Therefore the fate of the patient is very different. 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 undertaken for 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 compression destroys 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, 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 (see [Table 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 the differentiation of 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.