NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
254
REPORT OF THE LEPROSY COMMISSION:
Though these statistics evidently cannot represent the
absolute truth, they at least justify the belief in a loss of pro-
creative power causally related to leprosy, and tend to diminish
the fear of a diffusion of the disease through marriage with
lepers. This is also fully borne out by the history of the leper
settlement at Kalawao (Hawaii). 23 The latter was established
in 1866, and 2,864 persons were consigned there as lepers
from that time to 1884. At the end of this period of eighteen
years, 26 children survived who had been born at the settle-
ment of leper parents, and only two of these 26 were lepers.
From all these considerations then it may fairly he con-
cluded that marriages among lepers, and with lepers, do not
increase the risk of a diffusion of leprosy by means of the
offspring, and that this to a great extent is due to the rela-
tive sterility of lepers, whether males or females.
TABLE XIII.
Table showing the Fertility of Leprous Couples [both Husbands
and Wives being Lepers').
NAMES OF ASYLUM, ETC.
Almora
Belgaum
Bombay
Dehra Dun
Kapurthalla
Lucknow .
Madras
No. of
leper
couples.
9
1
3
4
2
2
1
No. of such
without
any issue.
4
1
3
2
1
2
...
REMARKS.
A leper woman married twice.
In one case a child was born who
died as an infant. No children
since.
A leper woman married twice.
(
22
) Report of Dr. Fitch : Appendix to Report on Leprosy in Hawaii, 1886,
page xxxi.
Hereditary Transmission and Predisposition.
255
Table XIII—continued.
Table showing the Fertility of Leprous Couples (both Husbands
and Wives being Lepers).
NAMES OF ASYLUM, ETC.
Mandalay .
Meerut
Nagpur
Patiala
.
Rangoon .
Rawalpindi
Sialkot
Subathu
Tarn Taran
Umballa .
.
TOTAL
No. of
leper
couples.
1
6
1
1
1
14
2
22
1
85 =
168 per-
sons.
No. of such
without
any issue.
1
6
1
...
1
7
1
11
1
55 =
647 per
cent.
REMARKS.
TABLE XIV
To show the Relative Sterility of Couples where the Husband is
a Leper and the Wife Healthy.
ASYLUM OR LOCALITY.
A g r a
....
A l i g a r h
....
A l m o r a
....
B a n g a l o r e
B e n a r e s
....
B o m b a y
Total number
of such
couples.
12
3
4
14
3
7
No. of
those which
are sterile.
2
...
3
6
...
7
No. of
those which
have children.
10
3
1
8
3
...
No.
of
children.
15
5
3
14
4
...
256
REPORT OF THE LEPROSY COMMISSION :
Table XIV—continued.
To show the Relative Sterility of Couples where the Husband is
a Leper and the Wife Healthy.
ASYLUM OR LOCALITY.
Burdwan
Calcutta
Calicut
.
.
.
.
Cawnpore
Conjeeveram .
.
Darjeeling
.
.
.
Dehra Dun
Delhi
.
.
.
.
Fyzabad
Gwalior
Gya
.
.
.
.
Hyderabad
Jubbulpore
Lucknow
Madras
.
.
.
.
Madura
.
.
.
.
Mandalay
Moulmein
.
•
Nagpur
.
.
.
.
Naini and Allahabad
Prome
.
.
.
.
Purulia
Rangoon
.
Sialkot
.
.
.
.
Subathu
.
.
.
.
Tanjore
.
.
.
.
Tarn Taran
Thayetmyo
Trichinopoly .
TOTAL
Total number
of such
couples.
4
11
10
5
9
1
5
2
5
5
9
9
5
2
27
32
19
3
25
15
9
12
6
1
3
3
6
5
5
296
No. of
those which
are sterile.
3
8
2
4
4
...
1
2
2
4
7
5
1
2
17
16
12
...
31
10
6
12
6
...
1
2
2
4
4
176
= 59.4 per
cent.
No. of
those which
nave children.
1
3
8
1
5
1
4
...
3
1
2
4
4
...
10
16
7
3
4
5
3
...
1
2
1
4
1
1
120
No. of
children.
2
6
16
2
10
1
7
...
4
3
2
11
8
...
24
44
12
7
11
10
6
...
...
1
5
1
8
1
6
249
Hereditary Transmission and Predisposition.
257
TABLE XIVa.
Table to show the Relative Sterility of Couples where the Wife is
a Leper and the Husband Healthy.
ASYLUM OR LOCALITY.
Almora
Bangalore
»
.
