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The most frequent complication which we have seen in our institutions is tuberculosis, particularly some 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 .

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 sufficient 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. 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 may pass into the other by a modification of the bacilli, and that thus the frequent combination of the two diseases is 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.

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 spinal cord 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 the presence 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 an affection 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 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.

STRUCTURE OF THE LEPROMA.

The leprous nodes have on section a smooth, white, glistening surface, if they are still sufficiently young. 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.

If one teases out preparations in osmic acid solution, or soaks a nodule in the solution some hours before teasing, the rods are coloured faint brown, and one finds them lying mostly in the cells . If one adds water to a fresh preparation, the bacilli move actively; even in the cells swollen up with water, one sees the bacilli moving; and this led us to regard them as movable, although we at the same time indicated a doubt whether the movement was not simply a molecular one; for the movements were equally vigorous in strong osmic acid solution as in water, and on the addition of glycerine or strong solution of albumen to the preparations, the movements ceased. All later observers, with the exception of Unna, regard the bacilli as motionless. We have no ambition to decide this question, because we know no absolutely trustworthy distinction between molecular movement and independent movement of the bacilli.

The older the nodules become, the more large multinuclear cells are found, and in nodules of the skin and cornea one always finds small flat cells with processes, and with oblong nuclei, which we recognise as the connective tissue and corneal cells .

Unna, zur Histologie der Lepr?senhaut; in Leprastudien, Monatshefte f?r practische Dermatologie, Erg?nzhungsheft, 1885.

Neisser first drew attention to clear spaces in the bacilli; these Neisser regards as spores; we regard them as the first sign of breaking down of the bacilli into granules, and for the following reasons. We have made numerous attempts to cultivate the bacilli, and have attained in all our investigations only granules, and in examining a piece of a nodule which lay eight days on broth peptone agar, found all the bacilli beset with clear spaces. And as the result has always been the breaking down into granules, we believe we are right in regarding the appearance of these holes as the commencement of degeneration, and that we are not as yet familiar with spores of the lepra bacillus. It appears as if all bacilli in time break down into granules, particularly in the internal organs, where it occurs much earlier than in the skin nodules; whether this is the result of digestion on the part of the cell, we cannot say; but as the bacilli at first multiply in the cells, and the breaking down appears most definitely and freely when the cells are crammed full of bacilli, it is equally possible that it is the result of diminished nutrition, and as they break down more rapidly in the internal organs, it is also possible, indeed probable, that the higher temperature in these organs favours this disintegration. As we have unfortunately not been able to cultivate the bacilli, it is at present impossible to form a conclusion. At all events, we regard the transformation into granules as a degeneration, and believe that the bacilli thus altered are dead.

In a nodule, with exudation, which we have recently examined, we have found bacilli in the epithelium, and there are in several places distinct leucocytic nuclei in the bacillary groups, thus showing emigrated cells with bacilli in the epithelium.

Of the presence of bacilli in affections of the eye, it may be said in general that everywhere, where infiltration is present, bacilli are found. In the clouding of the upper part of the cornea described above, which we recognise as keratitis punctata, there are found groups of granularly degenerated bacilli close under the epithelium. This we have only once been able to determine on the living by excision of a lamella of the cornea; in this case the affection was, according to our own view, disappearing, because the bacilli were granularly degenerated. This corresponds with the fact that this characteristic affection of the cornea always ultimately disappears; the granules are probably absorbed. We have already stated that blood vessels precede the nodule into the cornea, and that they are surrounded by round cells. Here, as in the middle of the nodule, the corneal corpuscles are found apparently intact or filled with brown granules . The same is the case in nodules in the iris, in which one finds the stellate cells intact . Round cells are also found in the spaces in the cornea near the nuclei of the corneal corpuscles . All this appears to us definitely to indicate that at least most of the cells of the growth are migrated white blood corpuscles.

As already indicated, the testicles are affected with leprosy in all nodular cases. The affection is both inter-tubular and intra-tubular. In a testicle only slightly affected, we found bacilli everywhere in the endothelium of the vessels, and in several dilated vessels white blood corpuscles filled with bacilli ; and in some places also bacilli lying free between the red blood corpuscles . At the same time, and especially where the affection is more marked, the bacilli penetrate into the seminal canals, and lie grouped in their walls around the nuclei , and their epithelial cells are more or less filled with them .

