NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
294
REPORT OF. THE LEPROSY COMMISSION :
Table V—continued.
Evidence in Favour of Contagion afforded by Persons Eating and
Drinking with Lepers.
ASYLUM OR
CENTRE.
Aligarh .
Benares ,
Calcutta .
Delhi
.
Gwalior .
Gya
Mandalay
Prome .
No. of
Lepers.
1
4
19
2
7
24
No. of
persons
eating and
drinking
with them.
1
4
43
5
1
7
84
40
How many
of these are
affected.
1
1
1
3
...
5
3
REMARKS.
Child used to eat with a leper father,
and eight years after his death also
became tainted.
Child used to eat with leper mother,
and five years after her death became
also a leper.
In one instance two brothers used to
eat together, and within a year both
were lepers. In another, a child
had eaten with its leper father, and
was twelve years old when the latter
died. Sixteen years after his death
the child became a leper.
The wives were accustomed to eat
with their leper husbands, but it was
distinctly stated that they washed the
plates after the husbands had used
them, and before they employed these
for their own meal.
In one case a child used to eat from the
same vessels as her mother, and thir-
teen years after the latter's death she
also became affected.
In one instance a family of nine used
to eat from the same dishes. One of
them became a leper and died a year
later. They continued after this to
eat from the same vessels, and two
years later another member of the
family was attacked. The others
remained healthy.
Contagiousness of Leprosy.
295
Table V—continued.
Evidence in Favour of Contagion afforded by Persons Eating and
Drinking with Lepers.
ASYLUM OR
CENTRE.
Thayetmyo
TOTAL
No. of
Lepers.
10
86
No. of
persons
eating and
drinking
with them.
16
212
How many
of these are
affected.
5
21
REMARKS.
In one case the disease appeared in
two people at the same time, and,
therefore, one cannot be said to have
infected the other. In another case
the diagnosis of leprosy in the sup-
posed infected person was extremely
doubtful, and in a third instance two
persons eating together developed the
disease within a year of each other.
For the construction of this table, only the information ob-
tained from asylums and districts in which the Commissioners
paid special attention to this point, has been considered. In
all the cases, with the exception of those in Gya, families used
to eat at the same time, and out of the same vessels. Since
at Gya the wives previously washed the dishes from which their
leper husbands had eaten, these seven cases must be excluded
in calculating the possible influence of contagion. Hence the
figures show that of two hundred and five persons who exposed
themselves by eating and drinking with lepers to the danger of
infection, only twenty-one became affected. Moreover, in the
one instance where two individuals who had constantly eaten
together from the same vessels became diseased at the same
time, there can be no question of contagion. Again, cases of
persons who had not come into contact with lepers for a long
period cannot be quoted in favour of contagion. Five such
instances are to be found in Table V, one from Agra, one from
Aligarh, one from Benares, one from Calcutta, and one from
Mandalay. The assumption of so long an incubation period as
296
REPORT OF THE LEPROSY COMMISSION:
five years or more means practically reducing the influence of
contagion to an absurdity. Six cases, therefore, must be sub-
tracted from the twenty-one instances of possible contagion
through eating and drinking with lepers. Besides, in one case
(Thayetmyo), the diagnosis was extremely doubtful, and in two
cases (Calcutta and Thayetmyo), the disease may be said to
have commenced in the two persons at the same time, as they
were affected within a year of each other. It is also very
questionable whether one of the cases recorded from Prome
can be cited with all fairness as an example of possible con-
tagion from these causes. Allowing, however, that these cases
are free from objection, the figures show that of two hundred
and five persons who exposed themselves to the risk of con-
tagion by eating and drinking with lepers, fifteen might be
claimed as exemplifying an assumed influence of contagion, or
7.3 per cent. These figures cannot be said to favour the
hypothesis of an infection through eating and drinking with
lepers, especially when it is remembered that 7.3 per cent. is
probably considerably above the actual ratio, which perhaps is
more nearly represented by 5 per cent., even assuming that the
spread of the disease among these people depends on conta-
gion only.
