NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
268
REPORT OF THE LEPROSY COMMISSION:
" catches " the disease from her husband, or vice versâ. Yet
it is well known that bacilli may easily be found in the sper-
matic fluid, 10 and here then there is an opportunity offered for
oft-repeated inoculation through the mucous membrane of the
genital tract. Yet a case is hardly ever found where bond
fide the disease may be assumed to have spread from husband
to wife (Tables III and l\\a).
V. Next, vaccination has been mentioned as affording a
risk of diffusing leprosy. This statement is not borne out by
facts ascertained in India. Firstly, the number of persons
actually vaccinated in India is very small in comparison with
the general population. Taking the total number of people in
Bengal, North-Western Provinces and Oudh, Punjab, Central
Provinces, Berar, Lower Burma, Assam, Madras, Bombay, and
Coorg, it appears that in the year 1889 of 7,985,543 children
available for vaccination only 2,178,464, or 27.2 per cent. were
vaccinated. 11 Secondly, a considerable number of these were
vaccinated from the calf. Thirdly, where arm-to-arm vacci-
nation is practised, lymph is taken from the vaccinifer at an
age when leprosy rarely occurs. Fourthly, the experimental
evidence of the Norwegian doctors, quoted by Leloir, seems
to indicate that it is highly questionable whether such inocu-
lation, as vaccination implies, would be able to produce the
disease in another person, even granted that the vaccinifer
were a leper, and that the lymph contained bacilli. Lastly,
as will be seen more fully from the Laboratory Report, three
of the Commissioners vaccinated a number of lepers over
healthy and affected areas, and subsequently examined the
lymph for the characteristic bacilli. In no case were undoubted
leprosy bacilli found, either in the lymph or crusts ; of ninety-
( 10) ) Nature, Origin, Transmissibilily, the Methods of Propagation and
Transmission of Leprosy, by M. E. Besnier. Translated by Surgeon-Major
O. Baker. Calcutta, 1889, pages 8 and 10.
( 11 ) Twenty-sixth Annual Report of the Sanitary Commissioner with the
Government of India, 1889. Appendix to Section VII, page 164.
Contagiousness of Leprosy.
269
three specimens only six were slightly suspicious (Table VI
at the end of this chapter). It has been ascertained by
experiment (Laboratory Reports) that if a blister be raised
over apparently healthy skin, its serous fluid will be quite
free from the bacilli, while in blisters raised over leprous
nodules, bacilli may in some cases be found. And surely no
one would ever think of vaccinating an individual over a
tubercle or diseased part, or if he did so, would employ such
lymph to vaccinate another individual. The practical danger,
therefore, of leprosy being diffused in this manner, even
supposing the disease to be highly contagious, is minimal.
The instances quoted in literature of leprosy being " vaccinated "
on to a healthy child are too equivocal and ambiguous to
carry much weight. 12
Dr. Arning, 18 who obtained more positive results and found
bacilli in the vaccine lymph, states distinctly that he obtained
bacilli only in cases of extensive cutaneous leprosy. The latter
fact removes at once all fear, because all vaccinators would have
some hesitation in vaccinating from such a person. Surgeon-
Major Oswald Baker's results, 11 on the other hand, fully agree
with those of the Commission, although, in his vaccination
experiments, he selected sites solely with reference to the pre-
sence of characteristic patches of leprosy. From what has been"
said it is evident that practically there is no risk of a diffusion
of the disease in vaccination from arm to arm.
VI. Attempts were made to enquire into the possibility of
a leprous community becoming or acting as a centre whence
the pest might be diffused amongst the population. A research
of this nature is obviously connected with great difficulties in
a vast country like India.
( 12 ) W. T. Gairdner, Brit. Med. Journ., 1887; and Daubler, Monatschr. f.
prakt Dermat. 1889.
( 13 ) Journal of the Leprosy Investigation Committee, No. 2, Feb. 1891, page
131.
( 14 ) Nature, Origin, Transmissibility, etc., of Leprosy, by M. E.