The bacilli appear rapidly to break down into granules, and one finds, especially in the seminal canals, globi, sometimes enormously large, as if they were formed by the running together of several epithelial cells. We have found here globi where a nucleus and a little protoplasm were evident , and a globus where there lay in the vacuole small fragments stained with Bismarck brown . As it has been proved that a man affected with nodular leprosy may beget children, and as the globi lie in the seminal canals, it is not altogether impossible that these may be thrown off with the spermatic fluid, and that in this way the ovum is infected. But as, according to our view, these globi contain only broken down and degenerated bacilli, it must be regarded as very doubtful whether they are still infective. In examining the contents of the seminal vesicles, we have found in them neither bacilli, nor globi, nor any spermatozoa. It is an old conception that lepers suffer from satyriasis. This is, according to our experience, certainly not the case. The leprous testicle is finally completely destroyed by the scar-like contraction of the connective tissue, and one finds only here and there traces of the seminal canals around the globi which they enclose.

When the liver is severely affected with leprosy, there are evident macroscopically, fine white, or yellow, streaks or points, which shine through the capsule and are more evident on the cut surface ; they evidently lie in the acini. One also finds round cells with bacilli along the portal vessels and in the capsule of Glisson. Here and there we find also scattered bacilli in the acini, and as is evident from a specimen hardened in Fleming's solution, the bacilli lie in the endothelium of the blood vessels . In the liver cells we have never seen bacilli, but we have found here also, in the vessels, white blood corpuscles containing bacilli .

The affection of the spleen may also be recognised macroscopically by the yellow streaks and points in its substance , but the affection must be pretty severe to be recognised macroscopically; the cut surface is then somewhat dry. The affection has its seat in the arterial sheaths and the Malpighian bodies; and in this organ also one can in good preparations definitely recognise the position of the bacilli in the cells .

The glands in the hilum of the liver are, when that organ is affected with leprosy, definitely leprous, and the affection of the glands is often more evident than that of the liver itself. In the hilum of the spleen we have once or twice found leprous lymph glands.

This leprous affection of the glands is macroscopically very readily recognisable. The glands are swollen as a whole, without any alteration in their form. On section, one sees the ampullae and the medullary cords of a yellow or yellowish brown colour; this colour gives to the glands such a characteristic aspect that they can hardly be mistaken. The affection is best studied on the inguinal glands, and the retro-peritoneal ones in connection with them. The lowest inguinal gland is always most swollen, reaching sometimes to the size of a pigeon's egg; the ampullae and trabeculae are coloured throughout a deep yellow; but the somewhat thickened capsule and the connective tissue framework have retained their greyish semi-transparent appearance, so that the structure of the gland stands out very clearly, especially if the lymph sinuses are injected with blood pigment, which is sometimes the case when there have been peripheral haemorrhages in the nodules. As we advance upwards the glands are gradually less swollen, and the yellow colouring of the ampullae and trabeculae less intense, and one can further follow in the retro-peritoneal glands a gradual diminution of the affection until, about the level of the kidney or rather higher, normal glands are once more met with. The glands are permeable, but penetration is evidently more difficult, for the lymph vessels leading to them are dilated, especially those of the lowest and most swollen glands.

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 ampullae are affected. Microscopically the ampullae and trabeculae 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; nevertheless, the glands retain the infectious product, and if it pass one gland it is arrested and retained in the next. Sometimes the quantity of this infection is so small that one or two ampullae are sufficient to retain the whole of it. This indicates that the circulation in the gland does not take place exclusively through the lymph sinuses, but that the lymph reaching the gland must at once enter the ampullae. A similar process is seen in tubercular lymphatic glands, in which one often finds only one or one or two ampullae infiltrated with tubercle.