Bombay
.
«
Calcutta
Cawnpore
Conjeeveram
.
Darjeeling
Dehra Dun
Delhi
.
.
.
.
Gya
.
.
.
.
Hyderabad
Madras
.
.
.
.
Madura
Mandalay
Moulmein
Nagpur
.
.
.
.
Purulia
.
.
.
.
Rangoon
Rawalpindi
Tanjore
Tarn Taran
Umballa
TOTAL
Total number
of such
couples.
2
9
6
9
1
1
1
3
1
1
r
7
8
8
1
13
6
1
1
2
5
1
88
No. of
those which
are sterile.
1
6
5
6
...
1
...
3
1
...
4
6
4
1
11
6
1
...
2
3
1
62 =
70.4 per
cent.
No. of
those which
have children.
1
3
1
3
1
...
1
...
1
...
1
3
2
4
...
2
1
...
2
...
26
No. of
children.
1
5
1
4
1
...
1
...
6
...
3
4
3
10
...
6
...
...
1
...
3
...
49
s
258.
REPORT OF THE LEPROSY COMMISSION:
Summary.
The Commissioners have thus come to the conclusion that
there is no evidence that leprosy in India is transmitted
through heredity from parent to child, their reasons being—
(1) no authentic congenital case has ever been put on
record, nor was one seen in this country ;
(2) true family histories of leprosy could be obtained in
only 5 or 6 per cent. of the cases ;
(3) many instances occur of children being affected
while their parents remain perfectly healthy ;
(4) the percentage of children, the result of leper
marriages, who become lepers is too small to
warrant the belief in the hereditary transmission
of the disease ;
(5) the facts obtained from the Orphanage at the
Almora Asylum disprove the existence of a speci-
fic hereditary predisposition ;
(6) only 5 or 6 per cent. of the children born after the
manifestation of the disease in the parents be-
come subsequently affected ;
(7) the histories of the brothers and sisters of leper
patients with a true or false hereditary taint seem
to show that little importance can be attached
to inheritance as an agent in the perpetuation
of the disease.
For the same reasons it may be assumed that the specific
hereditary predisposition to leprosy is but slight and practically
does not exist.
Lastly, it has been shown that taking all the information
obtainable and even allowing the fullest influence to heredity,
there appears to be no risk of an increase to the leper popula-
tion of India, so far as the disease is dependent on heredity for
its multiplication, and that marriages with, or intermarriages
between, lepers cannot be regarded in the light of a danger
to the community.
Contagiousness of Leprosy,
259
CHAPTER V.
Contagiousness of Leprosy.
A LL modern authorities are agreed that leprosy is an
infective disease, that is, one caused by a microbe, the
bacillus lepræ, which obtains access to the body from without,
and subsequently multiplies within the organism, calling forth
the characteristic lesions. The next point to be decided is
whether or no leprosy is contagious.
It is only too frequently taken for granted that a disease
due to a pathogenic germ is necessarily also contagious.
That this need not be the case will be shown later on. Here
it may suffice to recall to mind two instances of infective
diseases which are by no means contagious, viz., malaria and
pneumonia.
With regard to the contagiousness of leprosy, the views of
authors are highly conflicting, and a brief allusion will be made
to the statements of some of them. These matters have,
during the last few years, been so much before the world that
this reference need only be very brief. Flügge 1 says : " the
diffusion of leprosy by contagion is exceedingly rare and evi-
dently can only take place under special and predisposing
favourable conditions" (the italics are not Flügge's). Now
it may be mentioned at once, as this will guide subsequent
arguments, that the more weight is attached to special favour-
able conditions, in fact what in clinical language is called " the
suitable nidus," the further contagion disappears into the back-
ground. Indeed, for all practical purposes—and these are
what the legislator or sanitary reformer has to consider—it
vanishes altogether.
Hansen, 2 on the other hand, is a contagionist, and expresses
( 1 ) C. Flügge: Die Mikroorganismen. Leipzig, 1886, page 221.
( 2 ) A. Hansen : Journal of the Leprosy Investigation Committee»
No. 2, and Lancet, June 28, 1880, page 1431.
s 2
260
REPORT OF THE LEPROSY COMMISSION.
himself thus : " I do not know the way in which leprosy is
communicated or transferred from a leper to a sound person
but I am most inclined to believe that it is done by a sort
of inoculation, that there is wanted a very intimate intercourse
and some defect in the integument of the infected." Now, in
the chapter on Heredity mention has been made of Hansen's
researches in America. And it seems strange that he should
consider the fate of the emigrated Norwegian lepers an absolute
proof against an hereditary transmission of the disease, while
he is unwilling to allow that the same argument applies à fortiori
against contagion. How is the fact to be explained that in a
community of one hundred and sixty lepers the disease should
die out amongst their descendants, without altogether dis-
believing in contagion, or attaching to it a nominal import-
ance ? In fact Hansen's facts seem to disprove the theory of
contagiousness much more forcibly than that of hereditary
predisposition.
