NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
372
REPORT OF THE LEPROSY COMMISSION:
SURGEON-MAJOR COOK'S DETAILED REPORT OF TWELVE CASES OF LEPROSY
TREATED WITH TUBERCULIN.
Case I.—Hindu, male, aged 39 years ; suffering from ANÆSTHETIC LEPROSY for last five
years.
Condition on June 3rd: A circular light patch immediately above the right eyebrow;
similar patches on the sides of the lower jaw. A large light-coloured anaesthetic patch on
posterior surface of the left elbow extending downwards. A large anaesthetic patch sur-
rounding the right knee and both legs. A small characteristic ulcer on the right heel.
Complete anaesthesia of both legs.
June 4th: "ooicc. of tuberculin injected, and injections carried on until June 16th,
when "009cc. was injected.
Practically NO REACTION : a slight rise of temperature at the commencement, and a
marked rise when the largest dose was administered.
Improvement : nil.
Weight on June 3rd: 108lb.
,7
„
„
8th: 941/2lb.
„
„
« 14th: 93lb.
Remarks.—Though the temperature was taken every three hours during the day, it has,
for the sake of simplicity, been registered morning, noon, and night in these charts.
Appendix II to Chapter VII.
373
Case II.—Hindu, male, aged 32 years ; suffering from 'ANÆSTHETIC LEPROSY for
last six months.
Condition on May 26th: Slightly raised patch on the forehead (macular) and face; a
small patch on the right cheek; nose slightly thickened. Two small light patches a little
above the right knee ; a dark characteristic patch on dorsum of left foot.
Loss of co-ordination of movement of left leg ; the foot falls when raised.
Slight anæsthesia of left leg and hyperæsthesia of face.
May 27th: '001cc. injected, and the usual injections continued.
Hardly any reaction, the temperature never rising above 101 0 , and then only alter
the maximum dose '01 had been given for the second time.
Improvements : June 14th; decrease of anœsthesia of left foot, also a certain amount
of increased power in that leg. Patches above right knee are paler.
June 19th : anæsthesia of left foot as before, and loss of strength also as before.
Thus no improvement.
Weight on May 27th : 1501/2lb.
,, ,, June
8th
: 154lb.
,,
„
,,
14th: 150lb.
374
REPORT OF THE LEPROSY COMMISSION :
Case III.—Dutchman, male, aged 20 years; suffering from ANÆSTHETIC LEPROSY
for six months.
Condition on May 28th: A well developed lad. Very slightly discoloured patches
(fairer than his natural skin which is of an olive hue) on the left cheek and on the
forehead. A dark patch (darker than natural skin) stretching from right arm to light
breast. These patches are not anæsthetic. A raised irregular darkly coloured eruptive
patch, raised above the level of the skin, on the abdomen — not anæsthetic. An eruptive
anæsthetic patch on the right knee. Anæsthetic patches on right leg and foot.
May 29th: '001cc. injected, and injections continued until June 18th. No reaction
until ' CO3CC. was reached when temperature rose to 102 o . Taking it all round the reaction
was weak.
Improvement : nil.
Weight on May 28th : 108lb.
,,
„ June 8th: 105lb.
„
„
„ 14th: 1051/2lb.
,,
,,
,,
19th : 105lb.
Appendix II to Chapter VII.
375
Case IV.—Hindu, male, aged 18 years; suffering from ANÆSTHEHC LEPROSY for eight
years.
Condition on May 26th : Small light anaesthetic patch on right cheek and forehead. A
large similar patch on the outer surface of left upper arm; another on the anterior aspect
of left forearm from elbow downwards. Large light patches on the outer surface of both
thighs and buttocks. Peculiar shiny appearance and discoloration of the skin of both
shins. A small circular patch immediately below the umbilicus. Loss of sensation in both
extremities.
May 27th: '001cc. injected, followed by considerable reaction. Injections continued up
to '01cc, and reaction showed itself fairly well throughout.