\ill\
Translated by Surgeon-Major O. Baker, page 4
270
REPORT OF THE LEPROSY COMMISSION:
The census returns present strong arguments against such
a spread of leprosy, since the ratio figures remain more or less
unchanged. An absolute value, however, cannot be attached to
these figures, as here the diagnostic powers of laymen and the
inaccurate statements of natives are liable to mislead an enquirer.
Nevertheless census returns do possess a high relative value,
especially if, as in the present instance, opportunities are offer-
ed of comparing the statistics of three decennial periods. On
these points reference must be made to Chapter III of this
report.
Tarn Taran allows valuable deductions to be drawn as' to
the risk of the spread of disease around a leprous community.
A quarter of the town, in absolute continuity with the rest, is
kept apart for, and inhabited solely by, lepers. This condition
of things, however, has not caused a diffusion of the disease
among the healthy population, the number of lepers remaining
more or less stationary, or, at least, never increasing beyond,
the original ratio. Nor has any diffusion, even to the imme-
diate neighbourhood of the leper quarter, ever been known to
occur. Lepers wander to Tarn Taran to bathe in its holy tank,
which is supposed to possess special healing powers, and thus
the number of lepers is always maintained. But the disease is
not especially prevalent amongst the people of the district, and
though this leper quarter has existed for many years, the
disease has not increased amongst the original inhabitants.
For the figures in support of this statement, reference should
be made to Chapter III, where this point is specially discussed.
Unfortunately on account of insufficient data this line of
argument cannot be followed out. But it may be remarked
and taken for what it is worth, that it is an almost universal
opinion of scientific and intelligent men in India that a spread
of the disease has never been known to take place from a leper
centre to its neighbourhood. 15
( 15 ) Cf. Chapter II : Belgaum and Bombay.
Contagiousness of Leprosy.
271
VII. It is believed in some parts of India, especially in the
hill tracts, that those who go barefoot are liable to be directly
inoculated with leprosy through wounds or ulcers of the feet.
In one station in Burma, visited by the Commissioners, they
were informed that leprosy had spread among the members of
a school after lepers had been in the habit of walking about
the compound. As, however, an examination of some of the
supposed lepers in this school showed that several of them
were not suffering from this disease, this statement was consi-
dered open to doubt.
At Almora an opportunity occurred of examining the paths
and banks in the asylum compound, on which the lepers were
in the habit of walking and sitting. One hundred cover-glasses
were prepared from earth taken from these sites, and only ten
leprosy bacilli were found in the whole number of specimens.
But at present no criterion of a living leprosy bacillus exists,
and in any case the small number found in an extended series
of observations, on the most favourable material, would sug-
gest that the danger of individual inoculation is possible, but
that the risk of the diffusion of the disease in this manner is
very slight. On the other hand, it is noteworthy that an exa-
mination of dust from huts inhabited by lepers suffering from
the tubercular and anaesthetic types of the disease, and afflict-
ed with ulcers on their feet and hands, confirmed the observa-
tion of Kaurin, 16 who has not succeeded in finding bacilli in
the earth, dust or air in the rooms of lepers (Table VII).
VIII. This chapter may be concluded by stating that the
Commissioners during their enquiries met with many cases
where people, either voluntarily or for various reasons, lived in
asylums with lepers, often eating and drinking with them, or
smoking with them, perhaps attending to their wants and ail-
ments, and yet remained perfectly untainted, often after many
( 16 ) Kaurin : Journal of the Leprosy Investigation Committee, No. 2, Feb. 1891,
page 68.
272
REPORT OF THE LEPROSY COMMISSION:
years of such association. The value of such instances may be
questionable as evidence against contagion, being entirely on the
•negative side, still they are highly instructive in throwing light
on the practical dangers of contagion, and until an actual positive
case, free from all objection, is published, increase in worth.
Such an absolutely positive case so far is not known, as a perusal
of the Journal of the Leprosy Investigation Committee will show.
In the absence of such information, it is permissible to deny the
practical possibility of the spread of leprosy by contagion. A
case can only be positive, if it answers all the conditions postu-
lated by Virchow : " It must be an observation made with the
full assurance and every guarantee of certainty." A study of
Tables IV and IVa will show that of one hundred and four
persons living with lepers in asylums, under the most favourable
conditions for contracting a communicable disease, only one, or
possibly two, became lepers (1 or 2 per cent.)..