Leloir, 3 who is also a contagionist, defends his views in the
following words : " Mais comme l'a bien dit le docteur Vidal le
13 octobre 1885 à l'Académie de médecine, il faut remarquer
que beaucoup de maladies dont la transmission par voie
d'inoculation n'est plus niée aujourd'hui présentent souvent des
inoculations difficiles, irrégulières telles la varicelle, la diph-
thérie, telle la tuberculose, etc. On pourrait ajouter à la liste
des affections le lupus, l'érysipéle lui-même." This statement
challenges some comment. Firstly, there can be no doubt as
to the ease with which diphtheria and erysipelas can be
inoculated, and it is a well-established clinical fact that these
two diseases spread par excellence through contagion. Very
few would venture to place them in the same category with
leprosy, and attempt to establish any analogy between them
and the latter. Secondly, if the contagiousness of leprosy is
( 3 ) H. Leloir: Traitè Pratique et Théorelique de la Lépre. Paris, 1886,
page 301.
Contagiousness of Leprosy.
261
no greater than that of lupus or tuberculosis, the whole matter
will be reduced to a question of abstract scientific interest, and
is thereby at once removed from the sphere of the legislator,
in so far as such strong measures as segregation and social
interference are concerned. No one would ever think of
enforcing such measures for lupus or tuberculosis.
Lastly, reference must be made to Virchow, 4 who, in 1859,
was asked by the Norwegian Government to investigate the
disease in their country, and examined hundreds of cases. He
sums up his views on contagion as follows : " Therefore all we
can say is, that all cases of supposed contagion or inoculation
brought forward may be explained in various ways, and more-
over are so rare that as far as the general aetiology of the
disease is concerned they may in any case be disregarded.'
Practically, leprosy, according to him, does not spread by
contagion, though it may scientifically be correct to classify it
amongst the contagious diseases. This point will be further
considered in another place.
Before giving a detailed account of the views held by the
Commissioners, it will be necessary to make a few general
remarks on some points which should guide the enquirer in a
similar research, and also to criticise the forms of argument
used by many authors. The importance of the subject will
excuse this digression.
Firstly, when the question of contagion is under considera-
tion, it is of the utmost importance to separate the abstract
and scientific meaning of the term contagion from the practical
one. It is not sufficient to determine by experiment, or on the
evidence of one or two authentic clinical cases, that a disease
is infective and contagious, but a careful enquiry must be
made into the part played by contagion under ordinary sur-
roundings and practical conditions.
Secondly, the connotation of the term infection must not
( 4 ) R. Virchow: Krankhafte Geschwülste, Vol. II, page 507.
262
REPORT OF THE LEPROSY COMMISSION :
be misconstrued or unduly extended. Bacteriological and
laboratory researches have certainly contributed much to the
knowledge of the aetiology of many diseases, but the actual
question of contagion cannot be settled in this way. Clinical
and epidemiological evidence is of the greatest importance.
To elucidate these points, let it be supposed that a disease
is known to be an infective one. When it is acknowledged
that a disease is infective, all that is asserted is, that " the
disease may be transmitted from the affected to the healthy
individual," but this premises nothing as to the natural mode
of diffusion of the disease in question, and whether, or to what
extent, under ordinary practical conditions, such transmission
does take place. " The natural mode of transmission of an
infective disease depends on the faculty pathogenic germs
possess of leaving the body of the diseased in the full posses-
sion of their power of setting up an infection. If they be
thrown off from any surface of a diseased organism in sufficient
quantity, and in ?.. sufficiently resistant state, a transmission of
the disease from the affected to the healthy person may take
place, and the diffusion of the disease in such cases, under
certain conditions, may be effected through contagion.* If,
however, the pathogenic germs reproduced in the body of the
diseased person never leave the latter, or only do so without
possessing the power of causing subsequent infection, the in-
fective disease caused by such germs is non-contagious. The
germs in such cases must have a place somewhere, whence
they can always de novo attack the healthy organism." 5
Amongst the infective contagious diseases remarkable
differences exist as to the degree of contagiousness, depending
partly on the unequal liability of the healthy body to be invad-
ed by germs, and partly on the resistance and quantity of
* If, however, the germs or their spores already are, or become, widely
distributed throughout space, the risk of contagion may be disregarded as compared
with the de novo acquisition of the disease.