Improvement : nil.
Weight on May 27th : 751b.
„
„ June 8th : 721/2lb.
„
,,
14th
: 72 ¿41).
„
,, ,, 19th : 721/2lb
376
REPORT OF THE LEPROSY COMMISSION:
Case V.—Eurasian, male, aged 22 years; suffering from TUBERCULAR LEPROSY for
ten years.
Condition on May 3oth : Slight tubercular thickening of nose, lobes of both ears and
chin, and tubercular thickening of the whole face. Dark patches over left shin. No
anæsthesia.
May 31st: '001 of tuberculin injected. The usual injections were carried on every
other day, and the maximum dose given on June 14th.
Reaction and rise of temperature practically nil.
Improvement : nil.
Weight on May 30th : 110lb.
„ „ June 8th; 1061/2lb.
„ „ „ 14th: 1081/2lb.
Appendix II to Chapter VII.
377
Case VI.—Hindu, male, aged 20 years; suffering from TUBERCULAR LEPROSY; dura-
tion of disease : four years.
Condition on June 3rd: Tubercular thickening of lobes and pinnæ of both ears, also
of nose and lips; general thickening of face. Discoloration of skin of trunk and extremities.
Epidermis scaly and desquamating. Fingers of both hands slightly thickened. Peculiar dark
discolorations over both shins. Toes of feet thickened. No anæsthesia.
June 4th: '001cc. of tuberculin injected, and injections continued until "009cc. was
reached.
Reaction : Well marked.
Improvement: nil.
Weight on June 3rd: '110lb.
,,
.,
„ 8th : '101lb.
„
,,
„ 14th ; 104lb.
378
REPORT OF THE LEPROSY COMMISSION:
Case VII.—Hindu, male, aged 2S years; suffering from TUBERCULAR LEPROSY for two
and a half years.
Condition on June 1st : Tubercular thickening of lobes and pinnæ of both ears ; minute
tubercles on the edge of the nose. Fingers of both hands thickened. Dark patches over both
shins ; toes of feet thickened and nails wasting. Psoriasis all over body. No anæsthesia.
June 2nd : '001cc. injected. When '003CC was reached on June 6th the temperature
rose to 102.8°, and to 103 o the next day.
Reaction has been well marked throughout.
Improvement : nil.
June 19th: Psoriasis much aggravated (cf. Cases VIII, IX, and XII).
Weight on June 1st : 102lb.
„
„
„ 8th: 1021/21lb.
„
„ „ 14th: 99lb.
Appendix II to Chapter VII.
379
Case VIII.— Hindu, male, aged 22 years; suffering from TUBERCULAR LEPROSY; dura-
tion of disease : eight years.
Condition on May 28th : Minute tubercles on the chin, lips, nose, and lobes of both
ears ; blight thickening of whole face. Thickening and peculiar glossy appearance of fingers of
both hands. Lower extremities discoloured and partially anæsthetic; toes of feet thickened;
ulcer on great toe of left foot. Peculiar glossy appearance of skin over shins. Toes of both
feet inclined to retract.
May 29th: '001cc. injected, and usual injections continued. When "005cc. was reached,
signs of severe reaction appeared.
Reaction : Well marked with larger closes.
Improvement: At one time there was a decided diminution of the anæsthesia; but this
passed off very quickly.
Psoriasis appeared all over the body (cf. Cases VII, IX, and XII).
Weight on May 2Sth : 119lb.
„ ,, June 8th : 115lb.
„
„
„ 14th: 113lb.
380
REPORT OF THE LEPROSY COMMISSION :
Case IX.—Hindu, male, aged 21 years; suffering from MIXED LEPROSY ; duration of
disease : seven years.
