LEPROSY 
 
 AND ITS PREVENTION AS ILLUSTRATED BY 
 NORWEGIAN EXPERIENCE
 
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 JLEPROSY 
 
 AND ITS PREVENTION] 
 
 As ILLUSTRATED BY NORWEGIAN EXPERIENCE 
 
 BY 
 
 ROBSON ROOSE, M.D., LL.D., F.C.S. 
 
 FELLOW OF THK ROYAL COLLEGE OF PHYSICIANS IN KDINBUBGH, AUTHOR OF 
 
 " GOUT, AND ITS RELATIONS TO DISEASES OF THK LIVER AND KIDNKYS," 
 
 "NERVE PROSTRATION AND OTHER FUNCTIONAL DISORDERS OF 
 
 DAILY LIFE," "INFECTION AXD DISINFECTION," ETC., ETC. 
 
 LONDON 
 
 H. K. LEWIS, 136, GOWER STREET 
 1890
 
 L 
 
 LONDO.N : 
 II. K. LEWIS, 13, GOWEB STKEKT.
 
 PREFACE. 
 
 DURING several visits to Norway, in recent years, I 
 have had many opportunities of observing cases of 
 leprosy, and of studying the forms and clinical features 
 of the disease as it appears in that country. I have 
 noticed, with deep satisfaction, the steady diminution 
 in the number of cases, as shown by trustworthy 
 ) statistics, and I have made inquiry into the causes 
 > which have produced so desirable a result. The little 
 ^ work, which I now offer to the profession, contains 
 many facts which came under my notice when prose- 
 \ cuting these investigations ; and I take this oppor- 
 tunity of thanking several Norwegian physicians 
 especially Dr. Kaurin, of Molde) for their courtesy 
 and kind assistance, and for the information they 
 readily afforded me. I do not, of course, profess to 
 have given a complete account of leprosy ; I have 
 narrated its history and symptoms, but my especial 
 object has been to point out the manner in which its 
 spread may be arrested, and to invite attention to the 
 lessons to be drawn from recent experience in Norway. 
 I would advise those of my readers who are anxious 
 obtain full information on the subject of leprosy, to 
 consult Dr. Leloir's magnificent Traite Pratique et 
 Theorique de la *Lere. 
 
 45, HILL STREET, 
 
 BERKELEY SQUARE, W. 
 November, 1889.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAGE 
 
 HISTORY AND PRESENT DISTRIBUTION OF LEPROSY i 
 
 CHAPTER II. 
 
 THK FORMS AND SYMPTOMS OF LKPROSY ... ... 23 
 
 CHAPTER III. 
 
 MORBID ANATOMY AND CAUSATION OF LEPROSY 47 
 
 CHAPTER IV. 
 
 THE TREATMENT AND PREVENTION OF LEPROSY ... 75
 
 ERRATUM. 
 
 Page 1 1, line 19, for "one-fifth" read "one-fifteenth."
 
 LEPROSY, 
 
 AND ITS PREVENTION. 
 CHAPTER I. 
 
 HISTORY AND PRESENT DISTRIBUTION OF LEPROSY. 
 
 LEPROSY is a chronic disease, distinguished anatomi- 
 cally by the formation of tuberous growths in the 
 tissues. Its external manifestations are local anaes- 
 thesia, maculae, thickening, and various alterations in 
 the colour of the skin, pemphigus, the development of 
 nodes or tubers, ulceration,- febrile attacks, loss of por- 
 tions of the extremities, atrophy of muscles, destruction 
 of parts of the face, and especially of the nose, mouth, 
 and larynx. Death occurs from marasmus, suffocation, 
 syncope, or coma, or from intercurrent disorders. 
 
 Much confusion has arisen with regard to the 
 disease, owing to the variety in the names by which 
 it has been designated. The term " lepra '' was first 
 applied by Hippocrates and others to the complaint 
 which is now named " psoriasis." When true leprosy 
 became known, the terms " leontiasis " and " ele- 
 
 i
 
 2 LEPROSY, 
 
 phantiasis " were made use of to describe it. The 
 latter name, however, was afterwards applied to the 
 complaint now known as " Barbadoes leg ; " while 
 "lepra" was held to signify true leprosy. Hence it 
 came to pass that very different diseases were described 
 under the same name. We now speak of Elephantiasis 
 Graecorum, or true leprosy (equivalent to lepra Arabum) 
 and Elephantiasis Arabum (equivalent to " Barbadoes 
 
 leg"). 
 
 The earliest accounts that we possess of the disease 
 known as " Leprosy" are to be found in the Books of 
 Moses. It would appear that the Israelites, either 
 while sojourning in Egypt, or during their wanderings 
 in the desert, were attacked by a disease of so serious 
 a character as to require the most severe and minute 
 regulations in order to prevent its universal spread. 
 Dr. Kalisch, in his excellent commentary on the Old 
 Testament, states that in old traditions leprosy and 
 other contagious disorders were not unfrequently repre- 
 sented as having really caused the expulsion of the 
 Israelites from Egypt. Moses, however, attributes the 
 Exodus to a very different cause, and his version of 
 the case is generally accepted. It is enough for our 
 present purpose to recognize the facts that leprosy
 
 AND ITS PREVENTION. 
 
 was the most disastrous of the various diseases 
 endemic among the ancient Hebrews ; that it clung 
 to them throughout their history, and that in all pro- 
 bability it first became known to them during their 
 stay in Egypt. The endemic character which the 
 disease acquired is shown by its prevalence during 
 the epochs intermediate between the Exodus and the 
 Assyrian, Babylonian and Persian periods, and that it 
 prevailed at much later periods is shown by the 
 number of miracles performed by Christ upon persons 
 described as lepers. Whether the leprosy of the 
 Bible was exactly identical with the disease of the 
 present day is a question upon which much con- 
 troversy has arisen ; Dr. Kalisch states that the so- 
 called " white leprosy " (which includes the anaesthetic 
 and the tuberous forms) is equivalent to the lepra 
 Mosaica or Hebraeorum, while elephantiasis, first and 
 mainly attacking the feet, is probably meant and 
 described in the Book of Job. Sir Risdon Bennett, in 
 his little work on The Diseases of the Bible, states 
 that there is no sufficient evidence that elephantiasis 
 (true leprosy) is denoted in any of the accounts to be 
 found in the Mosaic records. Perhaps the difficulty 
 may be solved by supposing that the " leprosy " of the
 
 4 LEPROSY, 
 
 Bible comprehended not only the disease as we see it 
 at present, but other cutaneous affections more or less 
 similar in appearance. 
 
 For many centuries after the time of Moses, Egypt 
 was regarded as the home of the disease; but there is 
 evidence to the effect that leprosy was known in India 
 in the fourteenth or fifteenth century B.C. Some 
 800 years later, we learn that the Persians were 
 afflicted with a complaint which was probably leprosy; 
 isolation and expulsion of the sufferers were the 
 simple measures they adopted. In process of time 
 the disease was heard of in Europe, Greece being the 
 country that was first invaded. It spread thence to 
 Italy, having probably been conveyed thither by 
 Pompey's troops. In the last century B.C. leprosy 
 became established in the Roman Empire. 
 
 The spread of the disease throughout Europe is 
 easily accounted for ; wherever the Roman arms were 
 carried, leprosy would necessarily follow. Military 
 operations are especially favourable to the spread of 
 contagious diseases. Many striking proofs of this 
 statement are afforded by the history of syphilis, be- 
 tween which and leprosy not a few similarities exist. 
 As a result of military invasions, not only is the
 
 AND ITS PREVENTION. 
 
 diffusion of contagia increased and accelerated, but the 
 gravity of the symptoms is liable to be much aggra- 
 vated by the circumstances attendant upon prolonged 
 and severe campaigns. The Romans doubtless con- 
 veyed the germs of the disease to Spain, France, and 
 Germany, and although there are no records which 
 enable us to trace its progress in Europe during 
 several hundreds of years afterwards, the steps that 
 were taken to check its spread in the seventh and 
 following centuries sufficiently indicate the alarming 
 frequency of the disease and the terrible character it 
 had assumed. 
 
 We learn from Virchow's researches that in the 
 early part of the seventh century, leper asylums 
 existed in Italy and Switzerland, and at Metz, Verdun, 
 Maestricht, etc. In 757 the Prankish King Pepin, 
 and Charlemagne in 789, enacted laws with regard to 
 the marriage of lepers. Dr. Hirsch's investigations 
 show that leper hospitals were established in the 
 Prankish kingdom in the eighth and ninth centuries ; 
 in Ireland in the year 869; in Spain in 1007; in Eng- 
 land in the eleventh century ; in Scotland and the 
 Netherlands in the twelfth, and in Norway in the 
 thirteenth century.
 
 6 LEPROSY, 
 
 During and after the Crusades, leprosy spread with 
 extraordinary rapidity, and excited the greatest alarm 
 among those who ' witnessed its ravages. Leper 
 hospitals were to be found in every part of Europe. 
 It is estimated that in the twelfth century there were 
 2,000 such hospitals in France alone, and 19,000 in 
 the whole of Christendom. It seemed as though an 
 altogether new plague had been sent to punish man- 
 kind. Indeed, some historians have asserted that the 
 leprosy of the Middle Ages was a newly-introduced 
 disease, brought for the first time from the East by 
 those who returned from the Crusades. As a matter 
 of fact, however, the earliest date at which any of the 
 Crusaders retraced their steps westwards was 1098, 
 and there is abundant evidence to show that several 
 leper hospitals were founded before that period. One 
 of these institutions was established in England by 
 Lanfranc, who died in 1089. Cases of leprosy of a 
 very severe type were doubtless frequent among the 
 returning Crusaders, and an extremely virulent form 
 thus became rapidly superadded to the disease already 
 existing in the various countries of Europe. The 
 history of this spread of leprosy after the importation 
 of new cases resembles that of the great epidemic of
 
 AND ITS PREVENTION. 
 
 syphilis towards the end of the fifteenth century. So 
 virulent were the symptoms of this outbreak that the 
 disease was erroneously supposed to have made for 
 the first time its appearance in Europe. 
 
 In some highly interesting articles which appeared 
 in the Edinburgh Medical and Surgical Journals for 
 1841-42, the late Sir J. Simpson has given an ex- 
 haustive account of leprosy and leper houses in Eng- 
 land, Scotland, and Ireland, from the earliest times. 
 He points out that these hospitals were simply re- 
 ceptacles for infected persons, and not medical insti- 
 tutions, for the disease was regarded as absolutely 
 incurable. The patients were engaged in religious 
 duties, and subjected to hard discipline. They appear, 
 however, to have been well cared for ; they were sup- 
 plied with good diet and clothing, and sanitary rules 
 of various kinds were strictly enforced. In England, 
 between uoo and 1472, no fewer than 112 such 
 hospitals were built and richly endowed. Some were 
 founded by the wealthy and noble after they had 
 themselves become victims of the malady. The 
 largest leper hospital in England was at Sherburne, 
 about three miles from Durham ; it was built by Bishop 
 Pudsey in 1181. At this hospital, we are told, refrac-
 
 8 LEPROSY, 
 
 tory lepers were sometimes chastised with the birch 
 " modo scholarium." Lepers, by English law, were 
 classed as idiots or insane persons ; they could not 
 inherit any property, and were in fact regarded as 
 though already dead. The Church performed burial 
 rites over a leper on his admission into hospital ; he 
 was clothed, and in all respects treated as a corpse 
 in foro ecclesiae. Sir J. Simpson tells us that in 
 France not many decades ago, the ritual still contained 
 the office for the separation of the leper from the 
 living. The ceremony must have been a painful one 
 to the miserable sufferer; its final act was terribly 
 significant. A shovelful of earth was thrown upon 
 the leper ! 
 
 The first notice of leprosy in Ireland is said to date 
 from 432. There is a legend to the effect that St. 
 Patrick maintained a certain leper in his house and 
 washed the sores with his own hand. It is certain that 
 the disease was very prevalent in later times. It was 
 ascribed to the constant use of raw meat by the 
 natives, and likewise to their foul gluttony " in the 
 excessive devouring of unwholesome salmon." The 
 complaint is said to have disappeared from Ireland 
 when the English made laws against taking salmon out
 
 AND ITS PREVENTION. 
 
 of season. There were at one period 18 leper hospitals 
 in Ireland. 
 
 Leprosy was prevalent in Scotland in early times, 
 though not to the same extent as in the adjacent 
 countries. A hospital was founded in Glasgow, in 
 1350, and another in Edinburgh in 1584. The latter 
 was pulled down in 1657. 
 
 The time at which leprosy practically disappeared 
 from the British Isles is a point of considerable 
 interest in reference to the causation of the disease. 
 It is certain that the malady became very rare during 
 the reign of Henry VIII. Shakespeare uses the word 
 "leperous" in the sense of "poisonous" (Hamlet, 
 Act I., line 779), and it is curious to notice that he 
 attributes the breaking out of a " vile and loathsome 
 crust " over a " smooth body " to the " leperous 
 distilment" poured into the ears. Milton, in his 
 description of the lazar-house in the eleventh book of 
 the Paradise Lost, does not mention leprosy as an 
 example of " maladies of ghastly spasm or racking 
 torture," though he had doubtless often heard of the 
 ravages of the disease. After the disappearance of 
 leprosy, the hospitals became filled with cases of 
 syphilis. Instances of the former disease were to be
 
 10 LEPROSY, 
 
 found in the northern islands of Scotland long after it 
 had disappeared from the mainland. It was very 
 general in Zetland in 1750, and Dr. Edmonstone saw 
 a few cases in Scotland at the beginning of this century. 
 In Ireland, the last recorded case was under treatment 
 in St. Stephen's Hospital at Waterford in 1775. 
 
 Throughout Europe generally a progressive dimi- 
 nution of leprous cases took place towards the close of 
 the fifteenth century. ^The decline was most rapid in 
 countries in which the condition of the people had 
 been decidedly improved, and the strictest segregation 
 of the lepers had been enforced. } There is also much 
 probability in Dr. Hirsch's view that physicians had by 
 that time learnt to distinguish between leprosy and 
 syphilis, and that a more exact diagnosis of each 
 disease had played a considerable part in reducing the 
 number of leprosy cases. Still the fact remains, that 
 for several centuries before the time in question leprosy 
 had prevailed as an endemic disease throughout Europe, 
 and that afterwards comparatively few cases were 
 heard of, except in Norway and certain special districts. 
 Dr. Leloir draws attention to the fact that in France 
 the tuberous form seemed to pass away earlier and 
 more rapidly than the anaesthetic variety.
 