Summary.—In coming to the conclusion that, as far as
practical conditions and surroundings are concerned, the danger
of leprosy being diffused and spread by contagion is exceeding-
ly small, arguments have been used which do not possess the
character of novelty. India, however, offers no other, and
since extended and numerous experiments obviously cannot be
made on man, and knowledge gained from animal inoculations
cannot be entirely relevant, deductions can only be drawn from
clinical evidence. This clinical evidence, for India at any rate,
is strongly against a measurable contagiousness of leprosy.
It is in fact with leprosy exactly as with tuberculosis, and all
that has been said about the latter affection may be applied
equally to the disease which forms the subject of the present
enquiry.
In leprosy, therefore, the disposition of the individual plays
an important part, just as it does in phthisis. With the as-
sumption of such disposition the practical importance of con-
tagion is reduced to a minimum, and it becomes the duty of the
reformer to find means to prevent and counteract this dispos-
Contagiousness of Leprosy.
273
ition. With the discovery of the bacillus lepræ by Hansen the
infective nature of the disease has been finally established, and
subsequent experiments have also shown that in the scientific
sense of the word the disease must be classed amongst the
contagious diseases as defined above. But these facts must
not obscure all other evidence, and it must not be forgotten
that contagion is but a relative term, and that where reforms
and similar measures are under consideration, the actual and
concrete influence of contagion is the factor to be considered.
This, however, has been shown to be as small as, or even rather
less than, in the case of tuberculosis.
274
REPORT OF THE LEPROSY COMMISSION:
APPENDIX TO CHAPTER V.
Several tables, with some necessary comments, will now be
given to illustrate the arguments used in the previous pages.
TABLE I.
Cases brought forward in Proof of the Contagiousness of Leprosy.
(1) Agra.—One of the dressers whose duty it was to rub gurjun oil into
the skin of lepers was said to have developed leprosy in consequence. The
hospital assistant, however, without being asked, volunteered the statement that
this dresser was a leper before he commenced his duties.
(2) Ajodhya.—A woman was supposed to have caught the disease from her
husband. On visiting her in her own home it became evident that she was
not even a leper, but had suffered from paronychia of the thumb of one hand
which had led to a slight deformity of the nail and ungual phalanx.
(3) Bombay.—(a) A patient in the Trombay Asylum emigrated to Mauri-
tius, and returned to India in 1884 with swelling of the eyebrows and black
patches on the cheeks. When this asylum was opened in 1885 he began
work as a ward boy, and continued in that capacity until a year ago, when
signs of leprosy became so marked that he became a patient in the asylum.
(b) A student in Bombay, while making an autopsy on a leper, pricked
his hand. A short time afterwards he suffered from fever, and the hand
became inflamed and swollen. Pain and thickening in the course of the ulnar
nerve followed, and later there was wasting of the muscles supplied by this
nerve together with anaesthesia over the area supplied by it. Similar nerve
symptoms then occurred on the opposite side, and the patient suffered from
pain in the region of the heart. He was under treatment for some time, and
the symptoms all disappeared. Shooting pains in the course of the ulnar
nerves recurred during some months, but eventually disappeared again and
he remained quite well. At no time did any discoloured anaesthetic patches
occur on the body, and the anaesthesia and wasting were confined to the
distribution of the ulnar nerve.
This history clearly points to a neuritis set up by septic infection, which
subsided under treatment. Yet the case when it first occurred was quoted as
an example of the inoculability of leprosy.
(4) Calicut.—The patient had been a sweeper at the asylum for twenty-
three years. In this capacity he also had to dress the worst ulcers. He used
Contagiousness of Leprosy.
275
to mix freely with the lepers and eat what they left. According to his own
assertions he was quite well twenty-three years ago and developed leprosy only
two years ago. He belonged to Calicut and was of a very low caste. His
father was not a leper, and this was confirmed by the cook of the asylum, who
had resided there for thirty years. The father had been a sweeper for six
years, his son succeeding him on his death. The patient's mother, and his six
brothers and sisters, were all healthy. An old inmate of the asylum, on the
other hand, asserted that the sweeper had suffered from leprosy for at least six
years, but was apparently healthy twenty years ago.