TABLE VI.
Observations on Lepers vaccinated at the Almora Asylum,
Eighty-six persons were vaccinated, and of these 40 successfully.
Of the 40 successful cases, 34 were anaesthetic lepers.
5 were mixed cases.
I was tubercular.
Observations on Lepers vaccinated at the Almora Asylum.
In 31 patients the vesicle was normal.
2
2
1
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
purulent.
purulent and mixed with blood.
normal on one arm and purulent on the
other.
Contagiousness of Leprosy.
297
In 31 patients the vesicle was normal but mixed with blood on punc-
turing it.
1
1
1
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
,,
immature and mixed with blood on
puncturing it.
immature.
immature and the crust removed for
examination.
Ninety-three cover-glasses were prepared and stained for bacilli, and
specimens were also taken later from the crusts of two vesicles which had
been normal.
Condition of site of vaccination —In
,,
,,
,,
12
13
1
patients the skin was normal.
„ sensation was diminished.
„ there was an anaesthetic
patch.
patient the skin was tuberculated.
Results:—In no case were leprosy bacilli undoubtedly found.
In two specimens prepared from a vesicle over a tuberculated
ear there were one or two badly stained bacilli.
In four specimens from an anaesthetic patch there were some
rods which stained with fuchsin and looked suspicious, but
none of these were certain.
TABLE VII.
I.—Observations on Earth at the Almora Leper Asylum.
SOURCE OF EARTH.
1. Path in front of office
2. Path down hill to leper
quarters
3. Path under bank where
lepers sit
4. Bank where lepers sit
TOTAL
No. of
cover-glasses
examined.
25
25
25
25
100
Number of Leprosy Bacilli found.
3 on 1 cover-glass.
2
,,
1
,,
,,
1 ,, 1 ,, ,,
1 ,, 1 ,, ,,
1 ,, 1 ,, ,,
1 ,, 1 ,, ,,
1 ,, 1 ,, ,,
No bacilli. [One suspicious.]
10 bacilli in 100 observations.
298
REPORT OF THE LEPROSY COMMISSION :
Table VII—continued.
II—Examination of Dust from Leper Huts.
SOURCE OF DUST.
1. Room inhabited by tubercular leper with
ulcers on both feet
....
2.
Ditto
ditto
3.
Ditto
with ulcer on right foot
4.
Three rooms inhabited by anaesthetic
5. lepers with extensive ulcerations.
6.
No. of
cover-glasses
examined.
100
100
100
50
50
50
RESULT.
Negative.
,,
,,
,,
Sanitation, Diet, Disease, etc.
299
CHAPTER VI.
Sanitation, Diet, and Diseases in relation to Leprosy.
Sanitation.
I T has been seen that heredity and contagion are altogether
insufficient to explain the spread of leprosy, and other
ætiological factors must be sought for. In diseases like le-
prosy and tuberculosis, it is always difficult to find the ex-
citing cause. For, with the recognition that a specific bacillus
enters the body, the matter is but little advanced. The en-
quirer must always ask, why a widely diffused microbe, such as
that of tuberculosis or leprosy, should cause a particular dis-
ease in some people and not in others. What is it that estab-
lishes the necessary specific predisposition ?
This question is as obscure for leprosy as it is for tubercu-
losis. In this chapter the more important causes, supposed to
bring about such specific predisposition, will be discussed.
When a disease, as is the case with leprosy, is so generally
distributed over a vast country, attention must be directed
to the general life and hygienic surroundings of the people.
Does defective sanitation cause a specific predisposition to
leprosy ?
Since all classes of the community and all races appear
to be subject to leprosy, remarks upon the sanitary environ-
ment of the inhabitants of India must be necessarily gene-
ral in character. In the cities and larger centres of population
considerable progress has of late years been made in sanitary
improvement, though very much yet remains to be done. In
the smaller towns and villages, however, little has been ac-
complished, or, indeed, is practicable in the present state of
native opinion. Fortunately the nature of the employment
of the great mass of the population necessitates an outdoor
300
REPORT OF THE LEPROSY COMMISSION:
life, and the free air-flushing of the village site, and the rapid
desiccation of the objectionable matters thrown upon it, go
far to reduce the consequences of habitual neglect of sanitary
principles.