 AND ITS PREVENTION. 11 
 
 The disappearance of the disease from Europe was 
 followed by its introduction into the Western Hemis- 
 phere. It was doubtless conveyed thither by the 
 European adventurers, and a much larger importation 
 of leprous cases resulted from the arrival of the negroes. 
 In later times the Chinese immigrants helped materially 
 to spread the disease. Whenever the natives avoided 
 contact with the strangers, as did the Indians of North 
 America, they remained free from the disease. Pro- 
 miscuous intercourse, on the other hand, as in the 
 case of the natives of Mexico, resulted in leprosy 
 becoming endemic. 
 
 One of the saddest instances of the introduction of 
 leprosy among a people previously free from it is 
 afforded by the history of the Sandwich Islanders. 
 According to several authorities, the importation of 
 leprosy into those otherwise fortunate Isles was due to 
 the Chinese immigration in 1840. It would appear 
 that at the present day nearly one-ijufi of the in- 
 
 lui 
 
 habitants are affected with the disease. , 
 
 Dr. Leloir points out that the history of leprosy 
 clearly shows that this disease has always followed the 
 movements of men, whether for warlike or commercial 
 purposes, and that when a leprous race has come into
 
 12 LEPROSY, 
 
 contact with one previously unaffected, the spread of 
 the disease has invariably followed. On the other 
 hand, the people who hold aloof from the invaders 
 escape from the plague, even if their condition as 
 regards hygiene be as unfavourable as possible. 
 Another fact deserves attention, viz., that the isolation 
 of leprous patients by public authorities has always 
 resulted in the diminution and eventual disappearance 
 of the disease, and the rapidity of its subsidence 
 has always been in direct proportion to the rigour with 
 which the necessary measures were put in force. \ In 
 subsequent pages, I shall cite several facts illustrating 
 the effects of isolation. 
 
 The geographical distribution of leprosy at the 
 present day is perhaps more important than even the 
 history of the disease. Beginning with Europe, we find 
 that the disease is endemic in a few districts, which 
 are for the most part closely circumscribed. The 
 most noted European centre of leprosy at the present 
 time is the west coast of Norway, from Stavanger up 
 to Tromsoe, most of the cases, as stated by Dr. Hirsch, 
 belonging to the departments of Sondre and Nordre 
 Berghus, which have been the head-quarters of the 
 disease in that country from the earliest times. During
 
 AND ITS PREVENTION. 13 
 
 a recent visit to Norway, and on another occasion 
 (1887), I devoted some time to an examination of 
 several leper hospitals, and through the courtesy of 
 my friend Dr. Ed. Kaurin, of Molde, I obtained 
 much interesting information with regard to leprosy 
 in general, and particularly as to its prevalence 
 in Norway. I found that the districts north of 
 Trondhjem, and the neighbourhood of the Sogne 
 Fjord were the principal centres of the disease, but 
 that even in these districts there had been a decided 
 diminution in the number of cases since 1879. The 
 disease is, certainly, most prevalent along the sea- 
 coast. Dr. Kaurin informed me that in 1885 Norway 
 contained about 1,195 lepers; he estimated their 
 number at the present day to be from 1,000 to 1,100. 
 In 1 88 1 the number was about 400 in excess of the 
 latter figure. 
 
 Since 1856, the number of lepers existing in Norway 
 has been carefully registered by the authorities, and 
 the results indicate a very gratifying diminution in the 
 number of cases. In 1856 the number of lepers was 
 reckoned at 2,113; U P t ^69 there had been but 
 little alteration, and some of the years show a slight 
 increase. The diminution has proceeded without
 
 14 LEPROSY, 
 
 interruption since 1870, and thus it appears that the 
 number has decreased by one-half in the course of 
 thirty-three years. Dr. Hirsch's statistics indicate a 
 still more remarkable diminution. He gives the 
 number of lepers in Norway in 1856 as 2,847. The 
 figures, however, which I have quoted above were 
 taken from the Norwegian Official Statistics. In 
 connection with these figures it is worthy of notice 
 that the Molde hospital, built to accommodate 150 
 patients, now contains only 80. Dr. Leloir states that 
 when visiting Norway in 1884 he found that the lepers 
 entered and left the hospitals just as they pleased. 
 They manufactured various articles, which were sold 
 in the streets, and even mended boots and shoes. He 
 saw at Bergen lepers standing in the market-place, 
 offering eatables and other objects for sale. In the 
 following year the Government decreed the absolute 
 segregation of lepers. These enactments will be after- 
 wards referred to. 
 
 In Sweden, a few years ago, about 100 cases of 
 leprosy were said to exist ; of these 86 were to 
 be found in a small district in Gefleborg. Iceland 
 probably contains about the same number. The
 
 AND ITS PREVENTION. 15 
 
 condition of the remaining countries of Europe may 
 be described in a few words. Cases exist, but are very 
 rare, in Austria-Hungary ; in Russia they are some- 
 what frequent on the shores of the Baltic, in Finland, 
 in the Crimea, and among the Cossacks of the Ural. 
 Leprosy is common in the Caucasus and in the delta of 
 the Volga. In Turkey, there are small centres of the 
 disease in Thessaly and Macedonia and in Crete (3-6 
 per 1,000). In Greece, there are a few cases on the 
 mainland, and many lepers (about 300) are to be found 
 in the islands of the Egean Archipelago. In Italy, 
 there are several small centres of leprosy ; one on the 
 gulf of Genoa, and another near Commachio on the 
 Adriatic coast. Sicily is another infected spot ; it is 
 said to contain about 100 lepers. In France, isolated 
 cases are to be found near the mouths of the Rhone, 
 in Provence along the shores of the Mediterranean 
 and in parts of the Riviera. Dr. Leloir says that 
 leprosy is perpetuating itself in these districts, and 
 that new cases constantly crop up among persons 
 born of healthy parents. In Spain, lepers are to 
 be found in several provinces, and especially in 
 Catalonia, Valencia, Andalusia, Galicia, Asturia, and
 
 16 LEPROSY, 
 
 Granada. In Portugal, the disease is somewhat 
 common, cases being especially frequent in Estra- 
 madura, Beira, Algarva, and in the mountainous district 
 of Lafoes. 
 
 With regard to Europe, the general assertion holds 
 good that, except in Norway, no attempt is made to 
 prevent the spread of the disease. 
 
 Of all the countries which make up the continent of 
 Asia, not one enjoys exemption from leprosy. In 
 Persia, China, Hindostan, Ceylon, and Indo-China, 
 the number of lepers must be simply enormous ; 
 Hindostan alone is said to contain a quarter of a 
 million. In China and Burmah there are more lepers 
 than can be found on the remainder of the earth's 
 surface. Leper hospitals are as common in China as 
 they were in England in the fifteenth century; they are 
 always full, but their number is altogether insufficient. 
 Near Canton there are two leper villages containing, 
 perhaps, 1,800 inhabitants, and according to another 
 statement there are 900 patients in hospitals within 
 the city. In Japan, the disease is very prevalent, and 
 widely diffused. We have, as might be expected, 
 much trustworthy information with regard to the 
 disease as seen in British India; no part is altogether
 
 AND ITS PREVENTION. 17 
 
 free from leprosy, but the prevalence varies greatly in 
 different districts. The disease is especially common 
 in the hilly country of Kumaon, in Burdwan (Lower 
 Bengal) and in certain parts of the Deccan. Hirsch 
 states that in 1872 there were in the three Presi- 
 dencies (Bengal, Madras, and Bombay) 99,073 lepers 
 in a population of about 183 millions, the proportion 
 to the population in the most leprous districts varying 
 from 19 to 41 per 10,000. It may be regarded as 
 certain that these numbers fail to denote the prevalence 
 of the disease at the present day. As stated above, 
 there is every reason to believe that the actual number 
 of lepers in British India is not far short of a quarter 
 of a million, and that the disease is steadily on the 
 increase. Leprosy is common in Arabia and Syria; 
 Dr. Kalisch states that a colony of lepers is still to be 
 found before the Zion gate of Jerusalem ; they inhabit 
 about 100 little huts. 
 
 The statement that no attempts are made to check 
 the spread of the disease may be applied to every 
 country in Asia. British India is, unfortunately, no 
 exception to this rule. A few leper asylums cer- 
 tainly exist ; but there is no compulsory isolation of 
 the patients. 
 
 2
 
 18 LEPROSY, 
 
 The condition of Africa as regards the prevalence 
 of leprosy much resembles that of Asia. With the 
 possible exceptions of Tripoli and Tunis, the disease 
 is everywhere endemic. Throughout Egypt and Abys- 
 sinia the ravages of leprosy are everywhere visible ; 
 in Morocco, Senegambia, and down the West Coast 
 lepers are constantly to be met with. In the Canary 
 Islands, not many years ago, the number of lepers 
 was officially stated to be 600. At the Cape, as we 
 have been informed by a recent writer in Blackwood's 
 Magazine, not only is the disease terribly frequent, 
 and of a very severe type, but the manner in which 
 the sufferers are attended to is disgraceful to a British 
 colony. There are, it is true, two leper hospitals ; 
 one at Robben Island, in Table Bay, and the other in 
 a mountainous district a few days' journey from Cape 
 Town. With regard to the former, the writer in 
 Black-wood says : " Here the patients live a death 
 to coin an expression comparatively uncared for, and 
 certainly unwept." As elsewhere, no measures likely 
 to be efficacious are taken to arrest the spread of the 
 disease. 
 
 On the continent of Australia, Dr. Leloir states 
 that the disease has commenced to show itself in New
 
 AND ITS PREVENTION. 1 
 
 South Wales and Victoria, as a result of Chinese and 
 Indian immigration. It is comparatively unknown in 
 South Australia, Western Australia, and Tasmania. 
 In New Zealand, according to Dr. Hirsch, the disease 
 was once prevalent among the natives, but has 
 decreased very much in recent years, though perhaps 
 only in proportion to the terrible depopulation of the 
 native territory. In Oceania the disease has become 
 endemic in the Sandwich Islands. Opinions differ 
 as to the date and manner of its importation. Accord- 
 ing to Dr. Hillebrand, of Honolulu (letter to Mr. Mac- 
 namara, February, 1866) the disease was unknown in 
 these islands before 1859, and, after close scrutiny, 
 could not be traced back further than the year 1848. 
 Soon after the character of the disease became recog- 
 nized the natives described it by two words signifying 
 " the Chinese disease." Dr. Hillebrand could not 
 determine whether the name was derived from a 
 belief in the Chinese origin of the disease, or whether 
 the natives had merely learnt from the Chinese immi- 
 grants that the complaint was common in China. At 
 the present time there are about 1,400 lepers in the 
 Sandwich Islands ; of these about 750 are in the 
 asylums on the island of Molokai (for ever hallowed
 
 20 LEPROSY, 
 
 by the life and death of Father Damien), and some 
 600 scattered about through the other islands. 
 
 It remains to add a few words with regard to the 
 prevalence of leprosy in the Western Hemisphere. 
 There are at the present time (Medical News, New 
 York, June 22, 1889) many more lepers in the United 
 States than at any previous period, the cases met 
 with being nearly all imported from Norway and 
 China. Their total number has been placed at 250, 
 but this estimate is believed to be too small. The 
 cases are most frequent in Minnesota, Wisconsin, and 
 Michigan, at San Francisco, and throughout California 
 and Oregon. In New Orleans there are no fewer than 
 42 known cases. In Canada, Norwegian immigrants 
 are said to be responsible for the introduction of 
 leprosy into New Brunswick, in the two counties of 
 Gloucester and Northumberland, on the shores of the 
 Gulf of St. Lawrence. In 1885 the Hawaiian Govern- 
 ment requested the authorities of New Brunswick to 
 supply information on certain points connected with 
 leprosy as seen in their districts. The questions and 
 answers have been published as a State paper, and 
 contain much interesting and valuable information ; 
 they will be referred to in subsequent pages. In
 
 AND ITS PREVENTION. 21 
 
 Mexico and Brazil leprosy is very common, scarcely 
 any district being exempt. The cases are especially 
 frequent in and about Bahia, Rio de Janeiro, and Per- 
 nambuco ; there are several large leper hospitals in 
 Brazil. The disease is more or less prevalent through- 
 out the States of Central America. In the West Indies 
 leprosy is endemic in many of the islands. In Trini- 
 dad, with a population of 180,000, there are more 
 than 480 lepers ; in Jamaica (440,000) there were, 
 not many years ago, about 800 lepers. Measures 
 taken for the segregation of the diseased would appear 
 to be of a very feeble character. 
 
 The following are some of the conclusions drawn 
 by Dr. Leloir from a study of the geographical dis- 
 tribution of leprosy : 
 
 " It is evident that the disease may develop itself 
 in many and diverse climates, e.g., in Iceland and 
 Norway on the one hand, in the West Indies and 
 Bengal on the other. It occurs both in hyperborean 
 and in tropical regions, on the sea-coast, and on the 
 elevated plateaux of the Himalayas, the Caucasus, and 
 Mexico ; its ravages are witnessed in mountainous 
 countries, in dry and airy localities, and in low, damp, 
 and marshy districts. It is difficult to determine
 
 22 LEPROSY. 
 
 whether climatic conditions exercise any influence 
 upon the spread of the disease. 
 
 " All branches of the human race are liable to suffer 
 from leprosy. The infected races may be classed in 
 the following order, according to the degree in which 
 the disease prevails among them : (i) the xanthous 
 or yellowish-brown race; (2) the black ; (3) the white; 
 and (4) the red race. Many of the Red Indian tribes 
 of America are still free from the disease, because 
 they have kept themselves aloof from infected races. 
 The tuberous form prevails in Norway, Trinidad, 
 Spain, Madeira, and the Sandwich Isles ; the anaes- 
 thetic form is more frequent in Hindostan, in the 
 Philippines, and in Guiana. The mixed or complete 
 form appears to occur with almost equal frequency all 
 over the world." 
 
 Other conclusions to be drawn from the geogra- 
 phical distribution of the disease will be mentioned 
 with the remarks on its causation.
 
 23 
 
 CHAPTER II. 
 
 THE FORMS AND SYMPTOMS OK LEPROSY. 
 
 LEPROSY appears in two principal forms ; in other 
 words, is capable of exhibiting two distinct groups of 
 symptoms. In one form, the skin is the principal 
 seat of the manifestations ; in the other, the nerves 
 are especially implicated. The terms cutaneous or 
 tuberous, and anaesthetic or nervous, are respectively 
 applied to express the difference in the symptoms. 
 That the two varieties are not to be regarded as two 
 distinct diseases is proved by the similarity of the 
 pathological products discoverable in both of them. 
 Moreover, the two forms often coexist, the symptoms 
 of one having been followed by those of the other. 
 Cases of this latter kind are described as mixed 
 forms ; in the majority, the nervous symptoms become 
 super-added to the cutaneous lesions. 
 