This case is the only one quoted in support of contagion which has not
utterly broken down, and whatever value it possesses in the way of positive
evidence must be conceded.
(5) Madras.—The cook of the asylum had been employed for fifteen
years, and was suffering from incipient leprosy. He had a discoloured and
anaesthetic patch over the right knee, and a similar patch on the right side of
his face. He asserted that these changes were of six months' standing, and
denied all family history of leprosy.
On making enquiries of an old patient (an intelligent Eurasian and a pupil
teacher), it was found that the patch in the face existed before the cook came
to the asylum ; moreover, at that time he attended as an out-patient and was
treated with gurjun oil. Without the knowledge of the patient his brother was
interrogated, and he assured the Commissioners that the patch on the face had
existed over fifteen years, and that their mother, another brother, and one of
the sister's sons also were lepers. This witness had always considered his
brother to be a leper.
It is quite clear that this case is valueless as an instance of contagion.
(6) Tanjore.—A Hindu, aged 45, who had suffered from leprosy for ten
years, stated that his wife had lately become a leper. He had constantly lived
with her. The Commission visited the latter at her house and found on exa-
mination that she complained of a feeling in the soles of her feet as though
she were walking on wool. She had no anaesthesia or patches, and was cer-
tainly not a leper.
(7) Trichinopoly.—A patient in the asylum stated that he suffered from a
skin eruption eleven years ago. He wished to be admitted into the asylum as
a patient, but admission was refused as the disease was too slight. He was
employed as a ward cooly, and used to dress the lepers' ulcers. He contra-
dicted himself as to dates, but was certain that the disease appeared after he
joined the asylum.
On referring to the records of the asylum it was found that the patient
"was admitted as a leper on the 25th of March, 1880, and discharged on the
17th May, 1880," when he was said to be cured. Further it was found in the
letter book of the asylum that the patient commenced his duties as ward cooly
T 2
276
REPORT OF THE LEPROSY COMMISSION:
in July, 1882, during the absence on leave of the former ward cooly. This
man, who happened to be in Trichinopoly, was questioned separately and
without his having had any communication with the patient. He stated that
when he returned from leave he threw up the appointment, and the patient
was confirmed in it. Three years later the leprosy became more marked, and
he was placed on the asylum register as a patient.
In this case the statement of the patient, that he contracted leprosy after he
became an attendant at the asylum, was clearly disproved by the evidence of
the asylum records and that of his predecessor in office.
The above eight examples illustrate very clearly the class
of cases usually adduced to prove the contagiousness of leprosy.
The cases at Madras, Agra, Trombay, Calicut, and Trichinopoly
all relate to persons employed, at one time or other, in the
asylums. At Ajodhya and Tanjore the evidence offered is that
of husband and wife, while at Bombay the case quoted is that
of a student who accidentally infected himself during an
autopsy on a leper. For the details of the last case the Com-
missioners are indebted to Surgeon-Major Hatch of Bombay.
The case was published when it first occurred, and was widely
quoted as an example of the inoculability of leprosy. 17 The
first symptoms, indeed, were very suspicious, but the Commis-
sion are of opinion that the further progress of the case, as
related by Dr. Hatch, entirely negatived the original diagnosis
of leprosy. Besides, it is well known that infective processes
are not unfrequently followed by peripheral and central nervous
changes.
In the two cases in which the wife was supposed to have
contracted leprosy from the husband, an examination showed
that the woman was not a leper at all, while in four out of five
cases in which asylum attendants were supposed to have been
infected by the inmates, the former were shown to have been
lepers before they entered on their duties.
Thus the Calicut case alone remains. But the statement
of the patient himself and that of the old inmate of the asylum
( 17 ) Lancet, May 17, 1890, page 1064.
Contagiousness of Leprosy.
277
are considerably at variance as to dates. And it must always
be remembered that in a country like India, where leprosy is
endemic, it is quite possible that the patient may have acquired
the disease from some source other than the asylum : in other
words, that the case may have been merely a coincidence.
