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ON THE

NATURE AND TREATMENT

LEPROSY,ANCIENT AND MODERN;

INCLUDING THE

JEWISH LEPROSY, LEPROSY OF THE MIDDLE AGES, LEPROSYOF THE CRUSADES, LEPROSY OF THE ARABIANS,

AND

ELEPHANTIASIS OF THE GREEKS:

WITH

A DESCRIPTION OF THE FORMS UNDER WHICH LEPROSY EXISTSIN BRITAIN AT THE PRESENT DAY.

BY ERASMUS WILSON, ESQ., F.R.S.

(Continued from page 148.)

ETiOLO&Y.—The cause of elephantiasis is an animal poisongenerated in, or received into the blood, accumulated therein,probably by a process analogous to fermentation, to the pointof saturation, then acting as a morbid stimulant, or irritant,and giving rise to certain phenomena which have for theirobject the elimination of the poison, either by the naturalemunctories, or by deposition in the tissues of the body, thesurface tissues in the tubercular form, the nervous centres inthe anxsthetic form, or by the discharges from ulcers. , Thenature and origin of the poison are wholly unknown, certainconditions of the human body, and of the elements around it,must have co-operated at its first production, and those con-ditions no doubt continued for a time, and may still be inaction more strongly in some countries than in others, for themaintenance of the poison, and for the perpetuation of the dis-ease. This constitutes the spontaneous or endemic origin ofelephantiasis; and in this point of view we may regard asspringing from such a source the two instances of Europeans,Cases 3 and 4, previously narrated.

Those gentlemen resided for some years in a country in whichthis disease prevails, and were afflicted with it in consequence;and a similar consequence may be entailed on anyone similarlyplaced. Fortunately elephantiasis is not very common in India,and, therefore, we may suppose that the causes giving rise to itare weak; but in the Mauritius, and particularly in Norway,they are still strong, and new residents in those parts are indanger of being afflicted by the disease. Several of the Europeansettlers in the Mauritius are now suffering severely from ele-phantiasis, chiefly of the tubercular kind, and Drs. Daniellsenand Boeck mention the case of a naval officer, who lived for ashort time in Norway, and was afterwards afflicted with thedisease.The doctrine of infection and contagion, as applied to ele-

phantiasis, has long been abandoned; several of the oldermedical authors expressed their doubts as to its communicabilityby this means, and modern authors are all agreed in denyingit; and not only is this the prevailing opinion, so far as ordinarysocial intercourse is concerned, but it is also denied that a hus-band can communicate the disease to his wife, or a wife to herhusband, or that a nurse can convey the disease to an infantby suckling. Thus the revulsion of opinion is complete; andadmits of no origin for the disease but that already stated, andhereditary transmission. An European gentleman from theMauritius, who lately consulted me, stated that he had residedin the island for twenty-nine years ; he had married a nativelady, who with her five children, was perfectly free from anytrace pf disease ; but that within the last twelvemonths,symptoms of an undoubted character had appeared in himself.I did not hesitate to say that I believed marriage had no sharein producing his present symptoms, and that the disease ori-ginated in endemic causes alone. His case was interesting, aspresenting the earliest phase of the complaint; he was feelingstrong and well, and perfectly free from pain or inconvenienceof any kind ; but there was numbness of his feet and legs andpart of his arms, and he had scalded himself accidentally withthe steam of a boiling teakettle, without being aware of anysensation.With regard to the second and more frequent mode of pro.

)agation of the disease—namely, hereditary transmission-theame variation of results is met with as is found in all otherlatural phenomena. Leprous parents may have all theirchildren affected, or one or two out of an entire family; or thechildren may escape entirely. The same may take placewhere the mother or father only is diseased; but it would seemhat transmission through the mother is more constant than onbhe side of the father. Again, the disease may pass overseveral successive generations, and show itself unexpectedlywhen the remembrance of such an inheritance is forgotten.

