Chapter IV: Part II: The Nosological Nature of the Disease (2)

An accurate drawing of the morbid appearances presented by Berns’ face was made at the time by Mr. Syme, now Professor of Drawing in the Dollar Academy. A copy of this drawing, with a history of the patient’s ailments, was forwarded to the late Dr. Willan; and I have Dr. Thomson’s authority for stating that Dr. Willan at once declared it also as his opinion, that Berns’ case was a genuine instance of the tuberculous leprosy or _Elephantiasis Græcorum_; a disease of which, as he informed Dr. Thomson, he had only seen one example in a patient shown him by Dr. Baillie.

Let us for a moment recapitulate the preceding evidence, with regard to the nosological nature of the English and Scottish leprosy:—_First_, various authors who personally witnessed the leprosy of the middle ages upon the Continent of Europe, in describing it, have described a disease having all the most characteristic symptoms of Greek elephantiasis. _Secondly_, in England a cutaneous disease prevailed at the same period, bearing the same name,—presenting the same chronic incurable character,—having its victims subjected to the same civil laws and restrictions,—marked (as we know from Gilbert, Gaddesden, and Glanville’s observations and writings) by the same train of nosological symptoms—and hence identical in nature with the continental disease and with the elephantiasis of the Greeks. _Thirdly_, in Scotland we find a malady having the same similarity in its general date,—in its name,—in its course,—and in the civil regulations enforced regarding it, with its symptoms, as they are accidentally described by Henryson in the sixteenth century, identical with those of Greek elephantiasis. _Fourthly_, in a part of the country where the disease has continued to prevail down to a later period, the infected, as described by eye-witnesses in the earlier part of the last century, presented the most unequivocal signs of the affection alluded to. And, _lastly_, we have as high medical evidence as could be adduced in regard to cutaneous affections (the evidence, namely, of Drs. Willan and Thomson), for asserting that the malady was seen in the members of a Shetland family in which it had been hereditarily transmitted,—and hence, in one of the last, if not the very last Scotch leper, was decidedly marked by the true and genuine characteristics of the _Elephantiasis Græcorum_.

LEPROSY IN THE NORTHERN COUNTRIES LYING NEAREST TO SHETLAND.

On a former occasion I alluded to the existence of true tubercular leprosy in the neighbouring Faroe Isles, in Iceland, and the nearest coast of Norway, as corroborative of the disease which has long existed in the Shetlands being of the same nosological nature. I might now, if additional proof were necessary, reverse the order of the evidence which I have just brought forward, and proceed to show at length that the disease which long existed, and still does remain, in Bergen and Iceland, and for which leper hospitals also are still maintained in these localities, is, in reality, the tubercular leprosy or Greek elephantiasis; and, from this point, argue back, that the disease which formerly prevailed in Shetland,—and, if in Shetland, in Scotland generally,—was of the same nosological nature. On this head, however, I shall content myself with offering a very few observations in proof of the specific character of the malady in the districts lying most contiguous to Shetland, and leave without further comment the inference deducible from such evidence.

_In the Faroe Isles._—These islands form the nearest land north of the Shetlands. The great cutaneous disease which formerly infected the inhabitants of Faroe had all the characters of tubercular leprosy. In proof of this, I may appeal to the description of the malady, given in the seventeenth century by Debes, who was Provost of the churches in these islands, and wrote an account, which was much esteemed at the time, of the country and its inhabitants. He observes, “As for the Leprosye itself, I would not omit, for the reader’s sake, to mention something of its nature. Physicians write that there are three sorts of Leprosies; namely, Tyria, from the serpent Tyrus. In this leprosy, the patient’s skin is soft, and sometimes falleth off in shells, and they have many spots and white wartes thereon. The second is called Alopecia, by reason the hairs fall off as those of a fox; he that is infected with this leprosy hath a red face, and his beard and eyebrows fall off. The third sort is called Elephantiasis, from the elephant, to whom they become like in their skin; the body and face of him that is infected with this disease is full of knobs. The Leprosie wherewith they are troubled in this country is usually Elephantiasis, for the face and limbs of almost all the infected are full of blue knobs, that break out sometimes as boyls, whereby they look very deformed in the face, being besides all hoarse, and speaking through their noses.”[204]

_Iceland._—That the leprosy of Iceland (the next land north of the Faroe Isles) is of the nature of the _Elephantiasis Græcorum_, is a point which might be proved by any of the descriptions of it by Petersen, Troil, Henderson, and Holland. Dr. Holland’s account is more concise than the others. He states—

