Original Communications. I.-Memoir on Leprosy in Syria. By JOHN WORTABET, M.D., Beyrout.1 Introduction. LEPROSY has recently attracted a considerable degree of attention among medical men. An awful scourge which afflicts the human body, highly ancient in its history, unknown in the largest part of Europe at the present time, and thus removed from the field of modern investigation and discovery, it has become a subject of great interest to scientific labourers. To the private contributions of various writers, chiefly the valuable work of Danielssen and Boeck of Norway, the British Government has been the means of adding a new and important book. At the request of Her Majesty's Secretary of State for the Colonies, the Royal College of Physicians issued a series of interrogatories which was sent to medical men in different parts of the world. The result was the accumulation of a vast amount of information with which was incorporated a number of highly valuable documents, such as the conclusions drawn by the committee of the College from an examination of the entire evidence submitted to them on the subject-matter of each interrogatory, the account of post-mortem examinations made by Dr. Carter of Bombay, and the notes of Professor Erasmus Wilson on nineteen cases of leprosy which had fallen under his observation. The Report of the College was printed at the expense of the British government, and will long be a rich treasure for reference on this disease. 'This instructive paper was sent by the author to me a few months ago, with the expressed desire to have it made known to the British medical public. Containing the results of a lengthened personal experience of the disease in different Asiatic countries, it will be found a valuable contribution to its general history in that region of the world. Dr. Wortabet, in reply to the interrogatories of the College of Physicians in 1863, communicated some interesting remarks on leprosy in Aleppo; these will be found at page 57 of the report of the College. The reader will now be enabled to compare the conclusions which a highly intelligent observer in the East has formed respecting various points about this obscure and momentous malady with those at which I have arrived from my recent opportunities of studying it in the West, and which are recorded in my report recently issued by the Colonial Office and presented to Parliament.-GAVIN MILROY, M.D. Having paid some attention to the study of leprosy in Syria, I venture to lay the results before the profession with the hope that they may be found useful in illustrating the conclusions arrived at by more competent observers, and, perhaps, in adding new information on some of the topics involved in the subject. My own study and personal observation of the disease occupies a good number of years, and I have rarely allowed a case of leprosy which came before me to pass without careful examination, and noting down its symptoms and peculiarities. I have thus collected a good number of cases which fell under my care either in private or dispensary practice. The rest of my cases are derived from the leper-houses of Damascus which I visited in the spring of 1868, and which were visited again for me by a medical friend in the spring of 1872. The order which I have adopted in the following pages is1. The symptoms and pathology of leprosy, with a few typical cases. 2. An account of the leper-houses of Damascus, with tabulated cases of leprosy. 3. Notes on the following topics:-Sex, age, comparative frequency of the tuberculated and non-tuberculated forms, duration of the disease to date of observation, topography, causes, hereditary taint, contagion, segregation, specific character of leprosy, Jewish leprosy, and treatment. Photographs were taken from cases in the leper-houses of Damascus. SECTION I.-Symptoms and Pathology of Leprosy with Typical Cases. General description.-The most prominent features of leprosy which form its peculiar characteristics are these :-Anesthesia of the extremities, often involving the face and rarely the trunk; the skin is generally thickened, and its colour is changed into a red, dusky, glossy hue; the hair of the face falls, sometimes completely; tubercules appear on the face and extremities, which break from time to time, or large bulla are formed on the extremities, rarely extending higher than the elbows and knees, and often converted into deep corroding fetid ulcers; the joints of the fingers and toes are almost ivariably involved during the course of the disease, some of the phalanges are destroyed, and the hands and feet, chiefly the former, become crippled; the voice becomes husky or is wholly lost; and the respiration becomes difficult. While these changes are going on, the general health is more or less impaired; and after a few years, the period being variable, the patient sinks from exhaustion, or from some intercurrent disease. Nomenclature. The Greeks called this disease elephantiasis, evidently from the hypertrophied condition of the legs which is often a concomitant of leprosy; and it still passes under this name in the classification of the older nosologists, E. Græcorum.1 They must, therefore, have embraced the disease known now as "Barbadoes" or "Cochin " leg and leprosy under one common name. The Arabs made a careful distinction between them, and called the former Da'el Fil (morbus elephantis), from whence we have now its classical name E. Araborum. Nor did they adopt the equally objectionable name of "leprosy," a word derived from the lepra of the Greeks and indicating an innocuous cutaneous disease of a scaly character, with which the disease under consideration has hardly anything in common. They substituted for it an Arabic word, el Judham, derived from a root which indicates the mutilating effect of the disease on the limbs. In the ordinary parlance of the people, it is often called ed Da' el Kebir, the Great Disease. Symptoms and progress.-One of the earliest symptoms, and of which the patient takes special notice, is altered sensation, commonly in one or both of the extremities, sometimes on the face, and more rarely on the trunk. When the disease is situated in the extremities, the most distal parts are generally first affected, the circulation becoming feeble, the colour dusky, and general sensation diminished. The patient describes it as one of numbness, sometimes he calls it stinging or pricking pain (formication); probably in most cases, there is both objective anaesthesia and subjective hyperæsthesia at the same time. The skin of the affected parts is at first puffy, and ultimately permanently thickened and somewhat scaly; and I have sometimes observed hard, corded, knotty lines running up the forearms, as if some of the superficial lymphatic vessels were enlarged. As the disease advances, the fingers and toes lose their usual sensibility, and the patient finds that his prehensile powers are considerably impaired, and that in walking he may cast off a loose slipper without his being aware of