These matters will now be dealt with in detail. As regards
conservancy, it is found that the cities and larger towns are
provided with suitable latrines, which are in charge of an ade-
quate conservancy staff, and which are largely used by the
people. The excreta from these latrines, and also the general
refuse and rubbish of the town, are regularly removed to a
distance, and there buried, burnt, or otherwise suitably dis-
posed of. Although differences exist in various localities as
regards the efficiency of these arrangements, they may be
described as upon the whole fairly good. But no large centre
of population is free from many nuisances. Ruined huts and
waste pieces of land are frequently used for purposes of nature,
cesspools exist in many courtyards and in immediate proximity
to wells, excavations full of fetid water are frequently observed,
and other sources of danger to the public health are only too
common.
In the smaller towns and villages little or no attempt at
organising conservancy arrangements is made. The villager
deposits the refuse and sweepings of the dwelling in the imme-
diate vicinity of the house or hut, in some cases from in-
difference, in others to avoid theft of such matters before their
employment for agricultural operations. For purposes of nature
he generally resorts to a field in the neighbourhood, or to the
banks of a stream or pond. Refuse water is allowed usually
to flow from his hut into the adjacent road. It should be no-
ted, however, that despite the frequently objectionable nature
of its surroundings, the interior of the average village dwelling
is usually fairly clean.
Most cities and towns have a more or less satisfactory
system of drainage as regards the main thoroughfares, but the
climatic conditions of the country, and the fact that so many
Sanitation, Diet, Disease,
etc.
301
months of the year are almost rainless, render the flushing
of these water-ways a matter of extreme difficulty, and often
an impossibility. Where the configuration of the land permits,
attempts are often made to utilize streams and other sources
of water for the purpose, but a glance at a physical map of
India will show how in the extensive flat plains of the country
no such procedure is possible. Again, although much has
been, and is being, done to ensure efficient drainage of in-
habited sites, such efforts have up to the present time been
more especially directed to the carrying off of water from the
thoroughfares and streets. Small drains, it is true, connect
the dwellings with the larger channels, but inasmuch as the
inhabitants bathe at the public wells and tanks, and practically
only employ such water in their houses as is required for
drinking and cooking, little or no flow in these connecting
drains is usually observable. Few towns as yet in India pos-
sess a water-supply laid on in pipes to the houses.
In the villages and smaller centres of population water
finds its way more or less completely from the site through
small cuttings in the soil, or through a channel created natur-
ally by the heavy rainfall during the monsoon.
As regards water-supply, some of the larger towns and
cities, as Calcutta, Bombay, Madras, Agra, and certain others,
are provided with a good supply laid on in pipes. But the
great majority of places have no such arrangements, and here
the water is taken from wells, rivers, springs, tanks, or lakes.
From both wells and rivers the water is usually more or less
impure, though superior to that from lakes and tanks. Spring
water when obtainable is, as might be expected, usually good.
Attempts to sink Artesian wells have succeeded in a few locali-
ties, but have more generally failed. Local authorities in the
larger centres have of late years succeeded in improving the
supply by such measures as keeping in repair the wells that
hold good water and closing those of which the contents are
impure, by remodelling tanks and preventing their pollution,
302
REPORT OF THE LEPROSY COMMISSION:
but in the villages little at. present can be done in this direc-
tion.
Habitations necessarily vary in size with the wealth and
position of the owner or tenant. They are more generally built
of bricks and mud in the plains, of stone in the hill tracts, and
of bamboo and wood in Burma and certain parts of India. In
towns and cities they are usually placed in close proximity to
one another, and thereby efficient ventilation and air-flushing
of the site are interfered with. Overcrowding of these dwellings
is the rule, and in the hill tracts is often excessive. The
residents, however, live largely in the open air, and doors and
windows are either seldom closed, or are so carelessly con-
structed that air freely enters the house or hut.