“The leprosy of the Icelanders (_Likthra_, _Holdsveike_, or _Spitelska_), exhibits in many instances all the essential characters of the genuine elephantiasis or _Lepra Arabum_; and is a disease of the most formidable and distressing kind. Indolent tumours of the face and limbs are, generally, among the first symptoms of the complaint, attended by swellings of the salivary, inguinal, and axillary glands. The nostrils, ears, and lips are progressively affected with swelling deformity. The skin over the whole, or different parts of the body, becomes thick and hard; sometimes exhibiting a shining or unctuous surface, sometimes one rough and scabrous, which at a more advanced period of the disease displays numerous cracks or fissures. The senses are usually much enfeebled; and anæsthesia of the extremities generally occurs. The voice assumes a peculiar hoarseness and nasal tone, frequently with swelling of the tonsils, but without any hindrance of deglutition until the disease has made great progress in the habits of the patient: the breath and perspired matter are extremely fetid; and the hairs and nails frequently fall off. The tumours in different parts of the body gradually pass into malignant ulcers, which discharge an acrid unhealthy matter; in this state the patient often lingers during a long time; or where the disease has a more speedy termination, all the symptoms are rapidly aggravated, and he is carried off in a state of extreme debility and wretchedness.”[205]

The lepers in Iceland are received into four different hospitals, which have been long established for that purpose.[206]

_Norway._—Returning again to Shetland as a starting point, we find that the part of the continent of Europe which lies nearest to Shetland, and that in nearly a direct line westward, is the district of Bergen in Norway. The distance between Shetland and the seaport of Bergen does not exceed thirty geographical degrees. In the first part of the present essay I offered some reasons for believing that the spedalskhed prevalent in Bergen was a disease different, on the one hand, from the radesyge of other parts of Norway, and probably identical on the other hand with the Greek elephantiasis or tubercular leprosy.

The descriptions of those authors who had observed the disease at Bergen seemed to justify this view. In 1751 Pontoppidan, the Bishop of Bergen, cites the account and words which we have above quoted from Debes in reference to the Faroe Isles, as exactly applying to the disease in the district of Bergen. When it at last (he states) breaks out in ugly boils on the face, they are generally sent to hospitals erected for that purpose, of which there is one at Bergen and another at Molde in Romsdalen.[207] The excellent account of the disease in the Bergen hospital, which was drawn up a few years ago by the preacher Wellhaven, shows the malady to correspond in every important particular with the Greek elephantiasis;[208] and the long and more strictly medical description of the Bergen disease given in 1786 by Buchner,[209] appeared to be altogether confirmatory of the same opinion. I have lately become acquainted with a proof to the same effect, of such a strong character as to render it supererogatory to adduce the detailed descriptions of Buchner or Wellhaven in evidence. The Norwegian Government has recently (and with an anxiety towards the promotion of medical science that reflects little honour on the other richer courts of Europe) commissioned some of its more distinguished physicians to institute a complete inquiry into the nature of the endemic cutaneous diseases both of Norway and of other localities. Since the former part of the present paper was printed, Dr. Fäye of Christiania has, as one of these commissioners, visited this country with the purpose of examining into the nature of the Scottish sibbens, etc.; and I have learned from him with pleasure that the physician sent to Bergen to examine the spedalskhed, is prepared, after a careful study of the disease there, to report it as tubercular leprosy, and hence a species of malady perfectly distinct from the more general Scandinavian radesyge.

The date of the first appearance of leprosy in the Faroe Isles and in Iceland seems to remain undetermined.[210] In both localities it appears to have prevailed severely in the fifteenth and sixteenth centuries.[211] In all probability, however, it was introduced long previous to these dates. At all events, it appeared much earlier in Bergen, for, as I have already stated in the first part, one of the leper hospitals in that city was founded as early as the year 1268.

There is no evidence, as far as I know, of the period of its first appearance in Shetland. It had reached, however, as far as the north of Scotland early in the thirteenth century; for, as we have already shown, the leper hospital of Elgin was in existence in the year 1226,[212] or more than forty years, at least, previously to the institution of similar receptacles for the diseased in Bergen.

ERRORS IN ADJUDGING INDIVIDUALS TO THE LEPER HOSPITALS—CAUTIONS INCULCATED BY THE MEDICAL AUTHORITIES.