Condition on May 26th : Minute tubercles on chin, lips, nose ; thickening of nose ;
tubercles on eyebrows and middle of forehead ; general thickening of face ; lobes of ears
thickened and nodular. Fingers of both hands thickened and glossy. A big light patch a
little above the left knee, which is more or less anæsthetic. Skin over shins glossy and
discoloured. Both feet swollen; three inner toes of right foot, and the great and third toes
of left foot ulcerated ; nails atrophied. Total anæsthesia of left upper arm and left thigh.;
May 27th: '001cc. injected. The dose was never increased beyond "004cc:. on account
of the rise of temperature.
June 12th: There seems to be some improvement: the ulcers on the toes are healed,
the swelling of the feet subsided ; the anæsthetic patch on left thigh is regaining sensation ;
the tubercles on the face are not so prominent.
June 19th : The anaesthetic patch has again lost its sensation and the feet are as swollen
as before.
Psoriasis appeared all over the body (cf. Cases VII, VIII, and XII).
Reaction : Well marked.
Improvement : Slight and of passing nature.
Weight on May 26th 94lb.
,, ,, June 8th : 93lb.
„
„ „ 14th : S3lb.
Appendix II to Chapter VII.
381
Case X.—Hindu, male, aged 25 years; suffering from MIXED LEPROSY; duration : seven
years.
Condition on June 1st : Tubercular thickening of lobes and pinnæ of both ears ; nose
very nodular; general thickening of face. Skin over whole of trunk discoloured. Mammary
glands much enlarged. Raised anæsthetic patches on both lower extremities. Fingers
thickened ; left fingers retracted. Total anæsthesia of the extremities.
June 2nd: '001cc. injected. The usual injections administered every other day until '007
was reached and the temperature rose to 101º.
June 16th, the maximum dose was given and temperature did not rise above 101º.
Reaction : practically nil.
Improvement : nil.
Weight on June 1st : 100lb.
,,
„
„
8th: 91lb.
„
,, „ 14th : 100ft.
382
REPORT OF THE LEPROSY COMMISSION:
Case XI.—Hindu, male, aged 25 years; suffering from MIXED LEPROSY; duration of
disease : ten years.
Condition on May 26th : Tubercular thickening of the lobes of both ears, nose, chin;
general thickening of face. Discoloration of the skin of the trunk and upper extremities. Fin-
gers of right hand thickened ; fourth and fifth fingers of left hand slightly contracted and
atrophied ; thickening of skin of both upper extremities. Light patches on both thighs and
knees; dark patches on both legs, glossy in appearance. Anæsthesia of extremities.
May 27th : 'ooicc, injected ; when dose was increased to '003cc, a good reaction appeared.
Reaction: well marked.
Improvement: nil; on the other hand, became seriously ill, complaining of pains all over
his body and greatly reduced in general health.
Weight on May 27th : 1061/2lb.
,,
,,
June 8th: 991/2lb.
„
,,
,, 14th:
90,1b.
Appendix II to Chapter VII.
383
Case XII. — Hindu, male, aged 18 years; suffering-from MIXED LEV ROSY : duration of.
disease : six years.
Condition on June 1st : Minute tubercles on the edges of both pinnæ ; slight tubercular
thickening of lobes of ears and nose; discoloration of skin of face. Light anaesthetic patches
on both arms; discoloration of skin of both forearms; fingers thickened; fingers of right hand
slightly contracted, and also those of left hand Dark patches above left nipple. Anesthetic
patches on both legs; glossy appearance of skin over both shins; second toe of right foot
slightly contracted ; second toe of left foot thickened. Total anæsthesia of upper extremities
and of both legs.
June 2nd : "ooicc injected, and usual injections given until '005cc. was reached, and the
temperature began to rise to 103°. Injections reduced then.
June 12th : "004.cc. was injected, but finding that the temperature rose up to 105 o , the
injections were stopped.
Reaction: Well marked, when '005cc. was given.
Improvement : nil.
Psoriasis
again appeared all over the body (cf. Cases VII, VIII and IX).
Weight on June 1st : 831/2lb.
„ 8th: 841h.
