scars alone remain.
The determination of the commencement of the disease is exceptionally difficult, indeed impossible, for it must always be founded on thestatements of the patient, and the patients either observe themselves insufficiently, as may frequently be noted, or they conceal many facts. As a matter of fact we do not know the earliest symptoms of the disease. According to Danielssen and Boeck, the patients often suffer long and repeatedly, before the outbreak of the disease, from weakness, with rheumatoid pains and fever. This the patients frequently corroborate. But we are inclined to regard these attacks of fever as indications of the already existing disease. It appears to us more probable that the disease begins with some form of local affection which is so indistinct that the patient himself does not notice it, or at least lays no weight upon it, and that these local affections are analogous to others with which we are familiar, namely, the nodules which may last for years before new and such definite eruptions appear, that the disease cannot any longer be ignored or kept secret. We believe therefore, that the patients do not really know when they commence to be ill, and that they date the beginning of the disease from a later eruption. If at the commencement only the extremities are affected the patients may conceal their condition for years, and through this concealment become so accustomed to lie, that later it is impossible to receive from them correct information.
The cases are very frequent in which thepatients have for several years only scattered nodules, and then suddenly a fresh outbreak of numerous nodules. The disease always advances by outbreaks of eruptions which repeat themselves at longer or shorter intervals. It is very often the case that the older nodules soften during a fresh outbreak, and completely or partly disappear; and these outbreaks are always accompanied by fever, the temperature rising to 39° or 40° Cent. Now we know that the nodules, if the patient is affected by another febrile disease, may disappear. It is, therefore, difficult to decide whether the disappearance of the nodules is the cause or the result of the eruptive fever. But we possess certain observations in which the disappearance of the nodules has begun before the onset of the fever, and in which, therefore, the fever and the later eruption appear to be caused by the softening of the nodules. Supported by these observations we regard the eruptions as auto-infections, in which bacilli (or poison) from the older lepromata pass into the blood, and thus new areas of the skin or other organs are affected. We have often observed that an irido-cyclitis, or an affection of the throat, arises during an eruption, and also that the nerves beneath the nodules become swollen and painful, and once we have seen the testicle become swollen and painful during an eruption. As to the affections of the liver and spleen wehave no clinical observations; they appear to cause no clinical symptoms, or at all events, such indefinite ones that, although our attention has been directed to them, they have escaped observation.
The eruptions are of the most varied duration.Some last only a few days and cause so little fever that the patients experience no particular disturbance to health; they only know that a few new nodules appear, or that they are sore about the throat. Others last for weeks, indeed, months, with remittent fever, the temperature rising to 40°. Quinine has no effect. During such eruptions the strength of the patients is of course distinctly diminished, but when the eruption is over they recover rapidly and feel themselves all right again; only they are more leprous than before, or at least have more leprous manifestations. 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.
Therefore thefate of the patient is verydifferent. If the eruptions are frequent the growth of the nodules is usually luxuriant, and those nodules with diminished epithelial covering, and therefore moist, are very frequent. If then, the whole countenance and part of the extremities are covered with such nodules; if the eyes are blinded by the formation of nodules in the cornea; if the tongue and the pharynx are, through formation of nodules and infiltration, half ulcerated and sore; if respiration is made more difficult by the narrowing of the rima, and the voice inaudible; then the condition is as miserable as is possible to conceive.
If there is added to this, amyloid degeneration of the kidneys, liver, spleen and intestine, with diarrhœa, it can only be desired that death shall put an end to such a condition, and that usually takes place soon, although occasionally the patient may linger for months. Whether leprosy alone is responsible for the end is, we think, doubtful; as remarked above, the affections of the liver and spleen appear to be without much significance.
The biliary secretion is never influenced, and there is according to our observations no special leprous anæmia. The patients are indeed often anæmic, or become so during the disease, but we have not been able to convince ourselves that this is a direct result of the leprosy. In many examinations of the blood, which were indeed undertakenfor other purposes, we have never noticed anything remarkable in relation to the number or form of the blood corpuscles.
As in almost all cases of nodular leprosy nephritis is present, we are inclined to regard this nephritis as a frequent cause of the marasmus which ensues. Tuberculosis was formerly a frequent occurrence in our hospitals, where our observations have chiefly been made. The relationship between this and leprosy we will discuss later.