In connection with habitations, it should be mentioned that
not only in India but also in other parts of the world the
mosquito has been much feared. As Dr. Arning says : 1
" Ashmead seems to fear much the bite of the mosquito, and
I quite agree with him that the idea of transmission of leprosy
through the sting of an insect is a very plausible one." Dr.
Arning himself "frequently examined mosquitoes bacterio-
scopically, which were found inside the mosquito nets of beds
containing cases of severe cutaneous leprosy. He caught the
insects when they were quite full of the blood sucked from the
patients. He never discovered any trace of leprosy bacilli,
either in or upon them." Some members of the Commission
examined flies and mosquitoes, but also with negative result,
as will be seen from the Laboratory Report. Other consider-
ations, however, make it appear extremely unlikely that a
propagation of the disease should be due to these insects. It
is hardly possible that the toxic principle of the mosquito should
contain bacilli, even though they be present in the blood with
which the insect is gorged. Again, cases of transmission from
patients to hospital or asylum officials should be very common
( 1 ) Journal of the Leprosy Investigation Committee, No 2, February 1891. page
132.
Sanitation, Diet, Disease, etc.
303
if this theory be true. Yet in Calcutta, where mosquitoes and
flies abound, no instance of a transmission of the disease from
a leper to a healthy individual has ever occurred at the asylum.
All over the plains these insects are common, and nevertheless,
with the exception of a single case in Calicut, no instance of
infection could be found, even amongst the people who volun-
tarily resided with the lepers in the asylums. In fact it may be
said that the whole chapter on contagion lends no support to
the insect theory.
Personal cleanliness in India is very much a matter of cli-
mate. Where this is warm or mild all classes bathe frequently,
Hindus more especially. In such localities linen and cotton
clothes are worn and are regularly washed. But in colder
latitudes far less attention is paid to regular ablutions, and
where the climate demands the use of woollen clothing, such
garments are seldom washed and become extremely foul. In
the hill tracts the people may be said to rarely bathe, and are,
as a rule, extremely dirty in their persons and habits. Most
people possess shoes, but they are as often as not discarded
the owner walking for preference barefoot.
Scabies is very common all over India, and it has been
asked whether or no this may contribute to the spread of the
disease. This assumption may be refuted by the arguments
used against the theory of propagation by insects, and it will
not be necessary to enter into this question any further. It
may be mentioned, however, that itch pustules were examined
for the bacillus in several instances, but always with negative
result.
It is quite impossible to assume that defective hygiene,
whether general or personal, alone would originate leprosy.
For, as will be seen from the above short review, the hygienic
conditions vary considerably even in leprous areas, and the
disease capriciously spares certain portions of a country where
the condition of the population is identical with that of those
attacked. In India the disease is found in the richest and
304
REPORT OF THE LEPROSY COMMISSION:
poorest provinces. Defective hygiene, exposure to hardships
and privations, filthy dwellings and want of personal cleanliness
cannot be said to predispose to leprosy more than to any other
disease of like nature. They necessarily must aggravate and
accelerate it, when it is once established ; and for this reason,
where they exist, require improvement. 2
Diet.
The next question to be considered is the important one
of diet. Since the earliest days in the history of leprosy the
greatest influence in the aetiology of the disease has been
attributed to defective or bad dietetic conditions. In turn al-
most every foodstuff has been accused. In ancient medical
history the eating of certain kinds of fish, fresh or decayed,
was considered of great importance, and this opinion has per-
sisted to the present day. Too much or too little animal or
vegetable food has also been held responsible for the origin of
the disease, or specific predisposition to the same. This
influence of diet was naturally as keenly disputed by others.
That food should have a specific effect in the aetiology of
a chronic disease is à priori quite within the bounds of pos-
sibility. No one who believes in the infective nature of leprosy
would of course assume food to be a final exciting cause, for it
is implied in the term "infective disease" that this must be a
parasitic organism. It must be remembered, however, that
when these various food-theories were propounded, the bacillus
had not been discovered, and that, therefore, the views of
many of the older authors would not be misrepresented, by
stating that they claimed for diet only a direct effect in the
establishment of a specific predisposition.