 (l.) The tuberous or tuberculous form. The develop- 
 ment of the characteristic symptoms is usually pre- 
 ceded by certain phenomena of a more or less 
 indefinite character, and resembling those which are
 
 24 LEPROSY, 
 
 premonitory of other infectious disorders. They 
 exhibit, however, this peculiarity they are often 
 experienced at irregular intervals for months and 
 even for years before the appearance of the cutaneous 
 symptoms. Indications of dyspepsia; headache; 
 giddiness ; mental depression ; general debility ; 
 somnolence ; lassitude ; epistaxis ; cutaneous hyper- 
 aesthesia ; profuse sweating ; irregular febrile attacks 
 and pains resembling neuralgia and rheumatism are 
 the most common premonitory symptoms. The 
 entire group is very rarely found in the same patient ; 
 as a general rule, the history of the case shows that 
 some five or six have been experienced. Perhaps the 
 most common premonitory symptoms are the neural- 
 gic pains, the alterations in the cutaneous secretions, 
 the hyperaesthesia, and the febrile movements. In 
 exceptional cases, the prodromal symptoms are alto- 
 gether absent. They almost invariably subside when 
 the eruption appears, and the consequent relief felt 
 by the patient is often very considerable. 
 
 The setting-in of the eruptive stage is marked by 
 the appearance of deep-red spots or blotches on 
 the face and extremities. These are slightly elevated 
 and of various forms and sizes ; they show themselves
 
 AND ITS PREVENTION. 25 
 
 in crops at irregular intervals and are often tender 
 and irritable. A few of them may disappear alto- 
 gether, but as a rule they undergo changes in colour, 
 and become brown from pigmentary deposit, or else 
 peculiarly white and dull and more or less puckered or 
 striated. The maculae often extend at their margins 
 and coalesce, and this change may be in progress 
 while the centres are becoming white and depressed. 
 In the course of time, these maculae become the seat 
 of the tubercles or nodules. The macular stage may 
 be prolonged for months or even years. 
 
 The tubercles or nodules begin as minute growths 
 in the cutis, and slowly increase in size. Some of 
 them eventually become as large as a hen's egg, 
 others resemble peas; union of the nodules results in 
 the formation of large irregular masses. The growths 
 are soft, or at least not very hard, smooth, shining, at 
 first dusky-red or livid in colour, but becoming 
 yellowish-brown or bronze-like. The skin between 
 them is more or less infiltrated and discoloured ; 
 there is slight desquamation of the cuticle and con- 
 sequent roughness. The growths are usually tender, 
 but not decidedly painful ; they are not particularly 
 prone to ulceration, except as the result of injury.
 
 26 LEPROSY, 
 
 In some instances, the nodules coalesce and become 
 soft and yielding on pressure ; the surface gives way 
 and a serous fluid escapes, with ulceration and crust- 
 formation as a subsequent stage. After remaining 
 open for an indefinite time, some of these ulcers may 
 heal, while fresh crops of tubercles are being de- 
 veloped on other parts of the surface. Sensation is 
 more or less affected in the diseased parts ; in some 
 cases, the tenderness of the nodules is replaced by 
 anaesthesia; in others, the parts become intensely 
 painful, particularly at night. Cicatrices left by the 
 ulcers are for the most part devoid of sensibility. 
 
 The leprous nodules may break out on almost any 
 part of the body ; but they have a special predilection 
 for the face, hands, and feet. When the face is 
 covered by tubercles in various stages, the aspect of 
 the unfortunate patient is hideous to a degree. All 
 traces of normal structure are obliterated ; nodular 
 prominences, irregular in form and often separated by 
 deep furrows, are distributed over the surface; portions 
 of skin, visible between them, are hypertrophied and 
 rugose ; the lips and alae of the nose are enormously 
 thickened and furrowed, the nose itself is broadened 
 and flattened ; the supra-orbital and frontal regions
 
 AND ITS PREVENTION. '27 
 
 project ; the hair of the eyebrows, the eyelashes, and 
 beard are wanting; the upper eyelid is swollen and 
 everted ; the ears (especially the lobes) are enlarged 
 and prominent. Enlargement of the lymphatic glands 
 under the lower jaw is another marked feature and 
 adds to the hideousness -of the general aspect. As 
 can well be supposed, the face eventually becomes 
 quite devoid of expression ; the muscles are powerless 
 to cause any change ; suffering, misery, and hopeless- 
 ness are terribly evident, and a close resemblance is 
 observable among all the sufferers. It is impossible 
 for a visitor to a leper asylum to guess correctly the 
 ages of such patients ; a youth, affected as above 
 described, looks like an old man. When the eye- 
 brows are much enlarged and the swellings project 
 over the eyes, the countenance bears some resem- 
 blance to that of a lion or other animal : hence the 
 term leontiasis has been applied to the disease. 
 
 Not only the skin of the face, but the mucous 
 membrane of the nose, mouth, pharynx, and larynx is 
 liable to be invaded by the growths. In these parts, 
 flattened nodules make their appearance and sooner 
 or later become ulcerated and excessively painful. 
 In the nose, crusts form and obstruct the passages ;
 
 28 LEPROSY, 
 
 in the mouth and throat, the ulcerations render 
 swallowing both painful and difficult, while a similar 
 process in the larynx gives a roughness to the 
 patient's voice and often reduces it to a whisper. The 
 patient's breath, and indeed his whole body, become 
 horribly foetid. Destruction of the cartilages of the 
 nose and larynx is a further step in the process. 
 Another mucous membrane, viz., the conjunctiva, is 
 prone to be similarly affected. Yellow and dark pig- 
 mented deposits are dotted over the sclerotic portion, 
 and gradually spread to the cornea, interfering with 
 vision and perhaps becoming disintegrated and causing 
 total blindness. Iritis, irido-cyclitis, and synechiae are 
 by no means unfrequent. So common are diseases 
 of the eye among lepers that out of 60 of Dr. Kaurin's 
 patients, 41 were thus affected and of these six were 
 quite blind. Other symptoms, more or less frequently 
 met with, are connected with the generative organs. 
 In women affected with leprosy, menstruation often 
 becomes irregular, and sterility is the rule, to which, 
 however, there are many exceptions. In males, the 
 testicles are a common seat of leprous growths, and 
 atrophy of these organs is the general result. 
 
 The process of the deposition of nodules on other
 
 AND ITS PREVENTION. 29 
 
 parts of the body resembles that observed on the face. 
 Their formation is followed by their enlargement and 
 coalescence, until the affected parts are much in- 
 creased in size and exhibit the prominences and 
 furrows, and the livid or bronze discoloration char- 
 acteristic of the disease. The mobility of the limbs, 
 and especially of the hands, is much interfered with, 
 and serious excoriations and ulcers are liable to result 
 from the slightest injuries. Glandular enlargement is 
 another marked feature; besides those already men- 
 tioned, the inguinal glands are often swollen and pro- 
 minent. Certain internal organs, e.g., the liver, spleen, 
 and mesenteric glands, are also liable to be invaded. 
 
 Sooner or later the symptoms of the anaesthetic 
 form of the disease are superadded to those just 
 described. But before this addition takes place fresh 
 crops of tubercles are wont to appear from time to 
 time, their development being attended by marked 
 febrile movement, with headache, depression, pains in 
 the joints, etc. These symptoms subside after the 
 eruption of the tubercles ; but they often recur, at 
 irregular intervals, in the absence of any fresh local 
 manifestations. These febrile attacks tend still further 
 to reduce the strength of the patient ; sometimes they
 
 30 LEPROSY, 
 
 assume an intermittent form and closely resemble the 
 paroxysms of ague. In one set of cases, the nervous 
 symptoms become very gradually developed ; some of 
 the tubercles slowly disappear, while the anaesthesia 
 advances. In another group, a lengthy interval exists 
 between the subsidence of the tubercles and the first 
 nervous manifestations. 
 
 The course of tubercular leprosy varies greatly; in 
 some patients it may be described as acute, in others 
 as chronic. According to Dr. Bidenkap, the mean 
 duration of this form is assumed to be from eight to 
 nine years, but it is often much more prolonged. If 
 the nervous symptoms become especially marked, the 
 tuberous growths may subside, and the progress of the 
 disease is then generally retarded. 
 
 In answer to my inquiries as to the relative 
 frequency of the two sets of symptoms, Dr. Kaurin 
 informed me that 70 per cent, of his cases belonged 
 to the tuberous variety, and the remaining 30 per 
 cent, to the anaesthetic form. According to the same 
 authority, the latter is increasing at the present time, 
 while the tuberous form is diminishing in frequency. 
 Further details on this subject will be given in subse- 
 quent pages.
 
 AND ITS PREVENTION. 31 
 
 (2.) Nervous or Anaesthetic Xieprosy generally begins 
 in a very insidious manner. There may or may not 
 be such prodromal symptoms as articular pains, 
 resembling those of rheumatism, in various parts ; 
 weariness after slight exertion, pain and tenderness 
 along the course of certain nerves, especially the 
 median, ulnar, and peroneal ; loss of appetite, gastric 
 derangement, etc. The symptoms which eventually 
 supervene are those of neuritis, acute as well as 
 chronic. In the first instance, there are evidences of 
 irritation of sensory nerves, e.g., hyperaesthesia, 
 neuralgia, sensations of itching, tingling, formication, 
 etc. Sooner or later the motor nerves become affected ; 
 the limbs tremble and the muscles twitch ; motor and 
 sensory paralysis then set in. Another set of 
 symptoms, viz., an eruption resembling pemphigus, 
 atrophy of muscles and bones, and changes in the 
 cutaneous pigment, indicates disorder of trophic 
 nerves. 
 
 The disorders of sensation constitute the most 
 prominent symptom. At first the affected limb or 
 part is not only painful, but reddened in patches, 
 swollen and hot ; a nerve may often be felt through 
 the skin as a thick cord ; pressure upon it causes an
 
 3-' LEPROSY, 
 
 increase of pain and other abnormal sensations. These 
 symptoms recur more or less frequently, and then 
 gradually pass into the opposite condition of 
 anaesthesia, which finally becomes complete. The 
 capacity for receiving impressions of temperature, 
 pressure, and locality is more or less impaired, and the 
 conduction of all sensory impressions is considerably 
 retarded. In the later stages, when cutaneous and 
 muscular sensation is entirely abolished, injuries to 
 the part are unfelt by the patient. The portions of 
 the body most liable to be thus affected are the hands 
 and forearms, feet and legs. 
 
 The trophic disorders are manifested in the skin, 
 muscles, and bones. An eruption of pemphigus is 
 one of the most curious and characteristic symptoms. 
 The bullai are rapidly developed ; they contain a fluid 
 which is at first clear and yellowish ; some are very 
 minute, others are several inches in diameter ; after a 
 few hours or days they burst, and either heal quickly, 
 or lead to troublesome excoriations or ulcers. The 
 cicatrices left by the latter are at first more or less 
 pigmented, but gradually become white, shining, and 
 depressed. The sores are comparatively painless, and 
 are frequently neglected by the patients ; in some
 
 AND ITS PREVENTION. 33 
 
 spots, and especially under the heel, they may remain 
 open for a long time and increase in depth and width. 
 Similar large vesications frequently result from 
 injuries ; owing to the defect or absence of cutaneous 
 sensibility, the patients unwittingly expose themselves 
 to extremes of heat and cold. The pemphigus, on the 
 other hand, appears to be due to the irritation of the 
 nerve fibres by the leprous growths. When anaesthesia 
 is complete, the vesicles are usually wanting. 
 Pigmentary anomalies constitute another group of 
 cutaneous disorders, and appear in two forms. In the 
 first, there is abnormal deposit of pigment in various 
 portions of the surface ; in the second, the pigment 
 disappears from different parts, which become faintly 
 yellow or even quite white. In the latter case, the 
 condition resembles leucoderma. 
 
 The trophic disorders of the muscles give rise to 
 conspicuous malformations ; atrophy is associated 
 with complete loss of functional capacity. Just as the 
 tubercles show a preference for those surfaces which 
 are most exposed to the air, so the muscles most 
 prone to be attacked are those of the hands, feet, and 
 face. The adductor muscles of the thumb, the 
 interosseous muscles, and those of the little finger 
 
 3
 
 34 LEPROSY, 
 
 first begin to waste, and the natural roundness of the 
 outer and inner sides of the hand gradually disappears. 
 The muscles supplied by the ulnar nerve are most 
 severely affected. The thumb is extended, the palm 
 becomes flattened, the first phalanges of the fingers 
 are extended, while the second and third are flexed, 
 the hand thus acquiring that peculiar shape to which 
 the term main-en-griffe has been applied. Many- 
 other muscles of the hand and forearm, and sometimes 
 those of the shoulder, are thus affected ; those of the 
 feet are less frequently attacked. 
 
 The muscles of expression, supplied by the facial 
 nerve, are often invaded, the paralysis generally 
 commencing to show itself in the orbiculares 
 palpebrarum. Other mimic muscles are attacked, and 
 the power of expression is much impaired. The tears 
 fail to reach the puncta lachrymalia and flow over the 
 lower lids ; inability to close the eyes results in lesions 
 of the cornea. The lower lip falls, and dribbling of 
 the saliva adds to the repulsiveness of the patient's 
 aspect. As time goes on, and the muscular atrophy 
 in the arms and legs reaches an advanced stage, the 
 utter helplessness of the patient is the striking feature. 
 
 Another group of phenomena, connected with the
 
 AND ITS PREVENTION. 35 
 
 osseous system, often makes its appearance in 
 anaesthetic leprosy. As a result of ulceration about 
 the hands and feet, the muscles and fasciae are 
 destroyed, and one or more bones may become carious. 
 If such ulcers be neglected, destruction of the bone 
 will certainly result, and if many phalanges be thus 
 attacked, portions of the extremity, or even an entire 
 hand, may be lost. Another process is sometimes 
 observed in the phalanges and metacarpal and 
 metatarsal bones. One of the phalanges is found to 
 be swollen and bluish ; the swelling gradually 
 increases ; the skin eventually gives way, and an 
 open sore results, at the bottom of which dead bone 
 is found. After a while the bone becomes loose and 
 is detached, and the wound then heals. Sooner or 
 later, another bone is similarly affected, and the 
 process may go on almost indefinitely until but few 
 of the bones are left. The mutilations thus caused 
 are multiform to a degree, and when combined with 
 the results of muscular atrophy cripple the patient in 
 every possible manner. So prominent is this group 
 of symptoms in many cases of anaesthetic leprosy, that 
 it is often described as lepra mutilans, and regarded 
 as a variety of the disease.
 