While arguing, as I have done in the preceding paragraphs, to show that the epidemic leprosy for which so many lazar-houses were formerly founded in Europe and in Great Britain was the Greek elephantiasis, I by no means wish to insist that patients affected with that disease alone were admitted into these receptacles. There is only too great probability for the belief that persons who had the misfortune to be affected with any foul and inveterate cutaneous malady were isolated and shut up along with those actually labouring under true leprosy. After syphilis appeared, towards the commencement of the sixteenth century, with some analogous symptoms, and when the elephantiasis itself was already disappearing from most localities, we know for certain that a large proportion of the inmates of the continental lazar-houses consisted of cases of secondary venereal and other severe skin-affections. Dr. Bateman[213] adduces the strongest possible evidence in proof of this from the direct and personal observations made in the sixteenth and seventeenth centuries in the leper hospital at Ulm by Horst, at Alcmaer by Forrestus, and by Reedlin at Vienna. Similar errors were in all probability only too common even when the elephantiasis was more common and better known, and mistakes in the selection of the proper inmates of the hospitals would constantly occur in these times, from the kind of persons to whom the responsible and important task of selecting the infected was entrusted. The Act that we have already quoted of the Perth Parliament “anent lipper-folk” defines those who were charged in Scotland with the duty of searching out the affected. In the third clause it is statute “That the Bishoppes, Officialles and Deanes, inquyre diligentlie in their visitation of ilk (each) Paroch Kirk, gif ony be smitted (affected) with Lipper, and gif ony sik (such) be foundin, that they be delivered to the king gif they be Seculares, and gif they be Clerkes, to their Bishoppes, and that the Burgesses gar (oblige them to) keepe this statute under the paine conteined in the statute of Beggers [namely, gif they have broken it (the statute of beggars) they sall be in fourtie shillings to the King]; and quhat leprous that keepis not this statute, that he be banished for ever off that Burgh, quhair he disobeyis, and in likewise to Landwart.”[214]

In extenuation of the above edict, we must recollect that, at the period at which it was enacted (in 1427), the ecclesiastics to whom in this country it entrusted the selection of lepers were in reality the only existing physicians of the general community, and some of them seem to have devoted themselves as much to the practice of medicine as to the study of theology. But, even to a strictly non-medical observer, the diagnosis would, in the latter stages, be less free from doubt than might be at first supposed. For when once the tubercular leprosy became in any case completely developed in all its distinctive deformity, and with its full concourse of marked and peculiar external characters, as falling off of the hairs of the eyebrows, swelling and thickening of these parts, tubercles of the face, hoarseness of the voice, etc., there were few or no diseases for which it could be readily mistaken, provided any proper degree of care was observed. In the earlier stages and less marked cases of the disease, errors in the adjudgment of cases, in all probability, often occurred, and affections that had no relation to elephantiasis, except in their obstinacy and locality, were, we cannot doubt, frequently mistaken for true instances of tubercular leprosy.

Such errors, it has been often averred, would be almost as apt to happen in the hands of the truly medical, as of the non-medical examiners, in consequence of the knowledge and distinction of cutaneous diseases being exceedingly imperfect at these early periods of medical history. And it is certainly true that, in the writings of the older Arabian, Continental, and English physicians, we find almost all the different species of chronic cutaneous disease mixed up and described together under a few general heads and designations, as Lentigo, Impetigo, Morphea, Albaras, Gutta Rosea, etc. Indeed, the proper discrimination and diagnosis of different cutaneous affections was little known and studied until the end of the last century. At the same time, however, it must be recollected that the tubercular lepra, or Greek elephantiasis, certainly forms a striking exception to this general observation. For, in the medical writings of the thirteenth, fourteenth, and early part of the fifteenth century, the leprosy is almost uniformly described with a care and a minuteness that strangely contrasts with the superficial manner in which the whole remainder of chronic cutaneous diseases are either passed over or confounded together.