„
„
,, 14th: 80lb
384
REPORT OF THE LEPROSY COMMISSION:
CONCLUSIONS.
The following conclusions are based upon the observations
and arguments contained in the foregoing report :—
1. Leprosy is a disease sui generis ; it is not a form of
syphilis or tuberculosis, but has striking aetiolo-
gical analogies with the latter.
2. Leprosy is not diffused by hereditary transmission,
and for this reason, and the established amount of
sterility among lepers, the disease has a natural
tendency to die out.
3. Though in a scientific classification of diseases
leprosy must be regarded as contagious and also
inoculable, yet the extent to which it is propagated
by these means is exceedingly small.
4. Leprosy is not directly originated by the use of any
particular article of food, nor by any climatic or
telluric conditions, nor by insanitary surroundings ;
neither does it peculiarly affect any race or caste.
5. Leprosy is indirectly influenced by insanitary sur-
roundings, such as poverty, bad food, or deficient
drainage or ventilation, for these by causing a pre-
disposition increase the susceptibility of the indivi-
dual to the disease.
6. Leprosy in the great majority of cases originates de
novo, that is, from a sequence or concurrence of
causes and conditions, dealt with in the report, and
which are related to each other in ways at present
imperfectly known.
Conclusions and Practical Suggestions.
385
Practical Suggestions.
Segregation may be voluntary or compulsory, and in either
instance partial or complete. Complete segregation has never
yet been possible. Both in the Sandwich Islands and in
Norway it has failed.
" It appears that there has always been great difficulty in
the Sandwich Islands 1 in carrying out a full measure of segre-
gation. This fact comes out in several of the reports ; and in
the latest of them we see it stated that for some period during
the administration as President of the Board of Health of Mr-
Gibson, who apparently doubted its efficacy, the work of seg-
regation had been practically brought to an end. At the
present time there is an endeavour to enforce rigorously the
isolation of lepers."
Again, " the isolation of lepers in the Norway 2 asylums is
not absolute. The doors and gates of the institutions are
not locked, and more than once I met some of the inmates
in the neighbouring roads. The doctors informed me that
they allowed those to go out who showed no ulcerations, and
that no cases of consequent infection have ever been traced.
The lepers, however, are usually kept in on market days, and
at Trondhjem at least, and I believe elsewhere, they are not
permitted to enter houses and churches, and to come in close
contact with other people."
" To attribute the decline of leprosy in Norway 3 to com-
pulsory isolation is entirely erroneous. In the first place no
such powers exist or are likely to be sanctioned by the Norse
( 1 ) P. S. Abraham. Leprosy : A Review of some Facts and Figures. Epidem-
iological Society's Transactions, Vol. VIII., page 132.
( 2 ) Op. cit., page 136.
( 3 ) W. J. Collins. Note on the Leprosy Revival, Lancet, May 17, 1890, page
1064.
2 c
386
REPORT OF THE LEPROSY COMMISSION :
democracy ; if they did exist it would be impossible without
further accommodation to segregate even the reduced number
of lepers in Norway at the present time. Indeed, I met many
lepers in the streets of Bergen and on the quay going about
their usual vocations. It is not that segregation is stamping
out leprosy in Norway, but the increased material prosperity
of the people, the growth of foreign trade, the inter-com-
munication with town life, and the opportunities these give for
better and more varied subsistence, which have doubtless
effected beneficent changes in this direction."
The amount of legislation which at present exists in Norway
may be best expressed in the following words of Dr. G. A.
Hansen 4 : "Though the disease was steadily diminishing I
found that something ought to be done to check the spread
of the disease in the country, besides what might be done by
the entrance of lepers into our asylums. In consequence I
proposed a law which was enacted in 1885. This law gives
the Sanitary Commission or Board of Health in each district
the right to order a leper, if he will live at home, that he
must have his own room at least his own bed, that his clothes
ought to be washed separately, that he must have his own
eating apparatus,—spoon, fork, knife, etc. If he cannot, or
will not comply with this regimen, he is obliged to enter an
asylum."