 36 LEPROSY, 
 
 In the final stage of anaesthetic leprosy the patient 
 is reduced to a most miserable condition. More or 
 less of the surface of the body is completely insensi- 
 tive, the condition being always intensely marked in 
 the face, arms, and legs. Owing to paralysis and 
 atrophy of the mimic muscles, expression is entirely 
 lost ; the face resembles that of a corpse ; the lustre- 
 less, widely-opened eyes indicate abandonment of all 
 hope.* The hands and feet are horribly mutilated 
 and deformed ; many muscles of the limbs are pro- 
 foundly atrophied ; the surface presents ulcers in 
 various stages, and yielding copious and foul dis- 
 charges ; cadaverous emanations are given off from 
 the patient's body. Always thirsty, but having little, 
 if any, desire for food, racked by torturing pains, the 
 sufferer drags on a miserable existence, utterly heed- 
 less of all that is going on around him, unable to feed 
 himself, and perhaps even to move without assistance. 
 He often falls into a condition of stupor, and regards 
 with indifference the progressive mutilation of which 
 
 * In this form of leprosy the ophthalmic affections result from the 
 paralysis of the facial, and possibly from the anaesthesia, due to impli- 
 cation of the fifth pair. Out of 32 Norwegian cases of anaesthetic 
 leprosy 1 5 suffered from diseases of the eyes.
 
 AND ITS PREVENTION. 37 
 
 he is the subject. A state of complete fatuity often 
 precedes the termination of his sufferings. 
 
 The symptoms of anaesthetic leprosy vary in 
 different cases ; their development obviously depends 
 upon the intensity and localization of the process in 
 the various nerves. In the tuberous form the nerves 
 never entirely escape ; in the anaesthetic, the invasion 
 of these structures is both severe and early, and the 
 nervous symptoms are far more prominent than any 
 manifestations of the tuberous type, which may even- 
 tually be superadded. In both forms, however, the 
 growths affecting the nerves are precisely identical, 
 and hence there is abundant justification for regarding 
 the various phases of the disease as results of the 
 same pathological processes. Even in cases of the 
 tuberous variety the superficial nerves are consider- 
 ably enlarged. The connective-tissue sheath is filled 
 with a firm albuminous material in which the fibres 
 are imbedded. In the anaesthetic form the changes 
 are far more decided. Throughout the greater part of 
 their course the large nerve-trunks of the affected 
 part are thickened so as to resemble spindles, while 
 here and there well-defined swellings mark special 
 deposits of leprous material. The nerve-trunks also
 
 38 LEPROSY, 
 
 exhibit various changes of colour; some are red, 
 others reddish-yellow, and in advanced cases a 
 brownish or even dark brown colour may be pre- 
 sented. The jelly-like mass in which they are 
 imbedded is made up of small nucleated cells ; it 
 penetrates everywhere between the fibres, and even- 
 tually destroys them by compression, so as completely 
 to abolish their conductile power. The process maybe 
 regarded as a chronic peripheral perineuritis, invading 
 at the outset not entire nerve-trunks, but sets of fibres. 
 This mode of invasion accounts for the isolated macular 
 discolorations, and the apparently irregular distri- 
 bution of the pemphigus, and of the anaesthetic areas. 
 The process which affects the nerves may doubtless 
 extend to the great nerve-centres, but the implication 
 of the latter is always secondary, and occurs at a 
 somewhat late period. In the early stages, in cases 
 in which death has occurred from some intercurrent 
 disorder, congestion of the vertebral vessels, and par- 
 ticularly of the posterior spinal veins, constitutes all 
 the change in the central organs that can be detected 
 on examination. In later stages thickening and 
 opacity of the membranes and copious exudation into 
 the sub-arachnoid space have been noticed in several
 
 AND ITS PREJ'ENTION. 39 
 
 cases. At a still more advanced period a deposit of 
 whitish gelatinous matter has been found on the 
 internal surface of the spinal membranes, forming a 
 layer of varying thickness, and in some cases produc- 
 ing, by its pressure, atrophy of the posterior columns. 
 The cerebral nerves are 1 iable to be similarly involved ; 
 leprous deposits have been found in the Gasserian and 
 ciliary ganglia, and indications of perineuritis affect- 
 ing portions of the fifth, sixth, seventh, and eighth 
 pairs of nerves have been noticed in a few cases. All 
 the morbid changes found in the nervous system lead 
 irresistibly to the conclusion that the process advances 
 in a centripetal direction, and that the mutilations 
 which result from a leprous affection of the nerves 
 are essentially different from those which sometimes 
 occur in connection with primary affections of the 
 spinal cord. 
 
 It is a curious fact that the nerves of special sense 
 are very rarely attacked. Sight, hearing, and the 
 sense of smell are generally unimpaired, except as a 
 result of local processes developing in the sense- 
 organs. Taste is sometimes perverted or impaired, 
 but the change is generally due to the condition of the 
 tongue, which is often the seat of leprous deposits.
 
 40 LEPROSY, 
 
 The mean duration of life in patients suffering from 
 anaesthetic leprosy is said by Dr. Bidenkap to be about 
 1 8 years from the first appearance of the symptoms. 
 It is, however, often difficult to determine the exact 
 time of invasion, and the course of the symptoms as 
 regards rapidity is greatly influenced by the conditions 
 under which the patients live, and the care and treat- 
 ment they receive. 
 
 Remissions in the course of the symptoms are very 
 common. Sometimes the patient remains without any 
 marked change for several years ; in some cases, 
 indeed, there is decided amelioration. A return of 
 sensation to the anaesthetic parts has been occasionally 
 noticed, and evidences of improvement in the general 
 health are sometimes witnessed. So decided may the 
 change become that the patient is looked upon as 
 cured ; so favourable a course is, however, extremely 
 rare. Progressive depravation of health, chequered 
 by occasional periods of quiescence, or even improve- 
 ment of the symptoms is the ordinary picture which 
 the disease presents. If, as often happens, the tuberous 
 symptoms be superadded, the downward course always 
 becomes more rapid. 
 
 It remains to say a few words on the so-called mixed
 
 AND ITS PREVENTION. 41 
 
 forms of leprosy. Such forms are truly typical of the 
 disease ; a case of purely cutaneous or of purely 
 nervous leprosy must be regarded as non-typical. We 
 know that the virus exhibits a preference for the skin 
 and certain mucous membranes, for the lymphatic 
 glands, the nervous system, and certain viscera. If 
 all these parts and tissues be invaded simultaneously 
 or in very quick succession, the result is what Dr. 
 Leloir calls Idpre complete d'emblee, or leprosy com- 
 plete from the beginning. If the virus invade only 
 the integument, glands, and viscera, the picture pre- 
 sented is that of tuberous leprosy. If, in such a 
 case, the virus subsequently attack the nervous system, 
 the blending of the new phenomena with the previous 
 symptoms (which may, perhaps, diminish) results in the 
 formation of a second group of mixed leprosy. A 
 third group results whenever the virus, after having 
 given rise to the phenomena of nervous leprosy, ulti- 
 mately concentrates its action upon the integument, 
 and produces nodules or tubercles. 
 
 It has been stated in a previous paragraph that the 
 tuberous is more frequent than the anaesthetic form. 
 Dr. Kaurin's reports of the Recknaes hospital (Molde) 
 show that of 660 cases, 478 (72-4 per cent.) belonged
 
 42 LEPROSY, 
 
 to the former, and 182 (27-6 per cent.) to the latter 
 class. No definite statement can be made as to the 
 relative frequency of the two forms in other countries, 
 and we can only speculate as to the reasons why the 
 virus in one class of cases prefers to attack the skin, 
 and in another the nerves. 
 
 Prognosis. All that can be said with regard to the 
 prognosis of leprosy may be summed up in a few 
 words. The disease is practically incurable ; in the 
 vast majority of cases, the patient either succumbs to 
 its effects, or dies from some intercurrent disease 
 whose advent has been favoured by the condition to 
 which he has been reduced. In tuberous cases, the 
 mean duration of life is from eight to 12 years after 
 the first manifestations. Sometimes the course is 
 extraordinarily rapid, death occurring within a year. 
 The anaesthetic form runs a slower course, the mean 
 duration being perhaps 1 8 or 20 years in the absence 
 of complications. In Norway I have seen several 
 cases in which the disease had existed for over 
 20 years, and Dr. Leloir states that he has seen 
 cases of anaesthetic leprosy, in which the malady had 
 lasted for 25, 30, 40, and even 44 years ! In the mixed 
 class, those patients in whom the anaesthetic has
 
 AND ITS PREVENTION. 43 
 
 supervened upon the tuberous form generally live far 
 longer than others in whom the symptoms have 
 pursued an opposite course. While confessing the 
 general powerlessness of treatment to avert the fatal 
 issue, there is no doubt but that the course of the 
 disease may be decidedly retarded by the adoption of 
 remedial measures of various kinds. These will be 
 discussed in the chapter on Treatment. 
 
 A few words must be added with reference to the 
 cases reported as " cured." In Dr. Kaurin's statistics, 
 dealing with 596 cases and extending over a period of 
 24 years, only eight cases are thus recorded. These 
 were doubtless instances of the anaesthetic form, in 
 which the course of the symptoms was entirely 
 arrested, and the manifestations of the disease under- 
 went partial or complete retrogression. 
 
 A further examination of these statistics shows that 
 marasmus or exhaustion is the most frequent condi- 
 tion (45*7 per cent.) which immediately leads to death. 
 Next comes pulmonary tuberculosis (12 per cent.) ; 
 next diarrhoea (io'8 per cent.), and next suffocation 
 (9*3 per cent.). In 10 patients (out of 398 fatal cases) 
 death was attributed to disease of the kidneys. It is 
 obvious that the occurrence of complications of various
 
 44 LEPROSY, 
 
 kinds must greatly depend on the individual peculiari- 
 ties and general circumstances of the patients, and to 
 some extent upon the climatic conditions prevalent in 
 the infected districts. 
 
 Diagnosis. Owing to the great variety in the 
 symptoms and the insidious manner in which they are 
 often developed, the diagnosis of leprosy sometimes 
 presents considerable difficulty. As a matter of course, 
 the circumstances by which the patient is surrounded 
 frequently aid in determining the nature of the complaint, 
 even in the earliest stages. Where leprosy is endemic, 
 even the prodromal symptoms will afford a clue to the 
 real nature of the case. As a general rule, the anes- 
 thetic form is less easily diagnosticated than the 
 tuberous variety. Of the latter, the most characteris- 
 tic features are the early eruption of tubercles about 
 the face and hands ; the swellings above the eye- 
 brows with falling-off of their hair; the abnormal 
 deposits and losses of pigment ; the general brownish 
 hue of the growths. The tubercles may, in some 
 respects, resemble those of syphilis ; but they are 
 developed in a different manner, and are not subse- 
 quently covered with scales and crusts. Leprous 
 ulcers likewise differ from those of syphilis. They
 
 AND ITS PREVENTION. 45 
 
 are not serpiginous ; their course is very slow and 
 they often remain stationary. According to several 
 authorities, syphilis may co-exist with leprosy ; but 
 the two diseases are quite distinct as regards their 
 etiology. Lupus may resemble tubercular leprosy, 
 but its manifestations are generally limited to smaller 
 portions of the surface. The coexistence of large 
 superficial infiltrations with transformations of colour 
 in various spots is sufficient to distinguish leprosy 
 from lupus. 
 
 Anaesthetic leprosy is characterized by the altera- 
 tions of sensation in various parts, especially in the 
 extremities ; the painful swellings along the course of 
 the nerves ; the atrophy of the muscles and the 
 vesicular eruptions. The deformities and mutilations 
 are quite peculiar to the disease. 
 
 There is one affection, viz., vitiligo or leucoderma, 
 the appearances of which somewhat resemble those of 
 leprosy. Vitiligo is characterized by the development 
 of white patches, with borders marked by a deposit of 
 pigment. Small at first, they gradually increase in 
 size, and by their coalescence produce discolora- 
 tion of large areas, to which the intervening portions 
 of normal (pigmented) skin offer a sharp contrast.
 
 46 LEPROSY. 
 
 Sometimes, and without obvious cause, the discolora- 
 tion rapidly spreads ; sometimes the patches remain 
 stationary for long periods. The hairs on the 
 discoloured portions invariably become white ; but 
 neither the functions of the skin nor the patient's 
 general health are in any way affected. In the 
 opinion of Sir Risdon Bennett (already quoted), the 
 leprosy of the Bible was really leucoderma. Whatever 
 view be taken of this question, it is obvious that the 
 two affections are in reality quite distinct from each 
 other. 
 
 The morbid anatomy of leprosy will be briefly 
 described in the next chapter.
 
 47 
 
 CHAPTER III. 
 
 MORBID ANATOMY AND CAUSATION OF LEPROSY. 
 
 THE formations peculiar to leprosy consist of granula- 
 tion or chronic inflammatory tissue, and belong to the 
 class of infective growths. The so-called tubers or 
 tubercles have their seat in the skin, subcutaneous 
 tissue, mucous membranes, connective tissue of nerves, 
 and in certain viscera. Diffuse infiltration also occurs. 
 The leprous tissue consists of cells in various stages 
 of development. In the cutaneous growths, these 
 cells are found close beneath the epidermis ; they 
 infiltrate the corium and thence spread into the sub- 
 cutaneous tissue. At first, they are identical with 
 leucocytes ; but eventually they become much larger, 
 reaching perhaps four times their original size, though 
 they usually preserve their shape. The tissue is 
 greyish-white and slightly translucent ; the cells are 
 pale and nucleated, and sometimes contain vacuolar 
 spaces ; the large cells are regarded as characteristic 
 of the leprous deposits. The nodules contain a copious 
 network of blood-vessels. The tissue once formed, is
 
 48 LEPROSY, 
 
 very stable ; the cutaneous growths may become dis- 
 integrated with consequent ulceration, but the latter 
 is much more often the result of injury. Complete 
 resolution of the growths is very rare ; it occasionally 
 results from fatty metamorphosis of the cells. Ulcera- 
 tion of leprous tissue deposited in mucous membranes 
 is very frequent. 
 
 The leprous growths in the nerve-sheaths have a 
 similar composition. As a result of the deposit, the 
 nerve-fibres are much reduced in quantity, and hence 
 we may account for the local anaesthesia and the 
 muscular wasting. Moreover, the inflammation which 
 accompanies the neoplasm causes the growth of new 
 connective-tissue, which still further interferes with 
 the functions and vitality of the nerves. 
 