The prognosis in the case of patients in whom the eruptions appear less frequently is more favourable, and they may live many years. Either they die from an intercurrent disease or as a result of their nephritis, or they become in time anæsthetic, that is, according to our view, they recover. When the nodules become stationary they ultimately soften, as described above, and may be absorbed without opening, though this is rare and usually occurs only with single nodules; or they burst and ulcerate; in either case they leave scars. If this takes place in all the nodules and the patient is attacked by no fresh eruptions, then anæsthesia gradually develops as the result of the affection of the nerves; in the nerves, too, the specific leprous affection disappears, and there remains only scar tissue, which by compressiondestroys the nerve fibres and thus causes anæsthesia. Then gradually all specific leprous affections disappear, and the patient is healed from his leprosy, and may live many years in perfect health, having lost practically nothing of his power of work. Such cases are unfortunately not very frequent; but we have had the opportunity of examining some after death and have not been able to discover in them any specific leprous affection.
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 nephritis appears either as the so-called parenchymatous or as the interstitial; according to our examinations it is never bacillary. Further, as nephritis is very much rarer in the maculo-anæsthetic form of the disease, it must be assumed that nodular leprosy in some way causes nephritis. The same is true of amyloid degeneration. The duration of life of a patient with the nodular form of leprosy is in general eight to nine years after the definite outbreak of the disease.
The most frequent complication which we have seen in our institutions is tuberculosis, particularlysome years ago, for then the institutions were over-crowded, and consequently the sanitary conditions were in many respects unsatisfactory.
In order to give an idea of the frequency of this complication, we have placed in tabular form at the end of this work the results of eighty-nine autopsies (seeTable I, page 128).
From the statistics there given it is evident that we have had ample opportunity of examining the combination of tuberculosis and leprosy. Most of these examinations were indeed made in the pre-bacillary era; but we are satisfied that thedifferentiationof tuberculosis and leprosy without an examination for bacilli is by no means difficult.
As Danielssen and Boeck had described a leprous affection of the intestine, we gave great attention to this point, and as we were at the same time engaged in an investigation on the pathological anatomy of the lymphatic glands, we lost no opportunity of carefully examining these organs. It was during this investigation that we discovered the characteristic leprous affection of lymph glands, and had our attention first directed to the leprous affection of the liver and spleen, which affections are, macroscopically, so little evident, that we at first overlooked them.
The leprous and tuberculous affections of the lymph glands are macroscopically so very different,that it is impossible to confuse them, and the microscopical differences are still more evident. Both fresh and hardened preparations were always examined. And since the lymph glands are always affected with leprosy, if the organs which drain into them are affected, even if this affection is very slightly developed, we conclude from the fact that we have never seen a leprous bronchial or mesenteric gland, that there is no leprous affection of the lungs or of the intestine, and later examination of certain special preparations have only confirmed us in this view. But more of this later, and we will first treat of the differences between tuberculosis and leprosy.
In organs affected with tubercle one always finds, as is well known, giant cells and caseous degeneration; in the many, we can truthfully say, thousands of preparations of leprous affections, which we have had under the microscope, we have never seen either a typical giant cell with marginal nuclei or caseous degeneration. There are indeed multinuclear cells in the lepromata, but never giant cells like those of tubercle.
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 sufficientto 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. Anatomically therefore, we are justified in maintaining a sharp distinction between the two diseases.
So far as concerns the resemblance between the tubercle and lepra bacilli, we must not omit to mention that one almost always finds among tubercle bacilli some which are pretty long and somewhat bent; this is never the case among lepra bacilli. Baumgarten has indicated as a distinction between them, the fact that the latter is more easily stained; according to our experience this distinction can scarcely be regarded as sufficient. But the distribution of the bacilli in the tuberculous and leprous tissue is usually so very different, the tubercle bacilli being usually arranged singly, the lepra bacilli always in large quantities in masses and clumps, that a confusion of the two diseases anatomically can only be possible in exceptional cases. Danielssen has repeatedly stated in his triennial report of the Lungegaards Hospital that tuberculosis and leprosy are such nearly allied diseases that the one (leprosy) may pass into the other (tuberculosis) by a modification of the bacilli, and that thus the frequent combination of the two diseasesis to be explained. This view we cannot, in view of the above demonstration, support. If an organ is attacked at the same time by tuberculosis and leprosy, one can anatomically very readily separate the two diseases. We would rather seek the explanation of the frequent combination of the two diseases in our institutions in the great over-crowding and consequently insanitary conditions to which they were formerly subjected. Tuberculosis once introduced, we find a ready explanation in the bad habits of the patients in regard to expectoration, why it was difficult or impossible to root it out. In later years, when the institutions are no longer full and the sanitary conditions consequently much improved, tuberculosis has much decreased. Whether tuberculosis was as frequent a combination in the country as in our institutions we do not know. The duration of life of patients in the country is about a year longer than in our institutions, and possibly this depends on the absence of tuberculosis.