Elephantiasis may occur at any period of life, but is lessfrequent in infants than in children beyond the age of seven,and most commonly does not show itself until after the periodof puberty. It is also more common in the male than in thefemale sex. When it occurs before puberty, it is apt to cause-a suspension of sexual development.Amongst other conditions favouring the development of

elephantiasis is a damp and humid atmosphere. The diseasetook its origin, as we have seen, on the marshy banks of theNile, and its habitat still continues to be the banks of rivers;islands, as Mauritius, Madagascar, Madeira, the Greek islands,the Crimea, Iceland; and sea-coasts, as those of the Black Sea,Mediterranean, and, in particular, the coast of Norway. Tem-

perature is obviously an uninfiuential condition, for the diseaseat the present time evinces its greatest activity in the islandsof the Indian Sea, and on the Coast of Norway.We may pass over those speculations of human ignorance

which attributed the origin of elephantiasis one while to divinewrath as a punishment for sin, and another while to divinefavour, securing to the sufferers religious honours. ,

The known animal poisons are comparatively few, and thelaws which govern them being the same, or nearly the same,we are not surprised to find that elephantiasis has been attri-buted to the poison of syphilis, or, rather, that elephantiasis,being the earlier of the two, was supposed to pass into syphilis,and it is a curious fact, that syphilis first began to attract.attention in Europe when elephantiasis was on the decline.The points of resemblance between elephantiasis and syphilisare very striking and very remarkable, but hardly more so,perhaps, than between syphilis and other diseases originatingin an animal poison, and therefore it would be unphilosophicalto infer that there was originally but one animal poison fromwhich both diseases have sprung. It would be as correct andequally probable, to assume that two animal poisons existed atthe same time, the one being the poison of elephantiasis, theother that of syphilis, and that, existing together, for a time atleast, their symptoms were confounded by the early historiansand early medical writers. At the present day, even, I meetwith diseases of the skin which I am at a loss to classify underone or the other poison, although to one of the two they un-doubtedly belong. -DIAGNOSIS.—Elephantiasis may be confounded with consti-tutional syphilis, chloasma, melanopathia, leucopathia, andanaesthesia; and paralysis from ordinary causes. The muddyskin, suffused eyeball, dull-red or copper-coloured patches, con-gested fauces, even the tubercles and enlarged venules on

the surface of the skin, all belong equally to syphilis and ele-phantiasis at a certain stage of its course; but the pathogno-monic signs of elephantiasis are, the defective sensibility of theskin, the thinning and numbness of the fingers and hands,and the history and duration of the complaint. In the firstof the cases before narrated, the dull purplish red patches evenwith the skin, and leaving behind them smooth, brownish, orbronzed stains, more or less insensible to the action of irritants,although pointing to the suspicion of a morbid poison, weretotally unlike hereditary syphilis, and could not, from theage of the patient, as well as from the absence of other symp-toms, belong to ,the secondary period of acquired syphilis.The doubtful aspect of the eruption would lead the mind toelephantiasis as the only other known disease which could pro-duce similar appearances. In the second case the body wascovered with patches exactly resembling chloasma; and, butfor the other symptoms of elephantiasis, might have been takenfor that affection. In chloasma, however, the skin is generallydry, and roughened by a furfuraceous desquamation, besidesbeing more or less irritable; but these patches were smooth,

moistened by sebaceous secretion, unaffected by itching, and; clearly less sensitive than the surrounding skin. Still, the

distinction between them was such as could only be appreciatedby the experienced eye, and the diagnosis might have remaineduncertain but for the appearance of the fingers and hands, ther tuberculated and thickened skin of the face, and the frowning

and alopeciated brows. The third case was remarkable for a- settled chronic character, which does not belong to the more

