Part 9

But what would follow supposing traces _were_ actually to be found proving that what was known in Asia as leprosy did as a matter of fact first show itself in the genitals? Before we enter upon the closer examination of reasons for this supposition, we must quote a passage from the Work of _Von Roeser_ already several times mentioned, a passage equally important for the pathology of Venereal disease as for its History. _Von Roeser_, (p. 68.) writes thus: “Primary syphilis manifests itself _in Egypt in the very rarest cases on the prepuce or glans of the verge_; the chancres are more commonly found on the outer skin of the penis nearer the _mons Veneris_, or actually on this in the hairy parts which among Egyptians and Arabs are generally kept shaved, _or else on the scrotum_. _Pruner_[181] told me that the occurrence of a chancre on the prepuce, which indeed is absent in Mohammedans owing to circumcision, or on the _glans penis_ is in the ratio of 1: 3 to chancres on the last mentioned parts, hence in that country Astruc’s opinion that syphilitic ulcers hardly ever formed on the exterior of the verge, is strongly contradicted,—as is no less true amongst ourselves. That circumcision is not the sole cause of this phænomenon is manifest from the fact that in Smyrna and Constantinople I saw plenty of chancres on the _glans_, as well as amongst Jews at home, though I am not going to deny that circumcision may have some share in causing the rarity of the appearance of a chancre on the _glans_,—but this does not in any way explain the frequency of their appearance on the scrotum and the _mons Veneris_. A tendency to take the exanthematic type, a tendency which makes itself known also by the fact of _many chancres_ commonly appearing at once and _showing in a marked degree a preference for scurfy and scabby forms_, might very possibly afford a better explanation of the phænomenon in question.”

Now as to the supposition just expressed, this is based on a repeated examination of a passage of the very utmost importance in the history of leprosy, viz. Ch. XIII. of Leviticus—a chapter which has exercised Theologians no less than Physicians for Centuries, but without our being enabled to regard the investigations it has given rise to as in any way concluded. However it is no intention of ours to provide in this place a commentary on this Chapter, more particularly as we do not possess the philological acquirements necessary for a critical appreciation of the results so far obtained. Neither, speaking in general terms, has anything like sufficient progress in the study of original sources for the history of leprosy as yet been made to enable an adequate judgement to be formed; we much prefer to limit our efforts at present to contributing sundry observations, which stand in close connection with our immediate object, and at the same time may afford readers, whether scientific or philological authorities, an opportunity of favouring us with their judgement as specialists.

The correct understanding of the whole passage appears to us to depend in the first place on the success of the endeavour to find a certain and definite explanation of the expression בְּעוֹר בְּשָׂרוֹ (b’ôr b’sarô,—“skin of the flesh” in English Authorized Version). Luther rendered this by: _on the skin of his flesh_; the Septuagint translators give it as ἐν δέρματι χρωτὸς αὐτοῦ (in the skin of the surface); while _de Wette_ (whose Translation of the passage generally we hereby ask the reader to consult, space not allowing us to quote the whole Chapter) translates it _on the skin of his body_, and understands by the expression every part of the external skin.

Supposing this translation the correct one, it will be a hard matter to explain how it was the hair should simultaneously have turned _white_, a circumstance which strangely enough caused even Hensler no surprise. Rosenmüller in his Scholia on the passage says: _Schilling_ (_De lepra p. 7._) observat, in lepra alba pilos albescere_, (_Schilling_, On Leprosy p. 7. notes that in white leprosy the hair grows white); but it is only the _partes pilosae aut capillatae_ (hairy parts, parts covered with long hair) that are here intended, and these are to be understood as including merely the head, eye-brows, chin, armpits and pubic region. Obviously the hair on other parts of the body cannot be taken here into consideration, as it is specifically almost colourless, and though it is true it may have had a stronger coloration in many Jews, surely they did not _all_ belong to the race of Esau. Again all writers on leprosy, when this mischief affecting the hair is in question, speak solely of the hair of the parts named[182]. So when _Haly Abbas_ in a passage quoted by Hensler (_Excerpta_ p. 9.), in which he is treating of _Allopitia_ and _Tyria_ (forms of leprosy), says, _Nonnunquam totius accidit pilis corporis_ (Sometimes this happens to all the hair of the body), this also is to be understood merely of the parts above named. Indeed _Hensler_ himself (Vom Aussatz,—On Leprosy, p. 304.) assumes this when, after speaking of the hair of the head and beard, he goes on: “But this mischief may also attack other hairy parts of the body. _Haly Abbas_ says, (_Excerpta_ p. 9.) At times this affects also the hair of the whole body. True the passage of _Hippocrates_, in view of the erroneous punctuation, seems to belong more properly to what follows, still even by itself it would be probable enough, as _the preliminary symptoms are found particularly in the arm-pit and the groin_, and might of course extend their ravages there, just as much as on the head.” However should anyone wish to understand here _all_ the hairy parts of the body mentioned, and suppose the Author to be speaking in the first instance in a general sense, then what follows will not agree, for the hair of the head and beard was _not_ changed into _white_, but into _yellow_ (צָהֹב), as V. 30 states. There are left therefore only the eye-brows, arm-pits and the pubic region, to which the transformation to white can apply.