( 5 ) C. Flügge loc. cit. and also Flügge: Grundriss der Hygiene, page 466.
Contagiousness of Leprosy.
263
germs leaving the diseased body. Again, the paths by which
the microbes can enter may be such as only in rare cases
permit of their establishing themselves within the tissues, and
finally, the human body may possess certain protective means
which offer great obstacles to the attacking germ.
A disease may thus scientifically be grouped amongst the
infective and contagious diseases, and yet practically and cli-
nically hardly deserve this name. It is to be regretted that
the modern advances of bacteriology and animal inoculations
have tended to make not only the public, but also scientific
writers, disregard the evidence derived from clinical and epidem-
iological experience. Without, for a moment, under-estima-
ting the importance of bacteriological and animal experiments,
it is necessary to guard against taking a one-sided view of the
matter, a tendency to which, in these times, has often been
only too manifest. Experimenting, as the bacteriologist gene-
rally does, on highly susceptible animals, he easily runs the
risk of arguing beyond his premises, and of drawing conclusions
from his experiments which he applies without sufficient re-
serve to the natural mode of infection. It is quite impossible
to deduce the aetiology of an infective disease from bacterio-
logy alone ; clinical and epidemiological observations carefully
made must always be taken into account. A susceptible ani-
mal may easily be infected by experiment, and yet the case
may be quite different with man.
The best example to elucidate this point will be found in
tuberculosis. The researches of Koch have shown that this
disease is not only infective but also contagious. It is, how-
ever, equally certain that in the ordinary human surroundings
the conditions necessary for the multiplication and proliferation
of the tubercle bacilli never exist. The diffusion of the disease
depends thus, firstly, on its transmission from one individual to
another, and, secondly, on the fact that the bacilli may remain
dormant, in the full possession of their virulent properties, for
a considerable time, without, however, as was just mentioned,
264
REPORT OF THE LEPROSY COMMISSION :
showing any signs of proliferation. They are in fact true
parasites. Animals, such as guinea-pigs, are infected with the
greatest ease. Again, the tubercle bacillus, as Cornet 6 has
shown, is widely distributed throughout space without any loss
of vigour. À priori one would be inclined to assume that
tuberculosis must be a highly contagious disease. But ex-
perience teaches beyond doubt that of healthy individuals
living in the immediate neighbourhood of phthisical patients,
by no means all become affected ; " in fact perhaps only
slightly more than would become affected if the opportunity
for infection were less." 7 The disposition of an individual is
of the highest importance in bringing about a tubercular infec-
tion. In fact, as Flügge says, " the disposition actually gov-
erns the mode of diffusion of tuberculosis." And that in
tuberculosis the danger of infection is so small is chiefly ex-
plained by the fact that the existence of the bacillus, and its
introduction into the human body, are not sufficient to bring
about the infection without the necessary individual disposi-
tion.
The causes and nature of such disposition may be unknown,
but that it exists no one denies, and its bearing on contagion is
evident. The experiments of Monti, Leo, Charrin, Roger, and
E. Klein 8 have thrown much light on the nature of disposition
and susceptibility. These will be more fully alluded to in
Chapter VI. The greater the prominence given to this dis-
position, the less the absolute influence of contagion becomes.
" We notice the best example of an individual disposition in
tuberculosis, where the greater or smaller collection of resistent
germs around the human body has, as we know from experience,
a subordinate importance in the diffusion of the disease. It has
become an almost general practice in tuberculosis to counteract
( 6 ) G. Cornet : Ueber Tuberculose. Leipzig; and footnote on page 287.
( 7 ) C. Flügge : loc. cit., page 219.
( 8 ) Nineteenth Annual Report of the Local Government Board, 1889-90, Sup-
plement, page 217.
Contagiousness of Leprosy.
265
nearly exclusively this individual disposition, and not, as with
other infective diseases, aim at a careful removal of the patho-
genic germs." 9
Keeping these points in mind the nature of the contagious-
ness of leprosy will be discussed from a clinical point of view,
and the results gained from bacteriological work will be given
in the. Laboratory Report. The evidence collected by the
Commissioners during their stay in India can, in the first in-
stance, only apply to this empire. They have come to the
following conclusion, that though they consider leprosy an in-
fective disease, caused by a specific bacillus, and moreover also
a contagious disease, they are of opinion that there is not
sufficient evidence that leprosy is maintained or diffused by
contagion; indeed under the ordinary human surroundings
the amount of contagion which exists is so small that it may be
disregarded, and no legislation is called for on the lines either
of segregation, or of interdiction of marriages with lepers.