I would willingly appeal, in support of this last allegation, to the different chapters on lepra, as compared with those on the other cutaneous diseases, in the works of the Arabian physicians, and of those European medical authors of the middle ages whose writings I have already referred to. Indeed, the accounts and diagnosis of tubercular lepra, as given by Rhazes, Theodoric, Lanfranc, Arnold de Villeneuve, Gilbert, etc., might well stand as models of medical description even at the present day. And if, in France, the strong and earnest injunctions of Bernhard Gordon were in any degree respected, that no person be adjudged as requiring separation for leprosy until the second stage (according to his division of the disease) had supervened, and the _signa infallibilia_ of the malady had already shown themselves in the usual marks traceable in the _corruptio figurae et formae_ of the suspected individual, cases of unjust condemnation to the lazar-houses would be much less common than might be otherwise imagined. We have already seen that in England, in the fourteenth century, John of Gaddesden inculcated the same salutary rules and precautions, and insisted that no one be separated from the general community as a leper, unless already “_figura et forma faciei corrumpantur_.”

Certainly, on some occasions, the examination to which the patient was subjected, in order to ascertain if he were truly a leper or not, seems to have been of the most searching and scrutinising nature. I have already alluded to the strict rules of examination that have been preserved for us in the works of different authors, and quoted the method recommended by Guy de Chauliac to be followed by physicians before they remitted suspected patients with medical certificates to the magistrates (_cum literis medicorum ad rectores_). In the _Examen Leprosorum_, published by Gesner, and which appears to have been drawn up as an official formula, if I may so term it, for examining into suspected cases, the details are most elaborate and searching. There are between fifty and sixty signs of the disease which the examiner is requested to look for. Twelve of these signs are taken from the general state of the body; seven or eight of them from the hands and feet; six from the blood; five from the face; six from the mouth; eight from the eyes and eyebrows, etc. etc. The document commences by stating, “that it is the duty of the physician to be versed in, and attentive to, the signs of the disease, and to ponder often (_revolvere multoties_) upon them. He should put his trust (it adds) not in one sign, but in many, and he should see what signs are proper (_propria_) to the leprosy, and what are equivocal.” Before making the examination, the document states that (as is also recommended by Guy de Chauliac[215] and others), the physician should, in the first instance, give some words of encouragement and consolation to the patient, and show that this disease is the salvation of his soul, and that Christ has not despised such, although the world may shun them (_quod haec aegritudo salus est animae, et tales Christus non despexit, licet mundus eos fugiat_). Further, in order to have more certainty in the examination, it is added that the patient should be made, in the first place, to take oath to tell the truth on those points on which he is interrogated. We have already found De Chauliac recommending the examining physician to take the same precaution, “faciat eos _jurare_ veritatem dicere de interrogendis” (p. 310).

A decree, issued in the year 1314, by Milo, Bishop of Orleans, shows that it was occasionally necessary to guard the examinators against being imposed on in other more serious ways, than by direct prevarications or misstatements on the part of the suspected individuals who are subjected to their scrutiny. “Whereas it happens that in the examination of lepers mistakes as to identity, and deceptions, are caused by the interposition of other persons, we enact and command that whenever any person is suspected of the infection of leprosy, he be sent at his own charge if he have effects, but if not, that two responsible men of the parish having been sworn (_jurati_) before the priest and the officers of the church (_gajariis ecclesiae_), be sent at the expense of the parish with the suspected person to obtain the examination; they shall conduct the said suspected person to the said examination, and cause him to be faithfully examined, and bring certificates to us, that it may not be possible that, for the future, collusion should take place in the aforesaid matters.”[216]

I have not hitherto been able to find any evidence showing to whom the examination and seclusion of lepers was, in olden times, entrusted in England; or to trace out in that kingdom any special laws relative to this subject. There exist, however, upon record, in reference to one English case in the fifteenth century, some details that are particularly interesting in regard to the present point of our inquiry. The details in question have been preserved in Rymer’s _Fœdera_. The case to which they refer appears to have been brought under the cognisance of the Crown by the neighbours of the suspected female, in consequence of her being alleged to be affected with leprosy, and yet refusing to seclude herself, as was the usual custom, from intercourse with society in consequence of it. The reigning monarch, Edward IV., issued, in 1468, a Chancery warrant for the proper medical examination of this supposed case of the disease. The royal warrant, and the medical certificate which it called forth, have both been preserved by Rymer. I append a translation of these curious documents, as illustrative both of the general dread then still entertained of the malady, and of the minute care which, in this country, was occasionally taken, in order that a just and accurate judgment might be arrived at in cases of doubt and difficulty. The documents are entered by Rymer under the title of “Medicorum Regis, super morbo Lepræ, Certificatio.” They proceed as follows:—