Granting these considerations to be correct, it is impossible to understand the _b’ôr b’sarô_ as signifying the whole exterior surface of the skin; it must imply a local limitation. But the limited area intended can be nothing but _the genitals_, and this agrees best at once with the facts and with the usages of Biblical phraseology. In more than one passage, in fact, of the Old Testament _basar_, like σάρξ (flesh) in the New, has the meaning of “sexual parts”; and even in English the word _flesh_, particularly in ecclesiastical language, is consecrated by custom in this sense. So Luther was perfectly justified in the passage under discussion in translating as he did: _on the skin of his flesh_, that is to say, of his genitals. The particular combination of _b’ôr b’sarô_ we have not it is true been able to find used generally in the books of the Old Testament, but we must not therefore conclude absolutely that it is unique and peculiar to this XIIIth. Chapter; though indeed, if such _were_ the case, it would merely be an additional confirmation of the explanation we have given.

So far as the matter of fact goes, such an assumption offers no difficulties,—indeed it actually removes several, as e. g. that connected with the coloration of the skin, and not only proves that already at that date pustules on the genitals had been observed that were free from any suspicion of malignant character, but further that along with a suspicious pustule or similar symptom (scurf, ulcer) there went a simultaneous general affection of the skin as a whole, which was held to be diagnostic for the local malady, and accordingly proclaimed even the suspected leper free from taint after his recovery from it. For evidently we must take verses 12 and 13 as indicating this, where it is stated in so many words: “And if the leprosy break out (פָּרַח, —blossom) abroad in the skin, and the leprosy cover all the skin of him that hath the plague from his head even to his feet, as far as appeareth to the priest; then the priest shall look: and behold, if the leprosy have covered all his flesh, he shall pronounce him clean that hath the plague; it is all turned white: he is clean.” (English Revised Version). The last words have been wrongly referred by some Interpreters to the “Bohak” (bright spot), which is mentioned in verse 39., but really nothing more than this is intended:—after the eruption is dried up, and the skin has returned to its natural white colour, then the hitherto sick man is to be declared clean[183].

This diagnostic eruption again points to another fact, viz. that the leprosy must have had its seat in a part of the body, the cutaneous glands of which stand in a relation of lively sympathy with those of the skin generally, and this according to modern experience can only be the cutaneous glands of the genital organs. Sometimes inoculation with cow-pox lymph brings out a general eruption of the whole skin, but this circumstance cannot well be made pertinent here, as really and truly the lymph is a resultant product of a feverish affection, and therefore its innate tendency is towards a reproduction of itself under circumstances of feverish stimulation, and to set the whole organism, and consequently the whole cutaneous glandular system, in a state of enhanced activity. How the diagnostic eruption comes about may be gathered from the statement of the case given just above; while the passage quoted from _von Roeser’s_ Work will explain the rest. Still for the present this much may suffice to put the expert reader in a position to test our conjecture,—for indeed so far it makes no profession to be more than a conjecture. Supposing it found tenable, then the further consequences that cannot but grow from it for the elucidation of the Chapter in discussion may be readily developed. On the other hand, if it is devoid of justification, it would be quite useless further to elaborate a hypothesis, plunging a subject obscure enough without this in even deeper darkness. Further than this we only need to mention that _Hensler_ and others hold _mentagra_ to be indicated in the bald chin and scurfy (scall) chin of Leviticus (XIII. 29 sqq.), which if they are right would merely be another point in favour of our view.

Finally there can hardly be any need for us to observe that we have no idea of holding leprosy in general to be a consequence of excesses; on the contrary we believe, to return to the problem we started with at the beginning of this Section, that we are bound to agree to the opinion first explicitly laid down by _Becket_[184], viz. _that under the widely comprehensive notion of Leprosy were included other forms of skin-diseases owing their existence to some previous affection of the genital organs_,—in precisely the same way as this happened in the Middle Ages, and as may be the case occasionally even at the present day.