 It is now generally considered that leprosy is due to 
 the presence of a specific bacillus ; the grounds upon 
 which this opinion is based are thus stated by Prof. 
 Neisser.* 
 
 i. The bacillus is met with in all leprous processes, 
 in nearly all organs, generally within the cells con- 
 
 * See article in Ziemssen's " Handbook of Skin Diseases," and also 
 papers on Leprosy in New S) d. Society's " Microparasites in Disease,'' 
 p. 289, et. seq. (In the preparation of some portions of this chapter free 
 use has been made of Prof. Neisser's essay.)
 
 AND ITS PREVENTION. 49 
 
 stituting the new formations, more rarely free in the 
 tissues. In the recent state, and in unstained prepara- 
 tions, the bacilli are recognizable with difficulty; but 
 easily after staining the tissue with most anilin colours. 
 After staining, the covering should be rinsed in 
 acidulated water; the preparations should then be 
 dried and mounted in Canada balsam. By this 
 method, only the lepra bacilli remain stained, other 
 bacilli lose their colour. The micro-organisms thus 
 rendered visible are extremely fine, slender rods ; 
 sometimes pointed or tapering at both ends, from 
 \ to f the diameter of a human red blood-corpuscle, 
 their breadth is about one-fourth of their length ; they 
 are either straight or slightly bent. (See the illus- 
 tration in the Frontispiece.) The bacilli therefore 
 closely resemble those of tuberculosis ; but they differ 
 from the latter in their staining relations. Alkaline 
 solutions are required for the bacilli of tuberculosis ; 
 while those of leprosy can be tinted also in neutral 
 and acid solutions. The bacilli of leprosy are not 
 coloured by anilin brown or by any yellow dyes. 
 Instead of bacilli, small granular particles are some- 
 times found ; these may be either spores or products 
 of disintegration. 
 
 4
 
 50 LEPROSY, 
 
 2. The bacillus is constantly present in all forms of 
 leprosy, in all countries. The accuracy of this state- 
 ment is now universally acknowledged. 
 
 3. In every case of leprosy, the bacilli are found in 
 all the more recent new-formations in the skin, the 
 mucous membranes, the cornea, the interstitial nervous 
 connective tissue ; also in the connective tissue of the 
 spleen and liver; lastly, in the lymphatic glands, the 
 testicles, and epididymis. The quantity found in these 
 parts and organs corresponds with the degree of the 
 affection. It is further stated that when the symptoms 
 subside, and the new formations undergo partial 
 absorption, the bacilli found therein exhibit corres- 
 ponding signs of degeneration, become disintegrated, 
 and either wholly or partially disappear. 
 
 In the skin, the bacilli are present both in the 
 nodules and in the diffuse infiltrations. They are 
 found almost exclusively in the large roundish cells 
 described by Virchow. They may be either scattered 
 throughout such cells, or may appear in small circum- 
 scribed accumulations. (See the illustration in the 
 Frontispiece.) Sometimes two or three rods are 
 attached to each other by their extremities ; some- 
 times they are densely crowded together, so as to form
 
 AND ITS PREVENTION. 51 
 
 a compact pile. The oldest layers of cells are imme- 
 diately beneath the epidermis, and are often collected 
 together so as to form large round accumulations. It 
 seldom happens that free bacilli are found between 
 the cells in the meshes of the connective tissue. ' The 
 microscopical appearances in the mucous membranes 
 closely correspond with those observed in the skin. 
 Cells containing bacilli are found in the interlobular 
 connective tissue of the liver, and even within the 
 hepatic cells. Isolated foci, connected with large cells, 
 have also been observed in the spleen ; the lymphatic 
 glands exhibit extensive infiltrations in the peripheral 
 zones, in which " blood-pigment, even macroscopically 
 visible," has been found accumulated in large quan- 
 tities. According to Dr. G. Thin the presence of 
 bacilli in the blood-vessels has now been definitely 
 ascertained. 
 
 The discovery of bacilli in leprous deposits around 
 the peripheral nerves is a point of very great import- 
 ance, and serves to explain many prominent symptoms. 
 Neisser states that he failed to discover the bacilli in 
 specimens taken from advanced cases; but that he 
 found them in large cells, between the nerve-fibres 
 and the bundles, in a specimen derived from a leprous
 
 52 . LEPROSY, 
 
 patient who had succumbed to an intercurrent acute 
 disease. 
 
 Finally, it would appear that bacilli have not as yet 
 been discovered in the spinal cord or muscles, or in 
 any of the epithelial tissues of the skin. They are said 
 to take no part in producing the pemphigus and the 
 .affections of the bones and joints. These symptoms 
 may all be regarded as secondary, and as due to the 
 peripheral neuritis. Wherever the pemphigus appears, 
 the skin is always more or less insensitive. The epi- 
 dermis is declared to be inaccessible, both superficially 
 and from below, to any invasion from the bacilli. 
 
 4. With regard to the origin of the lepra cells, it is 
 sufficient to mention that two principal views have 
 been advanced. Virchow considers that the fixed 
 connective tissue cells are the mother cells of the 
 growths ; Neisser, on the other hand, alleging that 
 Virchow's views can neither be proved nor disproved, 
 maintains that the granulation cells are in reality 
 emigrated white corpuscles of the blood and lymph. 
 The same authority has experimentally demonstrated 
 the manner in which these corpuscles develop into 
 lepra-cells. He has also pointed out that bacilli may 
 be found in every dry preparation of pus discharged
 
 AND ITS PREVENTION. 
 
 by ulcerating leprous nodules. " Cells in no way 
 differing from ordinary pus-corpuscles are full of 
 beautifully stained bacilli." 
 
 5. Every developmental phase of the lepra cell is 
 accompanied by a corresponding state of the bacilli 
 therein contained. As the cells become older and 
 larger, the bacilli and their derivatives increase in 
 number. At a later stage the bacilli are collected into 
 large round agglomerations, sharply limited, and 
 possessing a marked waxy lustre, but deeply stained 
 by anilin. These masses represent the extreme phase 
 of the bacillary infiltration of the cell-protoplasm. 
 Changes likewise take place in the latter ; vacuoles 
 form, and large numbers of bacilli escape from the cells. 
 
 Prof. Neisser thus sums up the conclusions to be 
 drawn from a consideration of the facts thus far 
 enumerated : 
 
 A specific bacillus, which has gained access into the 
 tissues, is the exciting cause of the peculiar form and 
 nature of the lepra cell : leprosy is, therefore, a bac- 
 terial disease. The bacilli are capable of cultivation 
 on boiled egg-albumen, and on blood-serum with 
 gelatin. It is difficult to find a species of animal 
 appropriate for inoculation, and spontaneous leprosy
 
 54 LEPROSY, 
 
 has not hitherto been observed in animals. Neisser 
 inoculated two dogs by introducing small leprous 
 particles into the subcutaneous connective tissue, and 
 the result was the production of local neoplasms histo- 
 logically identical with the tubercles of leprosy, and 
 containing many bacilli. No general symptoms were, 
 however, exhibited. 
 
 6. Leprosy is a contagious and infectious disease. 
 Many facts may be adduced in proof of this state- 
 ment. In the first place, there are several examples 
 of leprosy having been introduced into countries pre- 
 viously free from the disease, and of its rapid spread 
 in the course of a few decades. The case of the 
 Sandwich Isles has been already referred to. Fifty 
 years ago, leprosy was unknown among the natives ; 
 at the present day, one-fifteenth of the aborigines are 
 suffering from the disease. Another instance is 
 afforded by the present condition of the Island of 
 Trinidad. In 1805, there were three lepers among 
 some 30,000 inhabitants ; ten years ago, there were 
 860 patients among a population amounting to 120,000. 
 
 A very strong argument in favour of the contagious- 
 ness of leprosy is supplied by those instances in which 
 persons who have immigrated into infected localities
 
 AND ITS PREVENTION. 55 
 
 have been attacked by the disease. Father Damien's 
 case is one of the strongest that can be adduced ; the 
 essential facts are few and simple. A young and 
 healthy European went to a distant island in the 
 Pacific, and after living and working among lepers for 
 about ten years, began to show signs of the disease, 
 from the effects of which he ultimately died. It is 
 nothing to the purpose to say that we do not know 
 how the virus gains access to the body, and the 
 supposition that local telluric influences are sufficient 
 to account for the origin of the disease can scarcely 
 be regarded as tenable. As in the case of scarlet 
 fever, measles, and small pox, it may be regarded as 
 certain that a person never becomes leprous unless he 
 has received the infection, either directly or indirectly, 
 from a person suffering from the disease. Niemeyer's 
 remarks with regard to measles, as the type of an 
 infective disease, may be applied to leprosy. " It is 
 sometimes asserted that the first case could not have 
 been induced by infection, because at that time there 
 was no such disease from which the patient could be 
 infected ; the inference is then drawn that if the 
 disease developed spontaneously once, there is no 
 reason for denying the possibility of its doing so
 
 56 LEPROSY, 
 
 again. Such reasoning is idle. We know nothing 
 about the first development of measles," or (it may be 
 added) of any infectious disease. We shall see by- 
 and-bye that the most extraordinary ideas have been 
 advanced as to the causation of leprosy. 
 
 111,1866 the Government of India published a well- 
 known Report on the character and progress of leprosy 
 in the East Indies, being answers to questions drawn 
 up by the Royal College of Physicians, London. 
 Similar information was derived from other parts of 
 the world, and the College arrived at the conclusion 
 that leprosy was not communicable by contact or 
 proximity. It is worthy of note, however, that in 36 
 out of 107 medical reports from the East Indies, 
 an opinion was expressed in favour of the communica- 
 bility of the disease ; in 26 the question was regarded 
 as an open one, while in 24 communicability was 
 denied. The authors of several reports state that 
 leprosy is contagious only in the ulcerative stages. 
 It would probably be nearer the truth to say that the 
 disease is particularly contagious when open sores 
 exist. The discharges from these ulcers consist 
 largely of pus, in the corpuscles of which, as already 
 stated, bacilli can be easily demonstrated.
 
 AND ITS PREVENTION. 57 
 
 The opinion that leprosy can be propagated by 
 direct contact has been recently fortified by the 
 results of a very remarkable experiment. A murderer 
 condemned to death in the Sandwich Islands was 
 offered a commutation of his sentence (to imprison- 
 ment) on condition that he would allow himself to be 
 inoculated with leprous matter. The offer was ac- 
 cepted by the man, and the operation was performed 
 by Dr. Arning on November 5, 1885. In September, 
 1888, his condition was declared to be as follows : 
 Ears and forehead tubercular and considerably hyper- 
 trophied ; face, nose and chin show flattened tuber- 
 cular infiltration ; face generally presents a leonine 
 aspect. Hands puffed, proximal phalanges swollen, 
 tips of forefinger and thumb of left hand ulcerated 
 and anaesthetic. Body thickly marked with tubercles, 
 of a yellowish brown colour, and presenting many 
 patches of tubercular infiltration. Infiltrations on 
 thighs as far down as the knees ; legs quite smooth 
 and even to the touch ; feet cedematous, bluish. The 
 seat of the inoculation, on upper third of outer aspect 
 of left arm, shows a dark purplish scar, about i 
 inches long by i^ inches wide, irregular in shape, 
 keloid in aspect, dense and inelastic. Eyes affected
 
 58 LEPROSY, 
 
 with sclerotitis, muddy and injected. No signs of 
 paralysis about muscles of face, orbiculares palpebra- 
 rum, hands or forearms. The President of the Board 
 of Health and the Government Physician, Honolulu, 
 who furnished this report, state in conclusion " It is our 
 decided opinion that this man is a tubercular leper." 
 
 There can be no doubt as to the validity of this 
 conclusion ; but the objection may be raised that the 
 man was already leprous before the inoculation. It is 
 impossible to prove that he was not thus affected ; 
 but, considering all the circumstances of the case, 
 there is little force in criticism of this nature. Other 
 reported instances in which inoculation was per- 
 formed without any results would seem to contradict 
 the lesson to be drawn from the above-mentioned 
 case. -Dr. Leloir* records the following experi- 
 ments : Some 30 years ago, the venerable X en- 
 deavouring to discover the cause of leprosy, and fully 
 convinced that the disease was not contagious, inocu- 
 lated himself with fragments of the tubercles, blood, 
 pus, etc. After several repetitions of his experiments, 
 with some amount of septic lymphangitis as the only 
 result, he inoculated 20 other healthy persons, who 
 
 * " Traite Pratique et The'orique de la L&pre,'' p. 237.
 
 AND ITS PREVENTION. 
 
 consented to be thus experimented upon. Lymphan- 
 gitis alone was produced ; there were no local mani- 
 festations in any way resembling those of leprosy. 
 The patients were watched for many years, and all 
 remained healthy. Dr. Profeta inoculated two women 
 aged 25 and 31, and eight men, including himself and 
 Dr. Camina, all having been made aware of the risk 
 they were incurring. The result was the same in all 
 the cases an absence of any symptoms of leprosy. 
 
 Cases such as the above prove only that the virus 
 of lepra is not always capable of being conveyed by 
 inoculation from man to man. Various diseases 
 evidently possess different degrees of contagiousness ; 
 there is every reason for believing that no one, unless 
 already syphilitic, would escape infection, if inoculated 
 with the discharge from a hard sore or the secretion 
 of a condyloma. In the case of leprosy, other con- 
 ditions may be necessary for the success of the 
 inoculation, e.g., a depraved state of health, due to 
 one or more of a large number of causes ; or, as Mr. 
 Macnamara* expresses himself, " It may well be that 
 
 * Leprosy a Communicable Disease, 2nd Ed., 1889, p. 49. For many 
 interesting facts bearing on this question, see Archdeacon Wright's little 
 book " Leprosy an Imperial Danger.''
 
 60 LEPROSY, 
 
 the susceptibility to the development of the disease, 
 even by contagion, is not universal." 
 
 That leprosy is to be classed among contagious dis- 
 orders is shown, to some extent at least, by the 
 resemblance its spread sometimes presents to that of 
 diseases admittedly of this character. The case of 
 the Sandwich Isles may be taken to show that leprosy 
 introduced among a population previously free from 
 its ravages is capable of spreading with alarming 
 rapidity. In the Faroe Islands there have been 
 several epidemics of measles ; a very severe one in 
 1846 was the first that had occurred for 65 years. 
 One case that had been introduced infected the at- 
 tendants of the patient, and in the course of seven 
 months some 6,000 persons, out of a population of 
 7,782, were attacked by the disease. The spread of 
 syphilis and the frightful ravages committed by the 
 disease in Polynesia, are analogous to the progress 
 and to the characteristic features of leprosy, as seen 
 at the present day in several of those islands. 
 