In the nerves the bacilli are found partly in round cells, which lie around the vessels and between the nerve fibres, and partly in the cells of Schwann's sheath; here also they break down into granules, and in time completely disappear. The finer details of the affection of the nerves are best studied on the ciliary nerves when the eye is affected, because there one can examine the finest nerves without cutting sections or putting them through any manipulation which might injure them. One often sees the myelin sheath pressed in by bacilli or cells filled with granules , and one finds nerve fibres without a myelin sheath and with a more or less atrophic axial cylinder . These drawings clearly explain how the pressure on the axial cylinder at first causes pain, and later, when atrophy has set in, anaesthesia. And one can also understand that when the leprous affection passes off without complications, the axial cylinders are again restored and become functionally active.

But on those places above referred to, where the nerves run superficially over bones or joints, and are exposed to pressure and stretching, secondary inflammation is added to the process.

While the primary leprous affection hardly appreciably thickens the nerves, the secondary inflammation causes a very marked thickening. The ulnar nerve at the elbow may attain a diameter of 7 to 8 mm. or more, and when the secondary inflammation disappears the connective tissue contracts, and the previously thickened nerve becomes thinner than normal. This whole process usually advances very deliberately, and years are required before anaesthesia is developed to its full extent. While the section of the thickened nerve is quite smooth and of a pale brown colour from the numerous globi present, the section of the atrophic nerve, though also smooth, is as pale as the section of a tendon. It consists almost exclusively of connective tissue; every trace of bacilli has disappeared, and one sees hardly a suggestion of nerve fibres. The leprous affection is healed, but only a completely functionless rudiment of the nerve remains.

Just as the manuscript of this treatise was completed, a year and a half ago, we obtained at an autopsy a lung in which there was tuberculosis, but at the same time probably leprosy also. Most unfortunately the bronchial glands were not preserved for microscopical examination. Dr. Lie also permits me to state that he has found leprosy bacilli in two kidneys and in one lung. He had diagnosed tuberculosis of the lung, but at the autopsy he found only an indurating pneumonia, containing lepra bacilli, and no tuberculosis. In the kidneys, of the same case, he found lepra bacilli in the glomeruli, and in the interstices between the cortical tubules. He will describe the case more fully later. This is a mere preliminary note.

LEPRA MACULO-ANAESTHETICA.

Thus there disappears the sharp distinction between the two forms of the disease--the tuberous and the maculo-anaesthetic. We must regard them as the same disease, only with varied intensity in the action of the bacilli.

One can distinguish in the maculo-anaesthetic form, different stages in the course of the disease, but in general they cannot be very sharply defined from one another.

In the prodromal stage, which is of very varied duration, lasting for months or even years, the patients state that they suffer from exhaustion, general debility, rheumatoid pains of the joints or muscles, hyperaesthesia of the skin, neuralgic pain of certain nerve regions, sopor and mental depression. Ephemeral eruptions of spots are admitted; and pigmentary anomalies, sometimes atrophic, sometimes hypertrophic, were noted by Bidenkap.

Danielssen states that he has seen, at the very beginning of the disease, a slight vaso-motor disturbance, which is indicated by a bluish-red reticular appearance, which is evident most clearly on changes of temperature. These vaso-motor disturbances, which appear as slight patches which can be induced by friction, are chiefly characteristic of the maculo-anaesthetic, though they may appear during the earliest stage of the tuberous, form.

In fact, our view is that the so-called prodromal symptoms are nothing more than the earliest, indefinite, undiagnosable phenomena of infection.

One or more eruptions of pemphigoid bullae may occur in the commencing stage, but we have more often seen them later, both accompanying the patches and in the stage of anaesthesia and mutilation.

The symptoms of this neuritis are various; at first neuralgia, and later, widespread anaesthesia, with trophic disturbances, such as the formation of pemphigoid bullae; we have often seen hydrarthrus and pains in the joints. Motor pareses and paralyses are never absent, but they are not, as Neisser argues, due to a leprous affection of the muscles, but are a secondary neuritic symptom, as we have discovered from anatomical examination of the muscles. As the neuritis especially affects the peripheral nerve trunks, we find the secondary symptoms in the peripheral regions, usually only in the extremities and on the face. We will now more closely consider the various nervous symptoms.

Neuralgia is usually present in the extremities, in the ulnar and peroneal regions. The anaesthesia 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 anaesthetic; the face is always more or less anaesthetic. We have often found thermal anaesthesia present alone, or accompanied by anaesthesia or analgesia. The anaesthesia may become more and more extensive, or it may very gradually disappear, indicating that the neuritis of the affected nerve has disappeared.