§ 31.

What precise influence Climate exerted on the form taken and course run by affections of the genital organs _in Greece and Italy_, can be only approximately laid down, as the information supplied by Physicians, though ample in quantity, mostly leaves the point indefinite as to where the observations were made, whether in Asia Minor and Egypt (Alexandria), or in Greece and Italy. The last named country indeed was, as is well known, almost entirely devoid of independent native medical Writers.

The mild, genial sky of Greece and Italy impressed on all forms of disease, including diseases of the genitals, a mild character. There, on the confines of East and West, we find, it is true, the same natural tendencies prevailing as in Asia, but always on a less exaggerated scale. _Von Roeser_ (loco citato p. 70.) says: “In conclusion we should note further that in Egypt gonorrhœa is a complaint of very rare occurrence, in Greece and Turkey a very common one. That the exanthematic character taken by syphilis is not(?) responsible for the fact of its not manifesting itself as gonorrhœa is confirmed by the circumstance that it occurs much more frequently in Greece than amongst ourselves, whereas syphilis in that country has (though not in an identical form) the exanthematic type to an even greater degree than in our own.” _D. Hennen_[185] found Venereal disease rare in Cephalonia, but on the contrary gonorrhœa quite common.

No doubt the tendency to determine towards the skin is clearly noticeable in Greece as well, but not to such an extent as to outweigh the local affection. The latter accordingly takes a more independent form than is the case in Asia, and for this reason, though making its appearance more frequently, neither follows so rapid a course nor shows so destructive a character,—if only the organism is seconded to some extent in the efforts to combat the malady. This is shown by the statements _Galen_ has left as to gonorrhœa and ulcers occurring in connection with bubonic swellings,—a matter we shall have occasion to speak of later. While in Asia the skin affection is manifested by the formation of pustules and scurf, in Greece and neighbouring countries of the South it rather takes the shape of _papillae_ and small blisters or blebs, and only in obstinate cases breaks out in tubercles. Hence _lepra_, _psora_, _lichen_, and _elephantiasis_ are the forms under which we must look for it in the medical Writers of Antiquity, who however say nothing as to the origin of these diseases, or else, as we have seen before, refer them all to deficiency of the moist humours[186].

We have never yet succeeded, though we have before now expended much time on the effort, in getting a clear grasp of the ideas the Ancient physicians intended to express by the different designations they gave to the various skin-diseases. So we are constrained to postpone deeper investigation of the question to a subsequent occasion, or wait to see whether meantime some other enquirer, better equipped for the work, may not throw light on the chaos. Only so far as _Scabies_ (Scab) is concerned, it would seem allowable to assume allusions to be intended to vicious living as a cause of the malady. It cannot be without a reason that for centuries this one above all other skin diseases seems to have fallen under special disrepute; and the term to have been used by poets, by _Martial_[187] for example, to indicate that sensual indulgence had been at work. In fact, several of the earliest Writers on Venereal disease hold it to be a sort of _scabies_, and even at a later period there is for long frequent mention made of _Venereal scars or scabs_. Possibly also in Greece lepra (leprosy) was looked upon as a form of skin-disease that was come by in no reputable way, and commonly regarded as an inheritance of the debauchees[188], just as we saw to be the case with _mentagra_ at Rome.

Affections of the external skin consequent upon complaints of the genital organs being thus no less common in Ancient times than they are to-day, it follows that in inverse proportion forms of ulceration of the palate and nose, as well as complaints affecting the bones, must have fallen into the background and have been of more rare occurrence, just as is observed to be the case in the present day[189]. So, to combine all the varying forms under one generalisation, we may say that this represents a type of disease of an exceedingly mild and favourable character, particularly if attention is directed only to the external symptoms, as indeed was habitually done by the old pathologists. For even the skin-affection itself presents so little that is characteristic, or at any rate shows itself under such varying shapes, that even at the present day its diagnosis is extremely difficult, being very often based solely and entirely on the admission of the patient, whether voluntary or forced from him, of having suffered from gonorrhœa or chancre. But if the so-called secondary symptoms are more or less completely absent, or lack distinctness, what is there then left beyond the primary affections of the genitals and their succedanea? Full and sufficient descriptions of these are not lacking; we have already quoted numerous examples, and we shall find others yet clearer and more precise later on.