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transient syphilis; the tubercles on the eyebrows were hardand permanent, the patches on the limbs were darker, moreleaden, and more polished than the copper-coloured stains ofsyphilis. By the same characters also they were unlikechloasma. Then there was the deficient sensibility, the chilledsurface, the cold extremities, which pointed specially to thereal disease. In the fourth case, I recollect having the im-pression given me, at the first glance at my patient, of syphilis:the dusky-reddish stains sprinkled thickly over the face; theslightly-raised tubercles on the forehead and temples; themuddy skin, and suffused eye, all denoted syphilis. But whenI saw the attenuated fingers, and broad, bronzed patches onthe arms, some cedematous, and others shining with metalliclustre, and detected the coldness and numbness of the hands, Idiscovered my mistake. My first questions were suggested bythe coup cl’ceiL thrown on my patient at first sight; but I soonchanged my attitude of inquirer for that of listener, and was,glad’to be taught the curious phenomena and progressive history.of the complaint. In a word, ana;st7aesia is the diagnostic.character as well of tubercular as of ancesthetic elephantiasis,the,difference being one of degree only. In tubercular ele-phantiasis the morbid disposition seems to take place in the.peripheral nerves only, while in the anaesthetic form it occursjn the nervous centres; in the former, the numbness, insensi-bility, defective nutrition, and atrophy are slight, in the latterthey are extreme and fatal.

In comparing elephantiasis and syphilis, it is not uninterest-ing to observe the close resemblance in pathological phenomenawhich exists between the two diseases. The tubercles of bothare accompanied by an enlargement of the cutaneous venules,or rather by a development of venules where they normally do z,not exist; in both, the tubercles result from the transudation ’,of an albuminous fluid of jelly-like appearance; both occasiona, disorganization, apparently by solution of the structure of theskin; and both, as a consequence, leave behind them anatrophied state of that membrane when they disappear, as they,are wont to do, by interstitial absorption. Also, when they.pass into a state of ulceration, both give rise to ill-conditioned,corroding ulcers, which tend to eliminate the poison from the’blood.

The distinguishing character between morphcea alba and. leucopathia, on the one hand, and morphoea nigra and melano-.pathia, or chloasma, on the other, may be taken to be thepresence or absence of sensation as well as of colour, and thestate of nutrition of the affected skin. In morphoea, the com-panion and sometimes the sole representative of elephantiasis,there is always, in association with altered colour of the skin,defective sensibility, suspended nutrition, aud more or less dis-organization of structure. In morphoea nigra there is a tem-porary increase of secretion, which, however, soon fails, andin morphcea alba there is arrest of secretion and hair formation.

. PROGNOSIs.-In endeavouring to form an opinion as to theissue of elephantiasis, a question of much consequence as affect-ing the hopes of the patient and the exertions of the physician,: we derive very little aid from the writings of the ancients,.since by them so many cutaneous affections were includedunder the general head of Leprosy, that it is impossible to de-termine when the real elephantiasis is under consideration, andwhen some other and more curable affection. Thus the sacredwritings, usually exact and accurate in their description of.events, are so confused on the subject of elephantiasis as to re-quire to be put out of the pale of reference when treating onthis subject, and the pages of the Greek and Arab authors areequally uncertain. The prevailing opinion of the ancient. writers, as well as of many of the moderns, is that elephantiasisis i2.eca·able, or, to a certain and VU’Y linited extent, susceptibleof cure. While, on the other hand, we have before us the factthat the disease has ceased-in other words, has become curedin countries that it once ravaged, that the cure has been pro-gressive and complete, and that it has followed the coursetaken by the malady in its progressive march. That the causemay have lost its power in the countries once afflicted, is quitetrue ; but that it has ceased entirely is not so, for examples ofthe disease still continue to be met with in its old haunts, andthere is no reason why at some later day it may not regain allits old power, and become a second time one of the epidemicpestilences which are permitted from time to time to affectmankind. Therefore, while, on the one hand, we have theopinion of the incurability of elephantiasis, we have, on the- other hand, the proof of its curability in a race, however little.such reasoning may be applicable to the individual.Amongst other conditions which may influence the prognosis

of elephantiasis, are its hereditary or accidental origin, and itsaetive or chronic invasion. When the disease is accidental in

its origin, it offers a better chance of cure than when heredi-tary, and may be pronounced to be susceptible of cure; andwhen the disease is acute, it may be expected to yield morereadily to treatment than when insidious in its attack andchronic in its progress. Moreover, the new light and newvigour thrown into the subject by Drs. Danielssen and Boecklead us to hope that much more may be done in the cure of thisaffection than has been heretofore supposed; and that elephan-tiasis may be moved from the category of incurable into that ofcurable complaints.