From the above quotations it is at once evident that even in
the two countries in which segregation of lepers is commonly
believed to be complete, the actual procedure falls far short of
this. For India complete compulsory segregation may be
considered to be absolutely impracticable. Neither do the
conclusions given above as to the nature of the disease justify
any recommendation for absolute segregation. The presence
( 4 ) G. A. Hansen. Journal of the Leprosy Investigation Committee, No. 2,
pages 65-66,
Conclusions and Practical Suggestions.
387
of a leper in a healthy community is a source of danger no
greater than the presence of an individual suffering from tuber-
culosis. Both diseases are contagious in an equal and minimal
degree. The amount of ulceration which exists in both
diseases is to some extent a measure of the danger of
contagion.
It is impossible for the same reasons to advise compulsory
partial isolation. Voluntary isolation is, therefore, the only
measure left for consideration. Among civilised communities
the separation of those suffering from many diseases other than
leprosy is encouraged. The voluntary isolation of the leper
is, therefore, no exception to this custom. For this reason the
Commissioners recommend the adoption of a voluntary isola-
tion as extensive as local circumstances allow. Further, by
permitting marriages among lepers, the plan suggested might
be the more easily carried out.
In accordance with instructions received from the Com-
mittee of the National Leprosy Fund, the Commissioners are
required in their final report to describe minutely what they
believe to be the best plans for ensuring the efficient carrying
out in practice of their recommendations relating to the treat-
ment of lepers.
Conformably with these directions the Commissioners,
though they are fully aware that the extent and varying social
conditions of the empire may present great practical difficulties,
venture to suggest the following schemes.
The Commission are of opinion that the sale of articles of
food and drink by lepers should be prohibited, and that they
should be prevented from practising prostitution, and from
following such occupations, as those of barber and washer
man, which concern the food, drink, and clothing of the people
generally, quite apart from the dread of a possible infec-
tion.
Vagrant and indigent lepers living in the villages and scat-
2 c 2
388
REPORT OF THE LEPROSY COMMISSION
tered about the country are probably sources of little or no
danger. Disgust, and to a certain extent fear, rarely permit
their relations to the general community to be intimate, and no
harm is likely to result from their soliciting alms by the road-
side. The tendency at the present time, however, is for men-
dicant lepers to leave their homes, to crowd into the large cen-
tres of population, and this in the opinion of the Commission
should be discouraged. In the cities and towns they herd
together, living under circumstances of extreme poverty and
filth, and forming communities which are not only offensive
to public decency, but constitute from many points of view a
menace to the public health. Moreover, in such leper colonies
promiscuous and casual alliances are the rule, and the result is
that children are born to struggle for existence under circum-
stances most painful to contemplate. The Commission consider
that the best policy in dealing with this matter is to discourage
this concentration of lepers in towns and cities, and to this end
would suggest that municipal authorities be empowered to
by-laws preventing vagrants suffering from loathsome diseases
from begging in or frequenting places of public resort, or using
public conveyances.
The large Presidency towns and the capitals of provinces
in many cases already possess leper asylums, which might
be enlarged by municipal funds or private subscriptions.
Asylums should be built near towns where they do not already
exist, and the authorities should have the power of ordering
lepers infringing the regulations either to return to their homes
or to enter an asylum.
Competent medical authority should always be consulted
before action is taken under such by-laws.
In no case would the Commissioners suggest an Imperial
Act, especially directed against lepers as such, for these are
far less dangerous to a community than insane or syphilitic
people.
Conclusions and Practical Suggestions.
389
The effect of such bye-laws in large towns would be an
emigration into the surrounding country, and a furtherance of
the scheme now to be proposed for establishing experimental
leper colonies or farms in rural districts«
The experiment of the leper farm in Cyprus 5 has succeed-
ed. Though unwilling to argue from a small island to a large
empire, the Commission are of opinion that the success of leper
colonies, such as that of Sialkot, which is isolated in the centre
of a large agricultural district, and where lepers with their wives
and families cultivate the soil, leads to the belief that similar
farms scattered over the country would be productive of prac-
tical good.