TABLE II.
Table showing in how many Instances the Disease may be said to
" have spread " from one Member of a Family to Another.
NAME OF ASYLUM, ETC.
Agra
Aligarh
Almora
Bangalore ,
Benares .
Bombay .
Burdwan .
Calcutta .
Calicut
Cawnpore
Conjeeveram
Darjeeling
Dehra Dun
Delhi
Fyzabad .
Gwalior
Gya
Hyderabad
Jubbulpore
No. of
lepers.
28
5
39
4
10
60
12
40
13
8
2
44
5
7
2
16
7
8
No. of
people
living with
them.
55
19
86
15
34
105
37
67
43
20
40
8
116
18
20
9
46
12
22
No. of
such people
affected.
4
...
8
2
...
8
...
2
...
2
11
...
...
...
1
...
...
REMARKS.
One case is doubtful.
In one case the disease ap-
peared sixteen years alter
the death of the leper.
One case doubtful.
Of these two became lepers
many years after the death
of the leper they came in
contact with.
278
REPORT OF THE LEPROSY COMMISSION:
Table II—continued.
Table showing in how many Instances the Disease may be said to
" have spread " from one Member of a Fa?nily to Another.
NAME OF ASYLUM, ETC.
Jummoo .
Kapurthalla
Lucknow .
Madras
Madura
Mandai ay .
Moulmein
Nagpur
Naini and Allahabad .
Patiala
Prome
Purulia
Rangoon .
Rawalpindi
Sialkot
Subathu .
Tanjore
Tarn Taran
Thayetmyo
Trichinopoly
Umballa .
TOTAL
No. of
lepers.
1
2
5
60
5
79
9
67
6
1
20
25
20
9
1
5
7
37
24
6
7
719
No. of
people
living with
them.
3
2
6
156
21
205
14
166
14
2
62
53
33
19
3
14
16
53
51
6
20
1,691
No. of
such people
affected.
...
1
...
17
....
4
2
3
...
1
4
11
1
...
...
2
4
7
...
...
95
REMARKS.
This case is very doubtful.
Five cases doubtful.
In one case the child ac-
quired the disease at the
same time as the father.
These cases are both doubt-
ful.
One case doubtful.
Ditto.
These two cases are doubt-
ful.
Three cases are doubtful.
Diagnosis doubtful in seven-
teen cases.
In the construction of this table only those cases have
been chosen where it was stated that the members of the
Contagiousness of Leprosy.
279
respective families lived together. In many instances no
special notice had been taken of this fact, and all these have
been disregarded unless a case of leprosy occurred amongst
the children. Now, no doubt, as in many of the cases left out
on account of insufficient details there has been no separation
or segregation of the leper, this table will over-rate the chances
of a possible contagion rather than under-estimate it. It will
be seen that about 5 per cent. of the persons living in daily
intercourse with lepers under the same roof at one time or
other developed the disease. A number of children have been
left out of consideration because they died as infants or while
very young. This has been done in order to give the argu-
ment in favour of contagion every possible advantage, for surely,
where contagion as such is discussed, age need hardly be consi-
dered. If a disease be contagious it should be so at any age.
But if it is necessary to assume a long incubation period, as many
writers do, which sometimes extends through infancy and child-
hood, until what is called the probable age of attack is reached,
this is surely an unjustifiable extension of the term contagion,
or a practical denial of the influence of contagion by a reduction
to an absurdity. Again, in some cases entered in the table,
the diagnosis of leprosy was extremely doubtful, and in one
case the child contracted the disease at the same time as the
father. Thus by allowing the validity of these cases a further
advantage is allowed to the hypothesis of contagion. And yet
in only 5 per cent. of the cases could a possible influence be
assumed.
But the ratio obtained from this table of course cannot be
taken to represent the actually existing chances of infection.
For from among the total community coming into contact with
lepers, only a few have been selected. Moreover all other
causes, such as endemicity, or a de novo origin of the disease,
have been altogether disregarded. However, assuming, for
argument's sake, that all the above cases are genuine instances
of contagion, and that the spread of leprosy depends on this