it. In trying the extremities with a pin, I have sometimes found that the extensor surfaces were somewhat more anæsthetic than the flexor. About the same time, or very soon after, the face becomes similarly affected, the change of the complexion is more obvious, and the subsequent alterations produce that disfigured appearance of the features which is so peculiar to this disease. The colour becomes red, dusky and shining, and the skin thickened and knotted; the hair of the head and eyebrows, and the cilia drop gradually until they often disappear entirely; the eyes are red and watery with venules running across the conjunctiva. When it attacks the trunk, the skin becomes affected in patches, though the hair is not so apt to drop off. I believe the face and trunk are rarely affected, unless the extremities are previously at The language of Aretæus, however, when he says of it that "it is most powerful in dragging men to death, disgusting to the sight, and in all respects terrible, like the beast of the same name," would seem to indicate other points besides the hypertrophied condition of the legs. tacked. These changes are attended by fetid perspiration, chiefly of the hands and feet. It is difficult to believe that these earlier symptoms of the disease1 can usher it in without a considerable degree of constitutional disturbance. In his great concern as to the fearful consequences of his malady, the patient rarely speaks of it; but there is always more or less of general malaise, febrile flushes, disturbed dreams, a peculiar heaviness affecting the whole body, and depression of spirits. This latter phenomenon becomes ultimately a settled state of the mind; all active cheerfulness is lost, and the leper assumes a sad subdued mien through life. This state of mind is produced probably by moral as well as physical causes. The victim of an incurable and loathsome disease, shunned by his nearest relations, disabled from work and reduced to dependence if not absolute privation, his life becomes a burden heavy to be borne. I have known a case where this state of feeling became intolerable, and the poor man (who was in good circumstances) was so affected by the bearing of his wife and children that he put an untimely end to his life. Soon after the invasion of the disease, an eruption appears on the skin, limited to the forearms and hands, the legs and feet, and the face; very rarely, if ever, appearing elsewhere. Of this eruption we have two distinct forms, viz. tubercules and bulla; the former appearing on the face, forearms, legs and back of hands and feet; the latter on the extremities, chiefly their palmar and plantar surfaces. The tubercules are generally numerous, and rarely smaller than a pea. They rise from the skin, and like it are red and dusky in colour, and shining. During the course of the disease they become inflamed, crack, and discharge a thin sanious fluid; after which they heal and contract, others taking their place in different spots. The bulle appear in the form of large vesicles or vesicular blebs, are generally ovoid in form, and measure from three quarters of an inch to one or two inches in their diameter. They resemble so closely the blister of a scald that the patient often describes them as burns from too near an exposure to the fire, while the anesthesia of the parts failed to give him the needful warning. They soon break and discharge at first a thin lymphy fluid, and leave an ulcer which penetrates deeply into the integument, and often exposes the tendons of the muscles. The vesicle is thus converted into a deep, red ulcer which discharges fetid pus. When the ulcers are many, or the patient is not cleanly in his habits, the odour becomes intolerable. They generally heal, leaving often a well marked white cicatrix. The tubercules and The earliest symptoms of the disease are stated by El Kamory, an ancient Arabian author, as follows:-"Congested appearance of the eyes, duskiness of the skin, huskiness of the voice, fetid perspiration, puffiness of the face, with ulceration and increased redness, and gradual loss of the hair of the eyebrows." bullæ characterise, in a great measure, the two forms of leprosy called the tuberculated and the non-tuberculated, though these frequently appear in the same subject, but not to the same extent. The nose begins early in the course of the disease to discharge a fetid purulent fluid, arising from sores formed within the nasal passages. Breathing through this organ becomes difficult; the triangular cartilage is gradually eaten away; and the healing process begins only after the nose has been broken down and disfigured. About the same time, the glottis becomes affected with the same morbid infiltration; the voice assuming at first a hoarse unnatural sound, and subsequently reduced to a whisper. I have seen, however, well advanced cases where neither the nose nor the voice was completely destroyed. There is always more or less dyspnoea, but auscultation reveals nothing, when the air passages are not attacked, beyond feeble respiration. The smaller joints of the hands and feet are almost invariably involved in due time. Ulceration sets in, and the distal and the middle phalanges, generally, are loosened and come off. After the loss of the bones the ulceration heals, leaving the fingers and toes shortened, clubbed and sometimes bent by the contraction of the flexor tendons. Occasionally the destructive process stops at this stage, and the whole disease appears to be arrested. Under these circumstances, the disease is called by the natives "Kurtum." The larger joints are but very rarely attacked. The nails often crack, and a fetid discharge takes place beneath them. The extremities (forearms, hands, legs and feet) are generally more or less thickened, specially the latter. The hypertrophy is uniform, and the skin becomes dark, covered by scales of peeling cuticle. The lower extremity assumes then the appearance of the " Barbadoes" or "Cochin" leg (elephantiasis Araborum). The reproductive functions are always more or less affected. In males the sexual passion is at first weakened, and, as the disease advances, is often entirely lost. In females the catamenia are scanty, irregular or cease altogether. Fecundation is quite possible in the earlier stages of leprosy, whether we regard the agency of the male or female. When the disease begins before puberty, it is extremely doubtful whether the reproductive functions are ever properly developed; and it is worthy of remark in this place that these conditions are highly favorable to the limitation of the disease among leprous families. The general appearance of a leper is so peculiar that, when the disease has fairly declared itself, or even earlier, a single glance at the patient is sufficient to identify it. The changes in the faces are quite characteristic and not easily to be mistaken. To these may be added, later on in the history of the disease, the swollen, ulcerous, maimed or crippled state of the hands and feet, and 103-LII. 12 |