Before quitting the subject of the influence exerted by Climate, we are bound to return once more to the question, _in what relation did contagion_, if contagion there was, _stand to this climatic influence?_ The existence of contagion in the case of gonorrhœa is certified by the passage of _Galen_ already quoted by Naumann, which we propose later on to give in full, besides being implied long before by the law of purification of the Mosaic Books. So far as ulcerous formations, condylomata and skin-affections such as _mentagra_ etc., are concerned, proof is supplied by the facts we have previously given. According to more modern experience all forms of contagion exhibit in Southern countries a more fugitive type than elsewhere and spread with proportionately greater readiness. Whereas in such as are naturally fugitive, the intensity may for that very reason be less injurious, fixed and stable forms of contagion on the contrary must obviously lose in strength, at any rate so far as their local effects go. They will be the less able to make good a lodgement in the organism, from the fact that, stimulating the latter as they do to a general activity, they are the more readily resisted and prevented by this very state of enhanced activity. For just as, speaking generally, chronic complaints, uncomplicated by fever, can only be removed by artificially setting up a feverish condition, that is to say by calling on the organism as a whole to share in the local manifestations of disease. Precisely the same is true of local affections set up by any fixed and stable contagion, and so the removal of the actual contagion can only be successfully brought about either by direct decomposition and destruction of the affected tissue or by metamorphosis into a fugitive form.

Now inasmuch as the contagion was rapidly thrown off from the point of first infection upon the cutaneous glands,—and this happened the more readily, the more fugitive its character was,—the affections there set up by it standing in such clear relation as they did with the primary symptoms, were necessarily bound also to exhibit a greater or less degree of the contagious character, as indeed is observed according to _Jos. Frank_, _Biett_ and other authorities even in Europe to the present day. In Greece, where the transformation was less often to pustular and scurfy forms, more frequently merely to papillae or at worst little bladder-like risings, or blebs (Phlyctaenae), while at the same time the energy of the skin was not so pronounced, the interval between the appearance of the primary and secondary symptoms was greater, and the contagiousness of the skin-affections undoubtedly less prominent, it cost the organism in that climate much more strenuous effort to set in action the elimination of the disease by the skin. Consequently the nervous system as well was injuriously affected by sympathy to a greater extent, while the exanthematic forms showed themselves in more obvious conjunction with itch (_psora!_). This was partially the case in Italy too, though here the climate approximated more nearly to that of Lower Egypt, leading to a more frequent appearance of pustulous forms, as shown by the prevalence in that country of _mentagra_.

But just as climatic influence relaxed the intensity of contagion, and diminished concurrently the malignancy of disease-types, local as well as general, so on the contrary, in those cases where other influences tended to counteract its effect, while the organism was not strong enough to overmaster the assaults of the enemy by general or local activity, it sought to guard against the contagion rising to a higher degree of independence; it set up mortification of the ulcers, by which means the contagion itself was directly destroyed. From all this it may be concluded, that although climate must evidently be acknowledged to be an important factor favourable to the rise of affections of the genital organs in Antiquity as much as at the present day, yet on the other hand it tended by its own action to combat the mischief it had originated; and so, at any rate so far as the development of the morbid process is concerned, is to be regarded to an almost equal degree as a counteracting influence at the same time.

§ 32.

The experience of all ages has conclusively proved that a large proportion of such morbid phæenomena as occur in consequence of local climatic conditions are capable equally of being produced sooner or later in countries and neighbourhoods the climate of which is entirely different by help of the _genius epidemicus_; and that the readiness with which they are so produced varies in direct ratio with the degree in which the climate is associated with and seconds the favourable factors. It is indeed extremely difficult, in view of the low level of development to which the science of Epidemics, in general no less than in particular, has as yet attained, to show this as applicable in any given case, more especially if it is a question of the epidemic condition of some disease of which the pathological relations themselves are far from being as yet adequately known. Still this must not prevent us from making at any rate an attempt at investigation of the question, how much or how little effort has been manifested by such influence in the course of years.

But the influence of the genius epidemicus on diseases in general is a twofold one. _Either_ it supplies the capital, most essential external circumstances conditioning the production of a disease, in fact is related to it as cause to effect. In virtue of it the disease is an _epidemic_ disease, coming into existence for the first time concurrently with the development of the genius epidemicus, disappearing again with the cessation of its prevalence, and once again springing up if and when the genius epidemicus makes a second re-appearance. _Or else_ the most essential external conditioning circumstances are specifically independent of the genius epidemicus; while the latter takes merely a remote share in the way of favouring or counteracting the production of the disease, manifesting its influence rather in modifying the form and direction of such morbid reactions as have arisen in the organism without its intervention at all,—in other words _the disease is subject to epidemic influence_.