(1) In the tubercular form, after a prodromal period of indefinite duration during which there is
a gradual loss of power and vivacity, obscure pains in the limbs and joints, feveri.->h attacks and loss of appetite, the first definite signs to appear are symmetrical discoloured blotches, especiallj- over the back. These blotches are at the first most marked during feverish attacks. Soon afterwards, definite tubercles, at first i)ink but later brownish, arise ; the skin in these places is thickened and found to be infiltrated. The tubercles have a special tendency to form on the folds of the cheek, the nose, the lips, and the forehead. At this time some amount of ulceration about the soft palate often assists the diagnosis. The nodules enlarge and from time to time ulcerate and become en- crusted with discharge. In cases where the face is particularly attacked the expression is entireh' altered, and a most characteristic 'lion-like' or 'satp'-like' expression is developed. The leonfi- asis of Aretreus and the satyrias (= satyriasis) of Aristotle (dc Gen. Animal, iv. iii. 22) are both supposed on these grounds to have been true leprosy. As a rule the eyebrows fall out, and the eyes, in addition to suffering from keratitis, be- come staring in ajjpearance through scarring about the eyelids. The voice is often hoarse, and the breathing loud and wheezing through ulcera- tion of the vocal chords. The hands and feet, sometimes the first to suffer, always in time become ulcerated, though the most severe changes in them are probably secondary to nerve lesions. The disease from first to last has an average duration of nine years ; if it runs its full course and is not terminated, as is usual, by the onset of tubercu- losis, it leads to gradual mental decaj-, coma, and death.
(2) The anccsthetic variety, if not complicated, is not nearly so horrible nor so fatal. Here the incidence of the disease falls on the nerve trunks, which may quite early in the disease be felt thickened from infiammation due to bacterial in- fection. The prodromal symptoms are similar to those described, but the onset of the disease is often not remarked until the patient finds that certain parts of the body are without sensation. Thus it is narrated ot Father Damien that, although he had vague symptoms which made him suspicious, he was not convinced that he was a leper until he found he had placed his feet in scalding water without feeling the heat. As the disease progresses, the nerve lesions cause various discoloured patches and blisters on the skin, wasting of muscles and contraction of the tendons, a peculiar claw-like appearance of the hands, — the result of partial paralysis,- — disfigurement of the nails, deep chronic ulceration of the foot, and finally progressive loss of various fingers and toes, and even of the feet and occasionally of the hands. Many of these later changes also occur in the tubercular form as the nerves become affected. An anaesthetic case which keejjs to this type may last 20, 30, or even more years, and some such cases become 'cured,' that is, the disease actually ceases to progress, though the results of its work can never be remedied.
(3) In Palestine, as has been already suggested, the great majority of cases are of the mixed form ; cases of pure ana?sthetic type are exceptional.
Leprosy in modern Palestine is not a common disease, but is prominently to the front from three causes : firstly, because of the interest excited in Christians of all Churches, and the special appeal made to their charitable feelings from the tradi- tional view that these sufferers are the veritable lepers of the OT and NT ; secondly, because its results are so manifest and repulsive, and its pro- gress so slow, that a comparatively small number of cases are very much in eWdence ; and, lastly, because practically all the lepers in the land are
26
LEPROSY
LETTERS
segregated together by order of the Government in a few chief towns, all resorted to by travellers. There the lepers, being unable to work for a living, sit in groups in prominent places, and endeavour by an exhibition of the miseries of their condition to touch tiie sympathy of the passer-ljy. In .leru- salem, at any rate, thej' collect in this way large sums for their community. They live in iuits pro- vided by tiie Government at Sihvan (near Jeru- salem), Ramleh, and Nablus. At Damascus also tiiere is a community, some members of which are also drawn from Palestine, but the majority from SjTia and around Damascus ; tiie traditional ' House of Naamau ' is their home. In addition to these, there is the voluntary community — now number- ing nearly 60 — at the excellent Moravian Hospital in Jerusalem ; tiie patients there are not allowed to go begging, and are employed in various ways on the premises. Including these last, there must be between 100 and 120 lepers in Jerusalem, some 25 at Ramleh, about 40 at Nablus ; altogether, allowing for some Palestine lepers in the Damascus community, there are not more than 200 known victims of this disease in the country. It is quite possible tliat sometimes cases may be hidden away, as with the Jewish cases above mentioned, by their relatives ; but this cannot often happen in the villages, as the village sheikhs are very prompt in detecting early signs of tlie di.sease, and a sus- pected case is soon expelled from tlie community. Sometimes the heads of the village make mistakes ; cases of this sort have come to the medical officer of the Leper Hospital in Jerusalem, and tiieir friends learning that they have been mistaken, they liave been restored to their rights.