 Other considerations may be adduced in support of 
 the view that leprosy is contagious. The disappear- 
 ance of the disease under certain circumstances is a 
 fact of this character. Neisser formulates the rule
 
 AND ITS PREVENTION. (\\ 
 
 that the spread of leprosy stands in inverse relation 
 to the measures to which the patients are subjected in 
 the various localities. Wherever isolation is vigorously 
 practised, and proper hygienic measures adopted, the 
 spread of the disease is invariably arrested. The 
 truth of the statement cannot be disputed, and the 
 inference to be drawn from the fact is a very simple 
 one. Too much attention cannot be directed to the 
 Norwegian experience of the last 20 years. It is, of 
 course, not denied that the spread of leprosy and the 
 type which the disease assumes, are considerably in- 
 fluenced by such factors as climate, food, insanitary con- 
 ditions, etc., and a few remarks will hereafter be made 
 on these subjects. There is much reason for believing, 
 with Prof. Neisser, that the virus of the leprosy seen 
 in Europe is of a weaker quality than that of the 
 disease as it prevails in the Sandwich Islands and 
 many parts of the East. Pasteur and others have 
 proved that some of the qualities of bacteria may 
 undergo considerable modifications; their virulence, 
 for example, may become considerably lessened, while 
 their morphological qualities remain unchanged. 
 
 It remains to consider the various ways in which in- 
 fection may take place. The contagious material may
 
 62 LEPROSY, 
 
 certainly be conveyed directly, and perhaps through the 
 atmosphere and with food. It is not known whether 
 the spores retain their vitality in dead bodies, as is the 
 case with those of anthrax ; but such a retention of 
 power is not improbable. It would appear that the 
 bacilli cannot penetrate through sound epidermis ; 
 some lesion of the protective layer is presumably ne- 
 cessary. In all probability, it is the spores that gain 
 access to the organism, pass into the lymph-channels, 
 thence into the lymphatic glands, and from these to 
 various parts of the body. The parts most liable to 
 be first infected are the face, the hands, the genital 
 organs (as a result of sexual intercourse"), the mouth, 
 and the respiratory passages. The lymphatic vessels 
 are the principal, if not the sole channel for the spread 
 of the bacilli or their spores in the organism ; micro- 
 scopical investigations tend to show that the lymph- 
 corpuscles take an active share in the conveyance of 
 the bacilli. 
 
 Nothing definite is known as to the time required 
 for the incubation of leprosy. There is not, as in the 
 case of syphilis, any so-called primary lesion ; when 
 the symptoms are evident, the disease has, so to speak, 
 become constitutional. Dr. Leloir cites one case, seen
 
 AND ITS PREVENTION. 63 
 
 by himself in France, in which the period of incuba- 
 tion had extended to 14 years ; Dr. Kaurin thinks that 
 the ordinary period is from two to three years. 
 
 It is only fair to state that Dr. Hirsch and several 
 other competent authorities deny the contagiousness 
 of leprosy. Dr. Hirsch adduces the following facts as 
 telling decisively against the doctrine in question : 
 
 (1) The extremely narrow limitation of leprosy in 
 certain centres, often very small, while there is free 
 communication between their inhabitants and the 
 neighbouring population, and where the sanitary 
 conditions are such as would especially favour the con- 
 veyance of the disease sooner or later. 
 
 (2) At certain places, with a. mixed population, the 
 malady is confined to particular races or nationali- 
 ties, notwithstanding unrestricted social intercourse 
 throughout the community. 
 
 (3) The fact that in innumerable cases, the acquir- 
 ing of leprosy by one member of a family has led to 
 no other outbreaks of it in that family, even under 
 very insanitary conditions. Both parents very rarely 
 take it, and when this accident does occur, it may be 
 referred to infection of both from a common source or 
 to endemic influence.
 
 64 LEPROSY, 
 
 (4) There has never been a case known in which 
 the physicians or nurses of a leper-house have caught 
 the disease (?). 
 
 (5) No case has come to light hitherto, in which the 
 disease has spread from the leper-houses to residents 
 outside. 
 
 (6) Among the many cases of leprosy in Europeans 
 who had acquired the disease in leprous districts, not 
 one has ever been the occasion of the disease spread- 
 ing in the immediate neighbourhood. 
 
 One general remark maybe made with regard to all 
 these arguments, viz., that they are based upon a mass 
 of information, which is nevertheless imperfect. The 
 statement under No. 4 is contradicted by the cases of 
 Father Damien, and of several Sisters of Mercy, and 
 by the fact for which there is good authority that 10 
 per cent, of the attendants employed at Molokai 
 become lepers. Even if the argument were true, it 
 would by no means prove that leprosy is non-con- 
 tagious. The nurses, dressers, and others, in Lock 
 hospitals very rarely contract syphilis from the 
 patients on whom they attend, and yet no one denies 
 that syphilis is in the highest degree communicable. 
 The limits I have assigned to myself in this little work
 
 AND ITS PREVENTION. 65 
 
 will not permit of a longer discussion of this subject. 
 Abundant evidence in favour of the contagiousness of 
 leprosy may be found in Archdeacon Wright's and 
 Mr. Macnamara's essays. I would repeat the observa- 
 tion, made in a former paragraph, that the malignancy 
 of the virus of a contagious disease is not uniform 
 under all circumstances. Moreover, we have learnt, 
 from carefully-conducted experiments, that the same 
 virus acts differently on various races of animals, e.g., 
 of mice or of sheep ; it would therefore appear probable 
 that similar differences may exist among different 
 human races, and that even within the same race, the 
 receptivity of the several individuals may not always 
 be the same (Neisser). 
 
 The question as to whether leprosy can be trans- 
 mitted from parents to offspring comes next for 
 consideration. Dr. Kaurin informed me, a few 
 months ago, that in the opinion of himself and his 
 colleagues the disease was not thus transmitted. Dr. 
 Hirsch, on the other hand, states that this method of 
 the conveyance of leprosy cannot be questioned, and 
 that "there is almost complete unanimity on this 
 point among the observers of all times." The question 
 may be divided into two parts, viz., whether the
 
 66 LEPROSY, 
 
 disease is inherited as such, or whether it is only a 
 predisposition to be attacked that is thus transmitted. 
 Statistics are, of course, the only means by the aid of 
 which a decision can be arrived at. There are, how- 
 ever, two difficulties which must be borne in mind 
 when dealing with statistics on this subject. In the 
 first place, many of the observations have been made 
 in parts of the world where accurate information as 
 to the state of health of the lepers' ancestors could 
 scarcely be obtained. Secondly, when the cases are 
 collected in districts where the disease is endemic, 
 the possibility is always present that some of the 
 patients, even with a family history of leprosy, might 
 have become affected through contagion. Dr. Hirsch 
 mentions another objection against the doctrine of 
 heredity, viz., the difficulty of accounting for the rapid 
 extinction of the disease in such places as the Faroe 
 Islands and certain districts in Sweden. 
 
 An affirmative answer to the question of heredity is, 
 however, based on observations made in a considerable 
 number of small, closely-circumscribed districts, with 
 a tolerably fixed population, where the state of health 
 of the various families may be traced through several 
 generations. As examples of such places, Dr. Hirsch
 
 AND ITS PREVENTION. G7 
 
 mentions various points on the coast of Provence, 
 Commachio, Sicily, Southern Russia and the Caucasus, 
 Greece, certain islands in the East Indian Archipelago, 
 and New Brunswick. With regard to the last- 
 named place, Dr. Tache, in the Report already quoted, 
 states as follows : " The disease does not appear to 
 me to be hereditary, that is, transmitted, de toutes 
 pieces, from parents to offspring by procreation, or 
 stored in the blood of individuals or generations, in 
 its morbid nature and potential energy, without show 
 of its presence. I doubt not. however, that the greater 
 or less susceptibility to contract or acquire the dis- 
 temper forms part of constitutional inheritance. . . . 
 I know many instances where one member only of a 
 family has been affected with leprosy, while all the 
 other members remained free from any trace of it." 
 Dr. Hirsch's conclusions are of a different character : 
 " In all these places we do in fact find classical proofs 
 that the disease clings to particular families as a con- 
 sequence of continuous inheritance from generation 
 to generation, and that the extension and multiplica- 
 tion of these small centres of disease is due to inter- 
 marriages among members of leprous families and of 
 families who had been hitherto healthy."
 
 68 LEPROSY, 
 
 Another excellent authority, Leloir (a firm believer 
 in the contagiousness of leprosy), admits that the 
 disease may be transmitted to the offspring, but thinks 
 that many cases attributed to transmission are really 
 due to contagion. His arguments in favour of the 
 more frequent operation of the latter cause are as 
 follows 
 
 1. Leprosy is often observed among persons, none 
 of whose ancestors have suffered from the disease. 
 
 2. Leprosy has been contracted in the colonies by 
 Europeans, born of healthy parents, in non-infected 
 countries, and with no family history of the complaint. 
 
 3. It is quite impossible to demonstrate hereditary 
 predisposition in every case of leprosy, occurring in 
 an infected district. In 107 cases, collected by Dr. 
 Leloir, heredity could be traced only in 47 patients. 
 
 4. In some cases considered to be of hereditary 
 origin, the parents appeared to be in good health 
 when the child was born, though they subsequently 
 became lepers. 
 
 5. The children of leprous parents do not always 
 suffer from the disease. If such children live with 
 their parents their chances of escape are very small ; 
 under opposite conditions, their chances are very
 
 AND ITS PREVENTION. <>!) 
 
 much increased, and especially if they are sent into 
 a non-infected district. 
 
 6. The age at which the symptoms most often ap- 
 pear tends to contradict the theory of hereditary trans- 
 mission. In the majority of patients born and living 
 in infected districts, the symptoms become developed 
 between the loth and the 25th year. In four out of 
 149 such cases, the age at the commencement of the 
 attack varied from four to six years ; four patients 
 were between 52 and 56, and two between 62 and 
 64 years. It is doubtful whether leprous symptoms 
 have ever been observed in a new-born infant. 
 
 Taking into consideration the facts and arguments 
 as stated in the preceding paragraphs, it would seem 
 that heredity has a considerable share in the causation 
 of leprosy, but that it fails to account for the terrible 
 frequency of the disease. The prevalence of leprosy 
 is mainly due to contagion. 
 
 In order to complete this account of the etiology of 
 leprosy, some mention must be made of those con- 
 ditions which appear to further the development and 
 spread of the disease. Some of these predisposing 
 causes have been invested with a much higher degree 
 of importance than really belongs to them. Those
 
 70 LEPROSY, 
 
 which require notice are locality, climate, and rapid 
 changes of temperature ; deficient or unsuitable food ; 
 insanitary conditions of various kinds ; the influence 
 of previous diseases, etc. 
 
 1. Locality and climate. The inhabitants of dis- 
 tricts bordering on the sea have been regarded as 
 more prone to be attacked than persons living inland, 
 and the experience of Norway, Spain, Portugal, and of 
 many parts of India, China, etc., seems to confirm this 
 opinion. There are, however, many facts which point 
 to an opposite conclusion. In various parts of the 
 world the disease is even more prevalent hundreds of 
 miles from the shore than it is on or near the coast. 
 With regard to climate, the prevalence of the disease 
 is little, if at all, influenced by any such conditions as 
 temperature, moisture of air, rainfall, and the like, 
 save in so far as they may impair the general health 
 of the inhabitants, and render them more likely to be 
 affected by injurious influences. 
 
 2. Deficient or unsuitable food. It was only 
 natural that in former times the cause of the disease 
 should have been sought for in the diet of the suf- 
 ferers. That this view is utterly without foundation 
 is proved by the fact that leprosy occurs in some
 
 AND ITS PREVENTION. 71 
 
 countries and districts in which food is plentiful, and 
 in many respects appropriate. The immoderate use 
 of fish as food, of certain kinds of fish, and of salt 
 and putrid fish, has been thought to be the cause of 
 the disease, and this view has been adopted by Mr. 
 Hutchinson. The development of leprosy has been 
 ascribed by other authorities to the excessive use of 
 pork. With regard to fish-diet, it is doubtless true 
 that the food of Norwegian peasants and fishermen is 
 often poor in quality and very indigestible; gastric 
 catarrh and dyspepsia in various forms are very 
 prevalent among these classes. Their diet consists of 
 fish, and mainly of herrings, in a semi-rotten state, 
 pickled in tainted brine ; of other fish more or less 
 decomposed, salted, dried, and always imperfectly 
 cooked ; of curdled sour milk, kept, perhaps, for 
 weeks or months ; of small quantities of potatoes 
 with a little bread made of oatmeal ; of broth made 
 from the same flour, with a little salt meat or bacon 
 from time to time all such articles being often 
 washed down by mouthfuls of so-called aqua vitae. 
 Added to all these defects is the utter indifference of 
 the peasants as to the water they drink, and the 
 vessels in which it is kept. The water is not only
 
 72 LEPROSY, 
 
 bad, but it is generally kept in a sort of cask, or in a 
 hole made in the earth, and surrounded by impurities 
 of various kinds, and pools of dirty water. But that 
 such unwholesome food is not the cause of leprosy is 
 proved by the fact that the fishermen and peasants on 
 the north and south coasts of Norway, as badly fed as 
 their compatriots on the west coast, are nearly, if not 
 quite, exempt from the disease (Leloir). Leprosy is 
 also unknown among the fishermen of Newfoundland, 
 who live almost entirely upon fish. 
 
 With regard to the immoderate use of pork as a 
 cause of leprosy, Dr. Hirsch quotes recent statements 
 from physicians in Mexico, where leprosy is common 
 and pork is a staple article of food. "There are 
 many lepers who have never eaten pork, others who 
 have partaken of it rarely, and still others who have 
 lived on it to an excessive extent; but among all 
 these the disease occurred with equal intensity. We 
 conclude from this that the use of that article of diet 
 has no influence whatsoever either upon the produc- 
 tion of the disease or upon the severity of its type." 
 
 We may take another example, cited by Dr. Leloir, 
 and contrast it with Norwegian experience. Cases of 
 leprosy in the Riviera occur among persons dwelling
 
 JTS PREVENTION. 73 
 
 in a very healthy country. The inhabitants are not 
 exposed to cold ; they are cleanly in their habits ; 
 they do not eat fish ; but their diet consists almost 
 exclusively of vegetables, fruits, flour, etc. It is thus 
 evident that many of the causes and conditions to 
 which leprosy has been attributed are not to be found 
 in the Riviera. The patients are by no means in- 
 variably poor ; one leprous girl had a marriage portion 
 of 50,000 francs. 
 