“To the most Excellent and most Serene Prince and Lord in Christ, Edward, by the Grace of God, King of England and France, and Lord of Ireland, We, William Hatteclyff, Roger Marshall, and Dominus de Serego, Doctors of Arts and Medicine, your physicians, and sworn to watch over the health of your Person, send due Reverence with humility and worship:—

“Whereas a Petition was made to You in Your Court of Chancery, with regard to removing _Johanna Nightingale_, of Brentwoode, in the County of Essex, from general intercourse with mankind (_a communi hominum consortio_), because it was presumed by some of her neighbours that she was infected by the foul contact of Leprosy, and was, in fact, herself a Leper: Upon which Your writ was then prepared, and afterwards directed to the Sheriff of the said county, in these words:—

“Edward, by the Grace of God, King of England and France, and Lord of Ireland, to the Sheriff of Essex, Greeting: Whereas We have heard that _Johanna Nightingale_ is a leper, and is commonly holding intercourse with the people of the aforesaid county, and mixes with them both in public and private places, and refuses to retire to a solitary place, as is customary and befitting her (_et se ad locum solitarium, prout moris est, et ad ipsam pertineret, transferre recusat_), to the grievous injury and, on account of the contagion of the aforesaid disease, the manifest perils of the aforesaid inhabitants: We, willing to guard against such dangers, as far as in us lies, and as is just and customary in such cases, Do charge You, that having taken with You certain discreet and loyal men of the county of the aforesaid _Johanna_, in order to obtain a better knowledge of this disease, You go to the aforesaid _Johanna_, and cause her to be diligently viewed and examined in the presence of the aforesaid men. And if You find her to be leprous, as was reported of her, then that You cause her to be removed, in as decent a manner as possible, from all intercourse with other persons, and have her betake herself immediately (_indilatè_) to a secluded place, as is the custom, lest by common intercourse of this kind injury or danger should in any wise happen to the aforesaid inhabitants. Witness my hand, at Westminster, this day of July, in the eighth year of Our reign.”

“Wherefore The Reverend Father in God, Robert, by the Grace of God, Lord Bishop of Bath and Wells, Your Chancellor of England, consulted us on this subject, and determined to bring the same Johanna to us, with the intention that, according to what we have learned from our knowledge of Medicine, we should give information to Your Highness in Your Chancery, whether the said Johanna be in fact a Leper or not. We, therefore, wishing to obey Your Highness, in order that the truth on this subject might be made most plain and clear, have proceeded after this manner. First, we examined her person, and as the older and most learned medical authors have directed in these cases, we touched and handled her (_ipsam tradavimus et palpavimus_), and made mature, diligent, and proper investigation, whether the symptoms, indicative of this disease, were in her or not; and after an examination and consideration of each of the points, which appeared necessary to be examined and considered, in order to arrive at a true knowledge of this doubtful matter, We found that the woman neither had been nor was a Leper, nor ought, on that account, to be separated from ordinary intercourse with mankind.

“We are taught by Medical Science that the disease of Leprosy is known by many signs, also that each species of the disease, of which there are four, viz. Alopecia, Tiria, Leonina, and Elephantia, should be known and characterised by particular signs, and each should be specifically distinguished from the rest. Therefore, in the case of the woman brought before us, on going through upwards of twenty-five of the more marked (_famosiora_) signs of general leprosy (_Leprae in communi_), we do not find that she can be proved to be leprous, by them or a sufficient number of them. And this would suffice, generally, to free her from the suspicion of leprosy, since it is not possible for any to labour under the disease, in whom the greater part of these signs are not found. But, in order to give our opinion on the individual species, going through upwards of forty distinctive signs of the different varieties of leprosy, we do not find that this woman is to be marked as suffering under any of the four kinds, but is utterly free and untainted, as we have signified by word of mouth to Your Highness in Your said Chancery, and we are prepared to declare the same more fully to Your Highness by scientific process (_per processum scientificum_), if, and wherever, it shall be necessary.

“In testimony whereof, we, the said William Hatticlyff, Roger Marshall, and Dominus de Serego, have signed our name with our proper hands, and alternately affixed our seals.”

To the preceding document, which is one of the earliest, if not the very earliest, English medical certificate which either historical or medical records have preserved, it is added in the form of a note, “Et memorandum quod praedicti Willielmus Hatteclyff, Rogerus Marchall, et Dominus de Serego venerunt in Cancellarium apud Westmonasterium, septimo die Novembris, anno praesenti (1468), et recognoverunt scriptum praedictum, et omnia contenta in eodem, forma praedicta.”[217]