of hyperæsthesia and acute neuralgia. By degrees the great thickening of the nerve trunks decreases somewhat, the hyperæsthesia and neuralgia subside, and anæsthesia, paresis, muscular atrophy, and other trophic changes take their place. For a time the condition may fluctuate; the neuritis apparently may come and go with corresponding changes in the condition of the area subserved by the affected nerves. Sooner or later, however, fibrotic changes ensue in the neural leprous deposits, and the nerve tubules ultimately atrophy and disappear. The nerve tissue is now irreparably damaged, and trophic changes steadily advance. In other instances anæsthesia comes on without neuralgic pains, without hyperæsthesia, without constitutional symptoms, without discoloration of the skin, the patient discovering its existence by accident.
In nerve leprosy the anæsthesia begins most commonly in the feet, the thighs, hands, arms, forearms, and face. Later, and more rarely, it affects the trunk. The anæsthesia, though associated with well-marked lesions of the larger nerves, does not always, or even as a rule, coincide accurately with the anatomical distribution of their terminals; a circumstance which tends to show that the anæsthesia is not always and simply the result of lesion of nerve trunks, but that it may be the effect of the destruction by the bacillus of the nerve terminals themselves. This suggestion is strengthened by Gerlach's discovery that in anæsthetic leprosy the bacilli appear first in the skin around the nerve terminals, and only subsequently extend upwards to the nerve trunks. Another and sometimes a very striking fact in nerve leprosy is the symmetry observed in the distribution of some of the anæsthetic areas. This symmetry is by no means invariable; in not a few cases, however, it is very perfect and remarkable.
At the outset the anæsthesia in the affected patches may not be absolute; it may also come and go; and it may be very superficial, deep pressure being for a long time appreciable. But when the