It would be useless in an enquiry of this nature to take the
word of the native inhabitants. That the native ordinarily does
not fear the disease may be easily gathered from the fact that
in bazaars leprous vendors are not rarely found selling food or
sweets. Again, however unclean the natives may consider a
leper, as long as he is in the possession of money, he is almost
always welcome. The readiness also with which the native
police and their officials handled lepers brought up for inspec-
tion before the Commissioners was very noticeable. There are
of course differences in this respect in the various parts of India
and the Commissioners can only speak with confidence of the
places visited. This, however, has already been discussed in
another chapter. It has all along struck the Commission that
though a native on being questioned will, as a rule, state that
leprosy is a contagious disease, yet his own acts do not support
his statements.
( 9 ) C. Flügge : loc. cit., page 614.
266
REPORT OF THE LEPROSY COMMISSION:
Neither would it be permissible to be too much guided by
the opinions of medical observers in India. The leper, not
really being such an outcast or deplorable individual as Eu-
ropean opinion considers him to be, is seldom seen in the
dispensaries, preferring to haunt bazaars or other crowded
places to beg. Most Civil Surgeons have not much oppor-
tunity, therefore, of studying the aetiology of this disease, with
the exception of such of them as happen to have large asylums
under their jurisdiction. Moreover, the knowledge that no
treatment of an outdoor nature is of any service in these cases
prevents Civil Surgeons from encouraging their attendance.
The Commission have only been guided by facts obtained
by themselves. From these they deduce the following argu-
ments against a contagion which they deem worthy of a prac-
tical consideration.
I. All the cases brought forward and demonstrated to the
Commissioners as instances of contagion have broken down with
one possible exception. These, as a rule, concerned hospital
or asylum servants. A list of these cases is appended at the
end of this chapter (Table I). Now it seems very significant
that the cases which were supposed to prove the contagion
theory, and on which such theory was really based, almost
entirely collapsed.
II. In not a single case could contagion, or the possibility
of contagion, be actually demonstrated in a manner free from
objection. The native leper, in an overwhelming majority of
instances, offers no suggestion as to the contraction of his
disease ; denies that he has ever had any contact or intercourse
with lepers, and simply accuses fate. Occasionally they men-
tioned that for some time they had eaten with lepers, but their
stories were in most instances too extravagant for belief. For
instance, a patient who had been a sailor, says that while in
Demerara, a leper used to visit his ship, and all the crew used
to smok ethe same hookah with this leper. Two years later
this man contracted leprosy. Similar stories are not rare, but
Contagiousness of Leprosy.
267
they certainly cannot be regarded seriously. In other cases a
man will relate that many years ago he came into contact with
a leper. Such statements have led some authors to assume a
long incubation period for the disease. Now it may be ques-
tioned whether it is still possible to talk of contagion after an
incubation period, which, in many instances, must have extend-
ed over ten or more years. Whatever view may be taken of
this matter, the assumption of an irrationally and disproportion-
ately long latent period is certainly a weak point in any theory
of contagion. And it becomes still weaker when it is considered
that, in the case of leprosy the people who presumably have
been exposed to the risk of contagion during this "long incu-
bation period," have lived in an endemic area.
Special attention was paid by the Commission to the effect
of people eating with lepers. Table V, at the end of this
chapter, shows that seventy-nine lepers ate and drank for
some time out of the same vessels with two hundred and five
healthy people, and of the latter 7 per cent. afterwards became
lepers (Table V). Now these cases all occurred in families.
But it has been shown in Chapter III that leprosy has a tend-
ency to appear in families, though the cause of this is not a
specific hereditary transmission, nor an hereditary predisposi-
tion, but most likely explicable by the fact that the members
of a family are more likely to be subjected to the same abiding
external causes. But in any case the figures obtained from
Table V do not permit a great influence to be conceded to
contagion, even if the instances of possible contagion were
quite free from all objection.
III. In a family contagion has of course the widest play.
However, it has been found that the disease does not spread
sufficiently amongst the members of one family to warrant the
conclusion that it is contagious to any extent. Table II shows
that an assumed contagion could be traced in only 5 per cent.
IV. Again, when the intimate intercourse between man
and wife is considered, it is astonishing how seldom the wife