TREATMENT.—The treatment practised by the early physi-cians in this disease appears to have been founded on the prin-ciples of a rational medicine, and to the present day we havemade little progress beyond that point, having simply glidedfrom a rational expectant to a rational empirical system. Inadopting this latter system, we have perhaps attained all thatfor the present at least we may hope to accomplish, and ourenergies will be better employed in being devoted to the per-fection of this plan than in seeking farther into the obscurityof experimental medicine. Aretasus, who has left so excellentan account of elephantiasis in his writings, lays down as theproper plan of treatment the practice of venesection, followedby the use of purgatives, diluents, baths, and inunction withfat, assisted by a plain, nutritious, and wholesome diet, ac.companying the latter, if the powers of the constitution bereduced, with wine. The purgative most preferred is colo-

cynth, the diluent, milk attenuated with water, and amongstother medicinal substances employed, are decoctions of sim-ples, particularly the plantain, and the flesh of serpents, whichWas held in high repute by the ancients ; and when properlyprepared, seems to have made a very agreeable article of diet,corresponding with the turtle-soup of the present day. Otherremedies recommended by Aretaeus, are the plant calledsideritis (ironwort), the trefoil, sorrel, and iris ; alum, sul-phur, and carbonate and phosphate of lime, under the form ofelephant’s teeth. The fats used for inunction were those ofthe panther, lion, and bear.Etius follows the general plan of treatment described by

Aretseus, adding that amongst the Indians it was customary toexhibit as a medicine the urine of the ass, probably on accountof its diuretic effects, and prescribed as an article of diet theflesh of the crocodile. Serpents and reptiles seem to haveacquired their reputation in this and other diseases in whichthe skin is affected, from their periodical exuviation of thecuticle, and the magistral inference that their flesh partakenby man would enable him to throw off by a similar process ofexuviation the sordid covering of morbid secretions and scaleswhich is apt to form in these diseases.

Paulus aegineta, pursuing the same course of treatment, re-commends its adoption three or four times a year. To the

purgatives already in use, he adds aloes and white hellebore.and suggests the administration of an emetic, if needful. Healso mentions, in his list of remedies, squills, cummin, cala-mint, hartshorn, theriac of salmis, and theriac of vipers. Asa part of the hygienic plan of regimen, he prescribes gestation,vociferation, friction, and gymnastic exercises, particularlyleaping. The body is then to be anointed with the fat of someanimal, as of the bo, wolf, goat, or bird, or with butter.After inunction, the patient should betake himself to the bath,and be well rubbed with some stimulating juice or spirit, suchas fsenugreek, or gum ammoniac dissolved in vinegar; and,after the bath, he is to be anointed with a solution of gum am-moniac and alum in white wine, or with some gently-stimu-lating and aromatic oil, such as that of myrtle.

Rhazes, the Arabian physician, commences his treatmentwith emetics, and reserves venesection for cases of severity, orof long standing; he combines turbith (convolvulus turpethum)with colocynth for a purgative, and favours excitation of theskin by means of friction and hot baths, and further by thehelp of a liniment composed of onions and fennel, or of alotion of strong acetic acid, in which madder-root has been forsome time digested. If the powers of the constitution be re-duced by the treatment, he recommends the use of good whitewine.Amongst modem authors, Schilling, who had considerable

opportunities of experience in the treatment of elephantiasis,advocates a modified method applicable to the different periodsof the disease. He commences by enjoining a moderate andunstimulating diet, consisting of bread, broth and vegetables,and abstinence from milk. He prescribes laxatives, carefullyavoiding mercurials, and if there be signs of plethora, he admi-nisters purgatives, and takes blood from the arm. Exercise heconsiders important, as a means of promoting perspiration, and