 3. Other insanitary conditions may predispose 
 individuals to become affected with leprosy, though 
 they cannot of themselves give rise to the disease. 
 Exposure to very severe weather, want of proper 
 shelter, insufficient clothing and uncleanly habits of all 
 kinds may be placed in this category. That they play 
 only a very secondary part in the causation of leprosy 
 is demonstrated by the fact that the disease may be 
 absent when all the conditions co-exist. Thus in 
 Terra del Fuego we find a combination of almost all 
 possible insanitary conditions, and yet there are no 
 cases of leprosy. Examples of the same character 
 might easily be multiplied. It is, of course, admitted 
 that in infected districts the disease is more apt to 
 attack the necessitous classes than those who are
 
 74 LEPROSY. 
 
 more favourably situated, though persons in good 
 circumstances do not enjoy exemption. 
 
 4. With regard to the effect of previous diseases on 
 the development of leprosy, all that can be said is 
 that such disorders as syphilis, scurvy, tuberculosis, 
 and malarious fevers, in so far as they impair the 
 general health, adapt the individual, so to speak, for 
 the reception of the virus. It is, however, impossible 
 that any of these disorders can actually cause leprosy. 
 Some authors have gone so far as to declare that the 
 disease has sometimes been produced by fatigue, 
 excitement, etc. In Norway, however, the population 
 generally shows decided signs of vigour, and leprosy 
 selects its victims from the strong as well as from the 
 weak. 
 
 Leprosy is a contagious disease, and due to a specific 
 virus. It is capable of being transmitted by parents 
 to their offspring. Other alleged causes of leprosy are 
 operative only so far as they impair the general 
 health.
 
 75 
 
 CHAPTER IV. 
 
 THE TREATMENT AND PHEVENTION OF LEPROSY. 
 
 LEPROSY is an incurable disease ; that is to say, it 
 cannot be brought to an end by any form of treat- 
 ment. It is true that in some very rare cases the 
 morbid process appears to cease, but not until more 
 or less serious damage has been effected. The march 
 of the disease is arrested ; but such results as paralyses 
 and mutilations of various kinds are of course per- 
 manent. 
 
 It is not to be wondered at that many remedies 
 have been tried with the hope of finding some specific, 
 or at least some drug that would exercise a favourable 
 influence upon the course of the disease. The list 
 includes mercury, iodide and bromide of potassium, 
 antimony, arsenic, phosphorus, bismuth, etc. ; while 
 among vegetable drugs, sarsaparilla, hydrocotyle 
 asiatica, chaulmoogra, secale cornutum, anacardium 
 (cashew nut), gurjun balsam, chrysarobin (goa 
 powder), copaiba balsam, digitalis and many others 
 have been tried, but all in vain. Salicylic acid,
 
 70 LEPROSY, 
 
 carbolic acid, and creasote (both given internally as 
 well as applied to ulcers) have been lauded by some 
 physicians, and, so far as our present knowledge 
 extends, the use of these and of other antiseptics and 
 parasiticides may be said to offer some prospect of 
 success. In some cases, they certainly bring about a 
 decided improvement in the local manifestations ; and 
 this is, at least, sufficient to show that medical science 
 is not altogether helpless in the presence of this 
 terrible disease. 
 
 With regard to the mineral remedies, the general 
 statement holds good that all are useless, and some 
 extremely mischievous. Mercury and iodine belong 
 to the latter category; and each of these powerful 
 drugs has been very extensively used. Mercury 
 always does harm in cases of true leprosy ; it readily 
 produces salivation and ulceration of the mouth and 
 / throat in these patients. When, as not unfrequently 
 \ happens, a leper contracts syphilis, mercury may 
 perhaps be desirable. It should be given with the 
 greatest caution, and in very small doses ; it is less 
 likely to do harm in cases of anaesthetic leprosy than 
 in those of the pronounced tuberous type. Its alleged 
 beneficial effects in cases of leprosy can be explained
 
 .IMJ ITS PREVENTION. 
 
 only by supposing that the diagnosis was incorrect, 
 and that the patients were really suffering from 
 syphilis. Iodine is almost equally injurious ; 
 Danielssen states that its preparations are liable to 
 cause the symptoms to assume an acute form. A 
 similar remark applies to the bromides. 
 
 Arsenic, antimony and phosphorus exercise little, if 
 any, influence upon the course of the disease ; in 
 large doses, they would certainly prove injurious. 
 
 In a few cases, comparatively good results have 
 followed the employment of the vegetable remedies 
 above mentioned. Dr. Vandyke Carter and others 
 speak highly of chaulmoogra oil (Oleum Gynocardiae). 
 All that can be said is that occasionally the local 
 symptoms are much ameliorated under its use. It is 
 given internally in doses of gr. xv and upwards, and 
 likewise applied in the form of an ointment. 
 
 Gurjun balsam is another remedy of this class. An 
 emulsion is made with an equal volume of lime-water, 
 and this is used freely as a liniment and also given 
 in doses of four drachms several times a day. The 
 Norwegian physicians have given this drug an ex- 
 tensive trial, but without any decidedly good result. 
 Dr. Bidenkap states that frictions with the liniment
 
 78 LEPROSY, 
 
 seemed to have a favourable influence on the diseased 
 cutaneous nerves about the same as that of massage. 
 
 Goa powder and its constituent, chrysophanic acid, 
 have been especially recommended by Dr. Unna 
 (Monatshefte fur Pract. Dermatologie, July, 1885). 
 He states that the external application of the drug, 
 combined with the internal use of a preparation 
 named ammonium sulphichthyolicum, will cure cases 
 of incipient tuberous leprosy. His reports of two 
 cases are certainly very encouraging. In Dr. Biden- 
 kap's hands this treatment has perhaps done some 
 good in one case, but has completely failed in several 
 others. 
 
 According to Dr. Fleming,* Brigade Surgeon. 
 Bengal Army, carbolic acid is a valuable remedy in 
 cases that have not advanced beyond the first stages. 
 He used as an application to the surface a mixture of 
 carbolic acid and oil or glycerine (i to 8 or more) 
 and gave tt|j-iv. of the acid internally several times a 
 day. Ten cases were thus treated, and most of them 
 were decidedly improved. The internal administra- 
 tion did not seem to have any direct action upon the 
 
 * " Notes on the Carbolic Treatment of Leprosy," i 889. Reprinted 
 from the Indian Medical Gazelle.
 
 AND ITS PREVENTION. 79 
 
 disease, the progress being at much the same rate as 
 whn the acid was only employed externally. 
 
 Whatever estimate may be formed of the value of 
 the remedies thus rapidly passed under review, the 
 fact must always be borne in mind that, even in the 
 absence of any special treatment, the course of 
 leprosy is often interrupted by remissions, especially 
 in the early stages. Not only may the morbid process 
 come to a standstill, but a decided improvement may 
 take place, and may progress so far that the patient 
 appears to be almost, if not quite, free from the dis- 
 ease. A change of this character is a not very unfre- 
 quent result of removal from an infected district, and 
 of attention to the general health. The improvement, 
 however, in all but a small minority of cases, is not 
 permanent; reappearance of the symptoms is the 
 almost invariable rule. Hence the suspicion with 
 which one must regard all accounts of the "cure" of 
 leprosy ; and especially those in which the patients 
 have remained only a few months under observation. 
 As a case in point, Dr. Hardy cites that of Dr. Lepine, 
 who was said to have been "cured" by the use of 
 hydrocotyle asiatica. The disease proved fatal in less 
 than three years after the supposed cure.
 
 80 . LEPROSY, 
 
 Prof. Cornil, believing that leprosy is due to the 
 presence of a microbe, endeavoured to discover 
 another micro-organism, which would act as a 
 gendarme and overpower or destroy the microbe. 
 With this view he injected an infusion of jequirity 
 under the skin of a leprous patient. The result, how- 
 ever, was by no means satisfactory. No change took 
 place in the external manifestations, and some time 
 afterwards the symptoms of mixed leprosy broke out 
 in a very severe form. According to Dr. Leloir, Prof. 
 Campana had a still more unfortunate experience in 
 his endeavour to combat the leprosy bacillus. He 
 inoculated two lepers with matter obtained from a 
 case of erysipelas. The result was that the latter 
 spread to nearly all the patients in the ward, while 
 the leprous symptoms remained unaffected. 
 
 Attempts to cure the disease having proved unavail- 
 ing, it is satisfactory to learn that much may often be 
 done in the way of palliating many of the symptoms. 
 Thus the neuralgic pains, which frequently torture the 
 unfortunate patients to a degree almost indescribable, 
 are sometimes considerably relieved by vapour baths, 
 tepid baths, by cupping along the course of the 
 affected nerve, and by salicylate of sodium ad-
 
 AND ITS PREVENTION. 81 
 
 ministered internally. These remedies are frequently 
 used in Norway. As an application to the tubers, 
 and for the erythema, Dr. Bidenkap recommends the 
 Goa powder in the form of an ointment. Massage 
 sometimes produces good effects both on tuberous 
 growths and on thickened nerves. Nerve-stretching 
 has been tried for the relief of very severe pain, and 
 it may be resorted to if everything else fails. 
 
 The lesions of the eye, which constitute a frequent 
 and much dreaded complication of leprosy, and in the 
 absence of treatment often lead to total blindness, 
 can be much ameliorated by medical skill. Dr. 
 Kaurin, for instance, often performs keratotomy in 
 order to prevent the spread of the tubercles to the 
 cornea. Danielssen recommends, for the same pur- 
 pose, the application of caustics. Dr. Kaurin also 
 performs various operations with the object of raising 
 the lower eyelid, so that the eye can be partially 
 closed and the tears prevented from running over the 
 cheek. The importance of these operations may be 
 gauged by the frequency with which affections of the 
 eye occur among lepers. Out of 64 cases at Molde, 
 41 presented ocular lesions ; 37 of these had both 
 eyes affected, and six were quite blind (Leloir). 
 
 6
 
 82 LEPROSY, 
 
 Amputation of the affected limb is sometimes per- 
 formed, and with good results, when the neuralgic 
 pains have become insupportable in spite of all 
 remedies. Dr. Leloir records such a case, under the 
 care of Dr. Kaurin at Molde, in 1881. The operation 
 was followed by complete subsidence of the pain, and 
 the wound healed satisfactorily. Dr. Leloir thinks 
 that caustics of various kinds, and also the actual 
 cautery, may occasionally be employed with advantage 
 for the destruction of the tubercles. In his opinion 
 tuberous leprosy is sometimes a purely local com- 
 plaint, and he believes that the destruction or removal 
 of the growths at their first appearance, and when 
 only a few exist, might ward off general infection of 
 the system. He cites another case of Dr. Kaurin's, 
 in which the tubercles were confined to the left leg, 
 converting it into a misshapen mass covered with 
 ulcers. Amputation of the thigh was performed, with 
 improvement of the general health, as the immediate 
 result. During the succeeding nine months the 
 patient showed no trace of leprosy. 
 
 I have discussed at some length the subject of treat- 
 ment, in order to show that although no cure has as 
 yet been discovered for leprosy, many of the more
 
 AND ITS PREVENTION, 83 
 
 distressing symptoms can be much ameliorated by the 
 aid of medicine and surgery. This fact admits of no 
 dispute, and the lesson to be drawn from it surely is 
 that lepers should not be neglected in the fashion 
 which prevails in most of the infected countries, but 
 should be admitted into special institutions, and sub- 
 jected to kindly and careful treatment. As Dr. Leloir 
 says, a leper ought not to be an object of horror or of 
 neglect ; he ought to inspire sympathy and devotion. 
 Before discussing the question of prophylaxis, a few 
 remarks on some details of hygienic treatment will 
 not be out of place. In all but very advanced cases, 
 the patients should, whenever possible, be removed 
 from an infected district into a healthy country, enjoy- 
 ing a temperate climate. In any case, they should be 
 placed under as favourable hygienic conditions as cir- 
 cumstances will permit. The food should be nutritious , 
 and non-stimulating in character, and consist mainly 
 of meat, eggs, milk, and fresh vegetables. All in- 
 digestible articles, as salted meats, salt fish, etc., 
 should be forbidden. Alcoholic drinks, if allowed at 
 all, must be given in very small quantities. The skin 
 should be kept as clean as possible ; vapour baths and 
 tepid baths, containing a little permanganate of potas-
 
 84 LEPROSY, 
 
 slum, carbolic acid, or thymol should be frequently 
 employed. They act favourably on the skin, and on 
 the patient's general health. Cold baths are not 
 desirable. 
 
 When ulcers or sores exist, they should be kept 
 very clean, and dressed with various antiseptic oint- 
 ments and lotions. Ulceration of the mouth and 
 throat requires gargles, powders (by insufflation) and 
 fluid antiseptics and deodorants, applied by means of 
 the spray-apparatus. Tonics of various kinds, and 
 especially iron and quinine, are often useful. Sulphur 
 waters taken internally and used for baths, are said to 
 have produced good results. Any intercurrent 
 symptoms must be treated according to their 
 nature ; diarrhoea is sometimes very troublesome, and 
 requires astringents of various kinds. Tracheotomy 
 is occasionally necessary in order to avert impending 
 asphyxia. 
 
 The importance of all attempts to improve the 
 general health of leprous patients cannot be overrated. 
 Next in order comes the internal and external employ- 
 ment of antiparasitic remedies. 
 
 It now remains (i) to consider various measures 
 that have been adopted in order to check the spread
 
 AND ITS PREVENTION. 85 
 
 of leprosy; (2) to endeavour to estimate their real 
 value, and (3) to point out the lessons to be deduced 
 therefrom. 
 
 In the earliest times, and down to a comparatively 
 modern date, there was no difference of opinion with 
 regard to the contagiousness of leprosy and the 
 measures required for preventing its spread. More 
 or less rigorous isolation of the sufferers was enjoined 
 by laws, to the non-observance of which severe 
 penalties were attached. In most countries, lepers 
 were expelled from their dwelling-places, and made 
 to live apart beyond the gates of towns, in hospitals, 
 or in " houses of separation." Prof. Marks tells us 
 that "Jewish lepers were, under penalty of eighty 
 stripes, forbidden to approach the mountain of the 
 Temple ; yet they were not rigidly confined to isolation, 
 but were allowed to move about freely, and, in towns 
 without walls, even allowed to enter Synagogues. It 
 was of the utmost importance that they should, on the 
 remotest suspicion, present themselves for inspection 
 to competent authorities, such as the appointed priests, 
 and should be pronounced clean only after repeated 
 and most scrupulous examination. They had no right 
 to complain of a personal restriction which was imposed
 
 86 LEPROSY, 
 
 in the interest of society as well as in their own ; for 
 society was freed from apprehension and danger, and 
 they themselves from a distrust, which, even when 
 unfounded, was sure to injure their social position. 
 If declared to be infested with the evil, they were 
 required to make themselves strikingly known at first 
 glance; like mourners, they were to appear in public 
 with rent garments, bare head and covered beard ; 
 thus signalized they would surely be shunned ; but if 
 anyone should inadvertently come near them, they 
 were to warn him off by the loud wail, ' Unclean, 
 Unclean ! ' They were even interred in a separate 
 burial-ground." 
 