Certain forms of diet are capable of producing grave
morbid conditions, as, e.g., Lathyrus sativus and Ergot ;
others, on the other hand, cause more general changes in the
( 2 ) Cf. R. Liveing : op. cit., pages 76 and 77.
Sanitation, Diet, Disease,
etc.
305
body, and may thus possibly lead to those conditions which
establish a specific predisposition. 3 In fact the experiments
of H. Leo 4 lend much support to such a theory. " He admin-
istered phloridzin in small doses along with food to white mice
for some days previous to inoculation, with the result that
sugar became present in the tissues of the experimental
animal. He found that the animals which are normally but
little susceptible to glanders infection became highly suscepti-
ble to it, if previously dosed with phloridzin."
In connection
with this subject, it may also be mentioned, that Charrin and
Roger 5 have shown "that ordinary normal rats, which, as is
well known, are very little susceptible to anthrax, become
susceptible to this disease in a marked degree if they are,
when caged, made to work a treadmill so as to become tho-
roughly fatigued."
Food must necessarily modify the constitution of the tissues
and may do so in such a way as to prepare them to respond at
once to the introduction of microbes against which they would
otherwise have proved refractory or insusceptible.
Thus
Monti 6 has shown that by a separate injection of a sufficient
quantity of the chemical products of the Proteus vulgaris into
rabbits, mice or other rodents, these animals could easily be
made to succumb to an infection with cultures of the Diploc-
occus pneumoniæ, which through repeated subculture or age
had lost their virulence, and which without the chemical
products of the saprophyte were also entirely harmless. As
Dr. E. Klein, 7 who confirmed and extended Monti's experi-
ments, says, " insusceptibility of the tissues is, as is well known,
( 3 ) R. Liveing : op. cit., page 83.
( 4 ) H. Leo : Zeitschrift für Hygiene VII., 3; and Nineteenth Annual Report
of the Local Government Board ; Supplement, 1889, page 217.
( 5 ) Charrin and Roger: La Semaine Médicale, 1890, 4; and Nineteenth
Annual Report, etc., loc. cit.
( 6 ) Nineteenth Annual Report, etc., loc. cit.
( 7 ) E. Klein : Nineteenth Annual Report of the Local Government Board
Supplement 1889, page 217.
x
306
REPORT OF THE LEPROSY COMMISSION :
considered by some authorities to be connected with, if not
wholly dependent on, the chemical nature of the tissues ; so
that while the tissues are normal or in full vigour (if the
phrase may be allowed for the purpose of illustrating my
meaning), a particular microbe getting access to them fails to
thrive—cannot, so to speak, overcome the resistance or inimical
action offered by the tissues. This power of resistance of
tissues can, however, be greatly reduced or even abolished by
certain means, such as depression of their vitality either due to
ptomaines and certain other chemical substances which have
invaded them, or to nervous exhaustion, and the like."
Where food is considered of ætiological importance in the
production of an infective disease, there are, broadly speaking,
two ways in which it may cause the latter. " First, by a
direct introduction of the bacillus into the alimentary tract ;
secondly, by causing changes in the tissues capable of rousing
into activity a bacillus already existing in them," 8 or of offering
a suitable soil to a bacillus subsequently introduced into
them.
These points will be kept in view in the following discussion.
At the present moment three substances have been specially
singled out as having a causal relation to leprosy, vis., fish,
salt, and water. However, before discussing the effect of
food in general, and of these three articles in particular, a few
remarks on the diets of the Indian community must be made.
The inhabitants of India are almost entirely vegetarians,
and the majority of people do not touch flesh from one year's
end to another. Muhammadans, it is true, make flesh, other
than that of the pig, a regular article of diet, but expense
usually prevents its extensive consumption, and it is used
generally in small quantities to supplement the main vegetable
elements of their food. Hindus are vegetarians, but certain
( 8 ) Journal of the Leprosy Investigation Committee, No. 1, August 1890,
page 77.