rousing the patient from the state of apathy into which he is

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liable to fall; and he further acts upon the skin by means of copper, and seems to have given rise to a succession of painfuldiluents and hot baths, recommending the latter to be used symptoms affecting the abdominal viscera.with care in advanced stages of the complaint, as being apt to The vegetable specifics which have gained a reputation fromoccasion palpitations and faintings. The diluent remedies with time to time are, black hellebore, lauded by Aretaeus ; penny-which he proposes to dilute the humours are emollient and de- royal, praised by Pliny ; the plantain, esteemed by Celsus;mulcent drinks, as barley-water, gruel, decoctions of mallow, the anabasis aphylla, a plant which grows on the shores of theand pellitory, with infusions or decoctions of gently stimulating Caspian Sea, commended by Gmelin and Pallas, but not valuedor alterative herbs, such as agrimony, ground ivy, fumitory, by Martius ; the asclepias gigantea of India, hydrocotyle asia-southern-wood, veronica : and mild aperients, as senna and tica, dulcamara, mezereon, aconite, conium, ledum palus-rhubarb warmed with aniseed. He recommends these drinks tre, &c.to be taken in quantities of eight pints in the day, and con- The animal kingdom has contributed specific remedies fromtinued for six weeks at a time, and he states, as the effect of the class of reptiles, saurian, ophidian, and chelonian, and fromthe treatment, that the secretions of the bowels and kidneys the class of insects, cantharides. The latter remedy has ac-are regulated and brought into a healthy condition. After the quired a false credit, probably from error of diagnosis, someabove preparatory course of six weeks, he recommends the em- form of common lepra having been mistaken for this disease.ployment of stronger alteratives and sudorifics, such as decoc- Drs. Danielssen and Boeck make the same remark with regardtion of saponaria, sarsaparilla, squinanthus, contrayerva, ser- to tar, which has also and with little pretence been admittedpentary, pimpernel, rapuntium, zedoary, sassafras, juniper, among the remedies for elephantiasis.scolopendrium, holy thistle, pariera brava, and drinks of ver- Reverting for a moment to the treatment of this diseasejuice. He maintains a strict diet, and if nausea supervene, he pursued during the middle ages, we find it as at the presentdiminishes the dose of the remedy or suspends it for a while. day, displayed to us under the three aspects which constituteThis, like the former course, he continues for a period of six a rational expectant medicine-namely, hygienic, dietetic, andweeks, and, as the state of the patient or of the disease indi- medicinal. In its hygienic aspect, fresh air, sufficient exercisecates, he bleeds, purges, or adds tonic extracts to the pre- physical and moral, baths for cleanliness and to envigorateceding decoctions, such as fumitory, holy thistle, smaller cen- the skin, are as necessary now as they were then. In a dietetictaury, pimpernel, arum, and wormwood. During the sudorific point of view, a nutritive unstimulating diet is one of the firstcourse, he cautions the patient to avoid cold, lest it check a recommendations at present, as well as in the past; anclnzedi-critical perspiration and induce diarrhoea, and he also suggests ci7zally, diluents, laxatives, and alteratives, are almost mergeda cautious administration of purgatives, adding to those already in the general consideration of diet. Then there remain only,mentioned, namely, senna and rhubarb,-aloes, scammony, and special emergencies, which must be met with special remedies,the aperient salts of potash and soda. He prohibits acids and and the application of those new aids which the light of sciencespirits during the treatment, as calculated to excite febrile has made obvious to us, and those truths which she has taughtaction, but allows a more nutritive diet and a little good wine us in later times. In respect of air, an inland residence lying,if the constitution exhibit signs of exhaustion or debility. high and dry, is more desirable than that of a river, lake, orThe treatment should be pursued for some time after the the sea ; for it is in the latter situations that elephantiasis is .

patients have recovered, and discontinued by degrees. The chiefly found. The plough and the new-turned earth wouldskin should be restored to its proper state of tone by spirituous probably supply the double requisite of the best air and goodwashes and aromatic fumigations; and after his cure, the exercise. In respect of baths, we have no need at the presentpatient should carefully follow the prescribed rules of diet and day to enquire the nature of the fluid of which it should con-exercise. sist. The plain water-bath is as good as that of milk, and

In a case treated successfully by Baumes, there were taken better far than the bath of blood in which the monarch ofthree hundred baths in the course of a year; the chief remedies Egypt was was wont to seethe his leprous limbs. As diet, awere demulcent, diluent, and sudorific drinks, including asses’ judicious blending of the animal and the vegetable seems thatmilk, and the regimen was nutritious and unstimulating. which is best fitted to man in disease as in health ; it is that