Land might be granted, cheap buildings raised, seeds dis-
tributed,' and work supplied. The produce might partially
support the colony, and a small fixed money allowance might
be given, or a small bounty be paid on the produce raised by
each leper.
Comparatively few children would be born, and these
should, if possible, be removed to Orphanages. Only a certain
number of the latter would be required, as the inmates might
be discharged as soon as they were old enough to support
themselves. The advantages of such a method are fully illus-
trated in the Almora Orphanage.
In conclusion, the Commissioners believe, from the consi-
derations and arguments adduced in the foregoing report, that
neither compulsory nor voluntary segregation would at present
effectually stamp out the disease, or even markedly diminish
the leper population, under the existing conditions of life in
India. It can only be hoped that by means of improved
sanitation and good dietetic conditions a diminution of leprosy
will result. The Commission agree with most authorities in
believing that the decline of leprosy in Europe has been due
( 5 ) Dr. Heidenstam, C.M.G. Report on Leprosy in Cyprus, 1890, page 13.
39°
REPORT OF THE LEPROSY COMMISSION.
principaliy to improved hygienic habits and surroundings, and
increased material prosperity.
English Members ;
BEAVEN RAKE.
GEORGE A. BUCKMASTER.
ALFRED A. KANTHACK.
Indian Members:
ARTHUR
BARCLAY, Surgeon-
Major,
Bengal
Medical
Service. 6
SAMUEL J. THOMSON, Surgeon-
Major,
Bengal
Medical
Service.
SIMLA :
August, 21st 189F.
( 6 ) The name of the late Surgeon-Major A. Barclay is appended to this
report, as the conclusions and suggestions were drawn up previous to his death-
and were known to be in accordance with his views..
Appendix I.
391
Appendices I and II are printed separately for the following
reasons. In the interests of the investigation, one section of
the Commission commenced enquiries at Almora, while the
other began work at Simla. Subsequently, when the two
sections of the Commission met, it was found that the enquiry
had proceeded so far that it would be preferable to continue
experiments separately, especially as there was not sufficient
room in the laboratory erected by the Government of India at
Simla for the entire Commission to work together with facility.
The two sections met at intervals, compared their observations,
and discussed details of their work. Each Appendix conse-
quently represents independent observations for which each
section is separately responsible.
392
REPORT OF THE LEPROSY COMMISSION :
APPENDIX I.
Laboratory Work done in Almora and Simla.
BY
DR. BEAVEN RAKE,
DR. GEORGE ALFRED BUCKMASTER,
SURGEON-MAJOR S. J. THOMSON.
I.—The Bacillus Lepræ.
II.—Distribution of the Bacillus within the Body.
III.—Distribution of the Bacillus outside the Body.
IV.—Vaccination.
V.—Cultivation Experiments.
VI.—Transmissibility of the Disease by Experiment.
Explanation of Plate I.
FIG. 1.—Culture on May 28th from bouillon inoculated on May
14th, with capillary tube containing blister fluid
in which were bacilli. In the specimen the bacilli
are bright red. Stained with Ziehl's solution for
six hours, then 25 per cent. nitric acid and 60
per cent. alcohol. Drawn with Camera Lucida.
Winkel Homog. Immersion 1/14, ocular 4.
FIG. 2.—Culture on Agar on June 10th, 4th generation in ocula-
ted on June 8th. Stained and drawn as above.
Winkel Homog. Immersion 1/14, ocular 4.
FIG. 3.—Culture on plate, 2nd generation of June 18th, from
plate culture of two days earlier which was in-
oculated from 4th generation on Agar of June 8th.
Stained and drawn as above. Winkel Homog.
Immersion 1/14, ocular 4.