Trophic and vaso-motor disturbances are never absent if the neuritis is pronounced and lasts for any time; the skin may become oedematous, or it becomes thin, shiny, and slightly scaly . We have often seen, especially if the neuritis has lasted long, and the later symptoms such as mutilation have commenced, dark-coloured hyperkeratoses, usually symmetrical on the front of the leg, or on the dorsal surface of the hands. In one patient we observed on the toes horny, thick symmetrically placed formations, which when thrown off left a new-formed rosy-red skin, with intact sensibility; the patient had on the front of the leg the appearances of ichthyosis.

The changes in the nails are a part of the trophic disturbance; they become thickened, brittle and cleft, and sometimes thin and diminished in size, as one finds them, as we shall see later, in the terminal stages. The secretion of sweat is affected, being diminished over the anaesthetic areas, and the hairs there are altered and fall out.

We regard the pemphigoid bullae as a trophic symptom; they may appear at the very commencement of the disease, along with the macular eruption; but they usually appear late when the anaesthesia has become extensive; in this we agree with Danielssen. Neisser and Leloir give prominence to the early appearance of pemphigoid bullae, Neisser believing that the irritation of the commencing interstitial neuritis causes this trophic symptom. Our reason for regarding them as trophic symptoms is that we have never been able to find bacilli in the bullae we have examined, not even in those which appeared at the same time as the maculae, and their marked symmetry is also in favour of their nervous origin. The bullous eruptions usually appear suddenly. The patients will discover on awaking, one or more blisters which may be already burst; some have pain and fever for hours or days before their appearance; . They vary in size--they may be small, from the size of a pea to that of a bean, or as large as the palm of the hand.

Their contents are serous, but if the bullae persist, they become purulent. They usually rupture early and heal, leaving behind them violet-coloured scars, which after some time become pale. If irritant factors are added, if the bullae last long and become purulent, there develops after rupture deep ulceration, most frequent on the hands and feet.

Bullous eruptions of the mucous membranes, which Leloir has noted, we have never been fortunate enough to see.

We regard also as tropho-neurotic vaso-motor symptoms the acute rheumatoid affections of the joints, which are not infrequent in our hospital. The joints, especially the small ones of the fingers and hands, and also those of the knee and ankle, become painful and tender, and on palpation, a collection of fluid can usually be recognised. The affection is always symmetrical.

These affections of the joints, which belong to the earlier stages of the disease, usually appear simultaneously with the macular eruption, and disappear with it, but they may appear later; and after one, or it may be only after several attacks, thickening of the ends of the bones and ligaments, with stiffening of the limbs, is developed. Leprous affections of the tendon sheaths, which Wolff refers to, we have never seen. The contracture of the fingers and toes is not tendogenous, so far as we can decide from clinical and anatomical investigation; it is myogenous, the leprous paralyses, which we shall immediately describe, being the cause.

Paralysis with atrophy is most marked on the hands and forearms, feet and calves, and on the face.

As we have already mentioned, the eyelids can no longer be closed on account of the paralysis of the orbicularis palpebrarum, and consequently the under part of the cornea remains uncovered during sleep. This leads to a punctiform drying of the epithelium of the cornea, and further, to an injection of the conjunctivae at the under margin of the cornea; then the vessels gradually attack the cornea, which becomes opaque, at first around the xerotic spots, and later in its whole under part. It may go on to ulceration with rupture of the cornea and prolapse of the iris, and finally to complete atrophy of the globe. As a result of the paralysis, the lower lid is always ectropic, at first at its inner end, and later, completely. As the lower punctum is thus drawn away from the bulb, the tears run down over the cheeks, and the paralysed countenance looks still more woe-begone.

In the later stages, when the facial paralysis is very pronounced, the senses of smell and taste may be very much diminished, or completely lost.

We often see symptoms which are not proper to the disease itself developing during its course, such as obstinate cardialgia, acid pyrosis, and vomiting of a slimy nature indicating gastric catarrh. Diarrhoea or chronic obstruction is by no means rare, nor is albuminuria dependant on parenchymatous, interstitial or amyloid nephritis.

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