Specific remedies, as opposed to the rational expectant which his tastes select; it is that which the naturalist predi-system of treatment above laid down, have gained few sup- cates, from the structure of his teeth and conformation of hisporters and little credit. The mineral specifics that have been stomach, he was born to. We may, therefore, afford a smiletried from time to time are, mercury, antimony, arsenic, iodine, of pity at the contrariety of opinions that exist with regard tozinc, and gold. Drs. Danielssen and Boeck have had little ex- the nature of the diet employed, a contrariety as great as theperience in these remedies, their attention having been chiefly varied tastes of man; one while, the diet should be whollygiven to the physiology and pathology of the disease. Mer- vegetable ; now to consist alone of antiscorbutic plants to theoury, they say, has largely divided the opinions of physicians, exclusion of the cerealia and farinacea, then to be chiefly ofbecause their diagnosis was inaccurate; and, according to those the latter class; another while it should be milk, then, nowho are known to have had experience of the disease, both milk ; now, no fat, although the cod-liver oil is a remedy ofthat mineral and its compounds have been found to be not acknowledged excellence ; then asses’ flesh, and so on, untilmerely useless, but also injurious. The chloride and bichloride the mind is bewildered. But from this very contrariety, we

- of mercury have generally given rise to vomiting and diarrhoea, are warranted in drawing the conclusion, that a simple,.difficult to check, or failing this, have produced dyscrasis of moderate, and unstimulating diet is not only judicious butthe blood, a spongy and bleeding state of the gums, and a necessary.scorbutic state of the surface membranes. Antimony, the Amongst the specific remedies advocated in the treatment ofprimum mobile of Paracelsus, had great weight with the older elephantiasis, is one that I would fain have omitted all refer-physicians, in the fourfold capacity of purgative, sudorific, ence to, and I only mention now, to condemn, namely, ca8tm-diuretic, and alterative; but it is of little, if any, value in tion. Under the impression that the stimulus given to theelephantiasis. The preparations of iodine Drs. Danielssen and blood by the generative system was an excitant of the disease,Boeck found to produce a burning sensation with pain and patients have relieved themselves of these glandular organs,swelling of the skin in tubercular elephantiasis, when given in but without any benefit whatever; and the combined opinionordinary doses; but no such inconvenience when the iodide of of all modern authors is opposed to this barbarous practice.potassium, in doses of a grain or a grain and a half, was ad- (To ye continued,)ministered. In the latter case, a slight decrease of the tumours - .

—

was observed after a long period of continuance of the remedy, RAMSGATE CouNTY CouBT : SNOWDEN AND ZVEBSTERbut the improvement did not last. In the ansesthetio form, v. BoWLING.-This was a claim for ae8 12s. for medicines sup-the iodide of potassium relieved the pains in the bones which plied to defendant’s family, a portion of which was admitted;accompany this form of the disease; and the same effect re- the items objected to being for vaccinating children, andsulted from the use of the bromide of potassium. Of the pre- attendance upon and medicines for the late Mrs. Bowling.parations of gold these gentlemen had no experience; they The defence was, that the vaccinations had not been at themade trial of the chloride of zinc without benefit, and Donovan’s order of the defendant, and that the treatment of Mrs.solution was administered to seven patients, in increasing Bowling, when ill of typhus fever, was improper, leechesdoses, and for a long period, without utility. Four of these being applied when the patient’s strength was already toopatients suffered under the tubercular, and three under the much exhausted to endure them. Mr. Charles Tunnaly, ofanaesthetic, form of the disease. Of arsenic they speak in London, surgeon, was called to sustain the defence, but as heterms of equal discouragement, and in a manner to suggest the was of opinion that the deceased was properly treated, and asdoubt as to whether it could have been properly and carefully the plaintiff positively swore that the vaccinations had beenused to produce the effects which they mention. One pre- performed by the order of Mrs. Bowling, the jury gave aparation which they enumerate is new to me-the arseniate of verdict for the Diaintins for the amount claimed.