Doutrelepont has recently described in the transactions of the German Dermatological Society,On the Pathology and Therapeutics of Leprosy, a lung affection, probably developed by tuberculine treatment, which he diagnosed from the examination of the sputum. But the patient had a leprous affection of the larynx, and his account by no means excludes the possibility thatthe bacilli in the sputum came from a ruptured nodule in the larynx, possibly softened by the tuberculine treatment. We cannot, therefore, recognise this observation as infallible evidence of the presence of a leprous lung affection, any more than that case of leprosy of the lungs described by Bonome inVirchow’s Archiv, Bd. C. That author himself draws attention to the great resemblance of the affection to tuberculosis, and as it is quite evident from his description of the bronchial lymphatic glands that they were not leprous, and he notes the presence of giant cells in the pathological products, we cannot doubt that it was really a case of tuberculosis.
In the same case there was found an affection of the spinal cord, from which Bordoni-Uffreduzzi cultivated on glycerine agar an organism which he recognised as the lepra bacillus. Here we may remark in the first place that we have never seen a leprous affection of the spinal cord, and have never found bacilli in it. We must indeed admit that we have only examined the spinal cord in a few cases, because there appeared to be no indication for such an examination, since clinical symptoms do not point to an affection of that organ, and as in the profusely nodular cases, affections easily recognised appear everywhere, except in the liver and spleen, it was to be expected that an affection of the spinalcord would have been recognisable. In necrotic bones, which we have often examined, nothing leprous is found. This necrosis is therefore no specific leprous affection, but a secondary one. Secondly, we must remark that in spite of many attempts we have never succeeded in cultivating lepra bacilli on glycerine agar. We therefore believe that Bordoni-Uffreduzzi has cultivated tubercle bacilli instead of lepra bacilli. The only thing which speaks for the leprous nature of the lung affection and the cultivated bacilli, is the circumstance that the author did not succeed in inoculating guinea pigs and rabbits with tuberculosis. But, according to all investigations on tuberculosis, it appears to us not incredible that the tubercle bacilli may, under circumstances, become so weakened that they are no longer pathogenic.
Arning has described a miliary leprosy, and found in the products of this disease giant cells, and also leprous ulcers in the intestines. Dr. Arning has kindly sent us some preparations of this miliary leprosy, in which we find evidence everywhere that the case is one of tuberculosis, both because giant cells are found everywhere, and the bacilli are only present singly, and scattered. They are never present in the excessive numbers, and have not the arrangement, which they usually have in leprous products. In connection with thepresence of giant cells in leprous products, we may note that we have received from two foreign colleagues preparations in which they believed giant cells to be present. But we have found, on careful examination of the preparations, that they were cross and oblique sections of blood vessels, which with their endothelial nuclei gave the impression of giant cells. Without the use of a homogeneous immersion lens it was not possible to make a definite distinction.
According to our observation there exists a sharp anatomical distinction between leprosy and tuberculosis, and there is no such thing as leprosy of the lungs and intestines, the bones and the kidneys. In order to establish a differential diagnosis in doubtful cases, we recommend in the case of the lungs and the intestines a thorough examination of the bronchial and mesenteric glands. We ourselves have never sought in vain, in cases of these affections, for tuberculous or caseous degeneration in the glands, and we have seen in no single case anything resembling leprous affection of the glands.
So far as concerns the central nervous system, Danielssen noted that he had several times seen acute hydrocephalus in leprosy. We once saw severe cerebral symptoms with maniacal attacks. The patient, who was taken into a lunatic asylum, left this later, cured. Other indications of anaffection of the central nervous system in leprosy are unknown to us. Anatomically, we have not been able to recognise in the nervous system any traces of leprosy. In connection with this, we may note that we have several times seen pain and swelling of the knee joints during eruptions, which at their conclusion disappear. In these cases there is nothing to be made out anatomically. When we reflect that, as indicated in describing the eruptions, the bacilli and (or) their toxines most probably circulate for some time in the blood, it is remarkable that the organs above referred to are not affected by leprosy. We can give no reason for this; connective tissue, which is especially liable to be affected, is present everywhere.