2007年3月20日 星期二

淺談麻瘋及其後遺症

今天要跟大家談談漢生病和惱人的後遺症….


漢生病,舊稱麻瘋病或癩病,是一種傳染力低但極可怕的疾病,感染後外表起初僅出現一個小瘡,但不久便逐漸潰爛,然後人的鼻梁塌陷、豁嘴、眼瞎、脫髮,變得面目猙獰,手指、腳趾甚至整個手或腳都有可能因傷口二次感染引起內部潰爛而掉下來,肢體變得殘缺不全,所以自古以來,不論是東方還是西方,古代的人們均有把麻風病患者看成鬼怪情事,進而避而遠之,也有人訴諸為是命運、佛祖或上帝對有罪之人的天罰,所以又稱為天刑病。

Leprosy: Modern History 近代漢生病史


1873 - Dr. Armaur Hansen of Norway discovers M. leprae bacilli, indicating for the first time that leprosy was not a curse brought upon people for evil deeds, as it was previously believed.
挪威漢生博士發現痲瘋桿菌,頭一遭這個疾病與惡魔附身說法脫離
1950's - Doctors begin using Dapsone drug to treat leprosy.
醫師開始使用Dapsone(DDS)
1982 - Leprosy develops resistance to Dapsone. World Health Organization (WHO) recommends Multi Drug Therapy of Dapsone, Rifampicin and Clofazimine.
痲瘋桿菌開始對DDS出現抗藥性,WHO建議使用三合一治療




漢生病雖然可怕,但是傳染力極低,即使WHO公佈的傳然途徑仍為不明,推測是由飛沫或接觸感染,但由歷史上可以知道,漢生病的流行常常發生在天災人禍的時候,營養不足或免疫力差環境之下,發生的機會較高。最近一個例子是2007年一月份時候,蘇丹的達富爾地區,因為長年內戰關係,難民營也發生漢生病的流行。所幸,Robert Cochrane醫師使用1908年即發現的DDS1946年第一個有效治療藥物DDS開始投入治療之後,clofazimine等藥物相繼問世,有人斷言,希望漢生病成為下一個被終結的歷史疾病


漢生病本身其實並不可怕,可怕的往往是隨之而來的後遺症,針對症狀可做下列簡單的歸為四類:
1)
皮膚病變 decreased sweating (DS) 無汗, anesthesia 知覺喪失, erythematous/ purple/hypopigmented lesions + ( macule斑疹/papule丘疹/plague斑塊), scaling脫屑, ulcer潰瘍

2) 神經病變 thickened nerve(TN) 神經變粗大, neuralgia 神經痛

3) 四肢徵候 muscle atrophy(MA)肌肉萎縮, sensory neuropathy(SN) 感覺喪失, extriemities palsyFoot drop FD/Wrist drop WD肢體麻痺, limbs deformity (LD)肢體變形, secondary infection (SI)次發性感染

4) 五官徵候:cranial nerve palsy 腦神經麻痺, lagophthalmos兔眼(無法闔眼), Nose collapse(NC) 鼻褟陷uveitis眼球炎, cataract白內障, glaucoma青光眼







舉個例子來說,一個漢生病病友一開始的症狀可能是皮膚病變 (皮膚病變特徵之一是感覺喪失和汗腺消失,所以夏天體內熱氣無法透過毛孔散出去,是很痛苦的一件事),緊接著因為細菌喜歡寄居在溫度較低的神經和皮下生長,所以一些神經病變例如神經變粗大(不一定是淋巴喔)開始出現。



最常見的部位是手臂內側的尺神經,此外,鼻子、耳多和眉毛因為溫度較低而皮下容易寄居。總不能讓細菌在身體裡撒野,免疫大軍開過來是局部組織浩劫的開始。感覺和運動功能喪失加上莫名的神經痛說明了後遺症的原因,感覺喪失包含一般痛覺和溫覺,運動功能喪失來自於神經直接缺損而神經痛則是來自於局部神經因為免疫反應引起發炎物質所造成。因周邊神經病便感覺的喪失導致相當可怕的結果,不自覺的受傷,因為不會痛根本不知道傷口出現,導致已經感染,發炎潰爛,甚至嚴重到要截肢的比比皆是。運動功能喪失長期下來肌肉的萎縮也造成生活不便。因此,和糖尿病周邊神經病變相似的手套襪子症候群也可以見到,Drop foot, drop wrist也不少見。

除了四肢問題外,因周邊神經病變眼睛閉不緊關不好(兔眼),造成接觸性角膜炎,進而角膜潰瘍,失明的也大有人在。難怪樂生院民不少阿伯終日帶著墨鏡。耳朵、鼻子的軟骨因為免疫反應分泌出來的一些發炎因子使的軟骨最終也遭破壞,很多院民的鼻子和耳朵不得不進行重建手術。



漢生病有一個比較鮮為人知的名字,稱為富貴病,為什麼呢 ?因為在沒有特效藥的時代要認真治療漢生病所帶來的後遺症,必須要確保院民生活起居不會弄到傷口,患者均不需勞作,因勞作多多少少必會受傷,患者不可以烹飪,一個不小心的燙傷,可以弄一個月才好,所以,與傷口的疾病和平共楚,除非是大富大貴人家,這樣戰亂時代,不管是哪一所癩療養所,都是很難做到的。






正因為傷口很難治療,所以漢生病有傷口的照護,也考驗一個療養所的能力,無論是硬體上的無障礙空間,與清楚標示危險區域,還有對於院友衛生教育,教導她們如何愛惜自己,避免受傷,例如,有洗屁屁功能的馬桶,可以避免院民因為不知道擦肛門的力道要多大摩擦造成傷口,又接近肛門容易二次感染,還有工作鞋的設計,避免足底受力不平均造成組織壓力性缺血壞死,等等不可輕忽。


雖然這只是些小小改變,但卻可以避免漢生病友後遺症發生,類似周邊神經病變患者照護,也是我們可以更深入探討的。

高醫 尚儒 06.03.20.


18 則留言:

gofyycat 提到...

這篇文章寫得好清楚,瞭解疾病的整個背景,非常有助於認識樂生院的歷史脈絡。

請問可以轉貼這篇文章到我個人的部落格嗎?我會註明出處和原作者名稱。非常感謝。

gofyycat
我的e-mail:gofyycat@gmail.com

尚儒 提到...

沒問題
歡迎轉文
讓更多人認識漢生和樂生

喀飛 提到...

非常感謝!

gofyycat

mars 提到...

尚儒您好
想做一份樂生簡報檔,將您的資料引用如下,如完成會將檔案傳送出去,如有不妥煩請告知。如有建議也非常歡迎提供。http://blog.yam.com/mar543/article/9363103

mars 提到...

補充--
因本身醫學知識不足,整理了一些網路上的資訊,如有錯誤也煩請指教

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回應Mars
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有時間我會就我所知幫你看一下
大家都加油 樂生才有救

尚儒

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