 An account has been given in a previous chapter 
 (see page 7) of the discipline to which lepers were 
 subjected in England and abroad during the middle 
 ages. In some countries, strict isolation appears to 
 have been practised ; in others, lepers were allowed to 
 move more or less freely about the country, but were 
 compelled to adopt certain measures to prevent other 
 persons from approaching them. Thus we are told that 
 they were obliged to make a constant noise with a rattle, 
 to wear two artificial hands of white wool, one tied 
 on the breast, the other on the head, and to call 
 attention to their presence in various other ways.
 
 AND ITS PREVENTION. 87 
 
 2. It is not possible to determine, in a manner 
 approaching to accuracy, the real value of the preventive 
 measures thus briefly alluded to. The fact remains 
 that cases of leprosy became less and less frequent in 
 Europe in the fifteenth and sixteenth centuries) and 
 that the decline of the disease was in proportion to the 
 rigour with which isolation was enforced upon the 
 sufferers. Other causes, doubtless, co-operated in 
 producing the effect. During the middle ages, and 
 even at a much later date in some countries in Europe, 
 the articles of food consumed by the people in 
 general were for the most part of an unwholesome 
 and innutritious character. Fresh meat was a luxury 
 within the reach of comparatively few ; salted 
 provisions, both tough and indigestible, represented 
 the animal portion of diet ; fresh vegetables and fruits 
 were scarce and often unobtainable, and even the 
 bread was generally of a kind from which even the 
 poorest would now turn away in disgust. The habita- 
 tions and surroundings of the people presented many 
 conditions in the N highest degree favourable to the 
 spread of epidemics; water was generally scarce and 
 often bad ; the arrangements for the disposal of excreta 
 were of the rudest character. 
 
 Slowly, but surely, a progressive improvement took
 
 88 LEPROSY, 
 
 place in many respects. The food of the poorer 
 classes became more varied, more abundant, and more 
 nutritious in character, and some advance was made 
 in the art of cookery ; while, owing to the increasing 
 spread of commerce with other countries, bad harvests 
 were no longer followed by wide-spread famine. 
 Social conditions in general were thus rendered much 
 more favourable than at any previous time, and it is 
 highly probable that the disappearance of leprosy was 
 in some measure due to the improvements thus briefly 
 specified. The isolation of the sick was, however, 
 the most potent factor. 
 
 The condition of Norway, as regards leprosy, 
 furnishes abundant evidence of the value of isolation, 
 and it is to this subject that I wish to call special 
 attention. All the physicians, whom I met in Norway, 
 were unanimous in the opinion that segregation was 
 the most important part of the treatment of leprosy. 
 I would refer to the figures given on page 13, and will 
 here only repeat that the number of lepers in Norway 
 has decreased by one-half in the course of thirty-three 
 years. A still more rapid diminution may be expected 
 to take place in future, for it was only in 1885 that a 
 law was passed authorizing a forced seclusion of lepers.
 
 AND ITS PREVENTION. 
 
 Asylums for lepers were founded in Norway as far 
 back as the thirteenth century; but even in com- 
 paratively recent times their purpose, as Dr. Bidenkap 
 says, was not to restrain the spread of leprosy by 
 infection (which has only of late been accepted by 
 Norwegian physicians), but to treat the unfortunate 
 patients and to prevent the hereditary transmission of 
 the disease. In 1845 a law was proposed, aiming to 
 prevent the marriage of lepers, but was rejected by 
 the Parliament. Previous to 1885 there was no 
 effective law compelling the lepers to come into the 
 hospitals ; but the majority either came voluntarily or 
 were driven to do so by their poverty ; for the local 
 authorities would not relieve them, whereas the 
 hospitals supplied all necessaries. In 1885 a law 
 was passed that all lepers (not in asylums) should be 
 isolated in their homes, and that failure to comply with 
 this regulation was to be followed by their compulsory 
 removal to those institutions. Isolation of a leper in 
 his own house means that he must remain in one room 
 specially marked off for him ; he may, however, walk 
 about in the open air in the company of his friends or 
 others, but he must not go into any other room than 
 the one appointed to him. The adoption of these
 
 90 LEPROSY, 
 
 measures was entirely due to the indefatigable activity 
 of the Norwegian physicians. They have convinced 
 their fellow countrymen that leprosy is contagious, 
 and that isolation of the patients is the only efficacious 
 measure for stamping out the disease. At the same 
 time they are far from ignoring the good effects of 
 improved sanitation, diet, etc. There is every reason 
 for expecting that leprosy will become extinct in 
 Norway in the course of a few decades. 
 
 Another example, of a very different character, 
 enforces the lesson to be drawn from Norwegian 
 experience. Let us examine the statistics of leprosy 
 in an island in which isolation of the patients is not 
 carried out. 
 
 According to Dr. Neisser, the island of Trinidad 
 contained 
 
 In 1805 ... 3 lepers in a population of 29,940. 
 
 i> I 8l 3 73 ii ,i ii ii 3 2 >- 
 
 1878 ... 860 120,000. 
 
 Dr. Leloir states that in 1884 the number of lepers 
 was 450 among a population of 180,000 ; but he had 
 been assured by a resident physician, Dr. de Verteuille, 
 that that number by no means indicated the real state
 
 AND ITS PREVENTION. 91 
 
 of the case. His informant also laid special stress 
 upon the increasing frequency of the disease among 
 the white population. " Fifty years ago there were 
 not more than three or four white families among 
 whom a leper could be found." At the present time, 
 Dr. de Verteuille knows of at least fifteen such fami- 
 lies, and he believes that more could be discovered. 
 This increase is attributable to the fact that, although 
 an asylum exists, the patients enter and leave it just 
 as they like. It now contains three whites (two of 
 whom are Europeans) ; 97 Africans and Creoles and 
 43 coolies. Compulsory isolation has never been put 
 in force by the Government. A century ago, when 
 colonization began, there were a few cases scattered 
 about over the island. No precautions having been 
 taken, the number has steadily increased ; and the 
 proportion to the population was far less fifty years 
 ago than it is at the present time. The emancipation 
 of the slaves in 1834 was followed by a flow of 
 immigration from the neighbouring colonies and from 
 India, and the new comers brought with them a 
 certain number of lepers. In Cura9ao, another West 
 Indian island, where the Dutch Government has for 
 the last 40 years strictly carried out prophylactic
 
 92 LEPROSY, 
 
 measures, the number of lepers has been kept down 
 to ten or twelve. 
 
 Another instance, also cited by Dr. Leloir, is that 
 of the Guianas. The territories bearing that name 
 are three in number, and belong to England, Holland, 
 and France respectively. The Dutch territory is 
 between the other two, and the Government adopts 
 preventive measures with the same vigour as in 
 Cura9ao. The number of lepers is much less than in 
 the adjacent territories where no similar precautions 
 are taken, and where the complaint is decidedly on 
 the increase. A report, teaching the same lesson, 
 comes from Madagascar. Dr. Davidson says that 
 when isolation was practised the spread of the disease 
 was arrested, and that when the law ceased to be 
 enforced the number of lepers enormously increased. 
 
 It would be easy to multiply examples demon- 
 strating the value of isolation ; there is one which 
 must not be omitted. In New Brunswick persons 
 affected with leprosy do not communicate freely with 
 the rest of the community after the existence of the 
 disease has been fully ascertained. They are 
 admitted into a Lazaretto, where their friends and 
 acquaintances are allowed to visit them occasionally,
 
 AND ITS PREVENTION. 93 
 
 under certain restrictions. " For some years past," 
 Dr. Tache states, "the segregation has not been 
 enforced by violent measures ; but the exertions, par- 
 ticularly on the part of the clergy, to induce the sick 
 to enter the Lazaretto have been unceasing, and the 
 result has been that for many years all lepers, with 
 only two exceptions, have resorted to the Lazaretto." 
 This institution was first established in 1844; it is 
 supported at the public expense, and the patients are 
 under the care of Sisters of Charity, a chaplain, and 
 a physician. In 1885 the Lazaretto contained twenty- 
 two patients. Owing to strict precautionary measures 
 and to the effective isolation, the diminution in the 
 number of the patients has been steadily going on for 
 some years. Relatively to the population the decrease 
 is very considerable. 
 
 3. The lessons to be drawn from the facts thus 
 briefly narrated are significant and unmistakable. To 
 check the spread of leprosy two measures must be 
 adopted the sufferers must be isolated, and the 
 sanitary condition of inhabitants of infected districts 
 must be improved in every possible manner. With 
 regard to isolation, we find that Norway is the only 
 European country in which this method is carried out.
 
 94 LEPROSY, 
 
 Here in England we are so happily situated that a 
 leper is one of the rarest of prodigies, and becomes 
 an object of universal interest and commiseration. 
 In some of our colonies and in our Eastern empire 
 familiarity with leprosy seems to have bred contempt. 
 In Hindostan, at all events, the disease is regarded as 
 an evil far beyond the capacity of an all-powerful 
 Government to prevent. A former Viceroy is reported 
 to have said that one might almost as readily under- 
 take to rid India of its snakes as of its lepers. So 
 long as this notion prevails, any serious effort is of 
 course not to be looked for. India may perhaps 
 some day be governed by a Viceroy whose vocabulary 
 does not contain the word " impossible." The task 
 of ridding India of leprosy would be one of enormous 
 magnitude and difficulty, and would require years of 
 patient labour for its accomplishment. Yet consider- 
 ing what has been done in India, and the marvellous 
 excellence of its administration, it would be casting 
 an undeserved stigma on the governing classes to 
 declare that they are powerless to prevent the spread 
 of this terrible disease. It is unnecessary to repeat 
 the accounts, lately given by many Indian journals, of 
 the so-called " leper nuisance." These are some of
 
 AND ITS PREVENTION. 95 
 
 the statements, the truth of which is beyond question. 
 In India, lepers are allowed to wander about wher- 
 ever they please ; in large towns they haunt the 
 markets, tramway stations, and other places of public 
 resort, they squat around tanks, performing their 
 ablutions and dressing their sores ; and in the city of 
 Bombay they are wont to congregate close tp schools 
 where thousands of boys are educated. One might 
 well ask, What more could be done to promote the 
 spread of the disease? After describing the condi- 
 tion of lepers in Bombay, one Indian paper aptly 
 remarks : " We seem to be reading rather of the 
 insanitary foulness of a mediaeval city where medical 
 science was still in its infancy, and men's conceptions 
 of the duties and responsibilities of civic government 
 still rudimentary, than of the state of things in a 
 great city of the nineteenth century British empire." 
 
 The Indian Government has, however, done some- 
 thing ; it has passed a resolution that for the present, 
 at all events, it is impossible to do more than encour- 
 age the grant of medical and charitable relief in 
 voluntary hospitals and leper-asylums. We are also 
 told that instructions have been issued to district 
 officers to endeavour to provide asylums for lepers,
 
 96 LEPROSY, AND ITS PREVENTION. 
 
 and that leave has been granted to employ for this 
 purpose funds given for the support of dispensaries 
 and other charitable objects. In the opinion of 
 those well qualified to judge, steps of this character 
 will prove to be almost if not quite inoperative to 
 procure isolation of the sick and arrest the spread 
 of the disease. There will be no power to compel 
 lepers to reside in certain "places, or to remain in 
 asylums any longer than they choose. It is in vain 
 to expect any good results from such measures as 
 these. The leprosy question in India will have to be 
 grappled with some day, and it will become more and 
 more difficult as time goes on. Our knowledge of 
 the disease is doubtless imperfect, but we are fully 
 cognizant of its horrible character, and of the means 
 by which alone its spread can be arrested. Com- 
 pulsory isolation in suitable buildings and under 
 proper care is urgently demanded in the interests 
 not only of the general community, but of the 
 sufferers themselves. If leprosy cannot be cured, 
 some of the more distressing symptoms can certainly 
 be alleviated.
 
 INDEX. 
 
 A. 
 
 Africa, Leprosy in, 18. 
 
 America, United States of, Leprosy in, 20. 
 
 Anaesthetic leprosy, 31. 
 
 Antiparasitic treatment of leprosy, 76, 78. 
 
 Australia, Leprosy in, 18. 
 
 B. 
 
 Bacilli of leprosy, 48. 
 
 Bennett, Sir Risdon, on the leprosy of the Bible, 3. 
 
 Brazil, Leprosy in, 21. 
 
 C. 
 
 Canada, Leprosy in, 20. 
 
 Cape of Good Hope, Leprosy at the, 18. 
 
 Carbolic acid in treatment of leprosy, 78. 
 
 Cause of leprosy, 48. 
 
 Causes of death in leprosy, 43. 
 
 Causes. Predisposing, of leprosy, 69. 
 
 Chaulmoogra oil for leprosy, 77. 
 
 China, Leprosy in, 16. 
 
 Climate as a cause of leprosy, 70. 
 
 Contagiousness of leprosy, Proofs of, 54. 
 
 Curafoa, Leprosy in, 91 
 
 Cures of leprosy, 79. 
 
 Cutaneous leprosy, 23.
 
 98 INDEX. 
 
 D. 
 
 Definition ofleprosy, i. 
 Diagnosis of leprosy, 44. 
 Diet as a cause of leprosy, 70. 
 Disappearance of leprosy from British Isles, 9. 
 Disease, Previous, as a cause of leprosy, 74. 
 
 E. 
 
 England, Leprosy in, 7. 
 Eye, Affections of the, in leprosy, 36, 81. 
 
 F. 
 
 Food, Deficient or improper, as a cause of leprosy, 70. 
 Forms of leprosy, 23. 
 France, Leprosy in, 15. 
 
 G. 
 
 Geographical distribution of leprosy, 12. 
 Goa powder in leprosy, 78. 
 Greece, Leprosy in, 15. 
 Guianas, The, leprosy in, 92. 
 Gurjun balsam in leprosy, 77. 
 
 H. 
 
 Hereditary transmission ofleprosy, 65. 
 Hindostan, Leprosy in, 16, 94. 
 Hirsch, Dr., on contagion of leprosy, 63. 
 Hygienic treatment of leprosy, 83. 
 
 I. 
 
 Incubation of leprosy, 62. 
 Inoculation of leprous matter, 57.
 
 INDEX. 99 
 
 Iodine in the treatment of leprosy, 76. 
 Insanitary conditions as causes of leprosy, 73. 
 Isolation of leprous patients, 85. 
 
 J- 
 
 Japan, Leprosy in, 16. 
 Jews, Leprosy among the, 2, 85. 
 
 K. 
 Kaurin, Dr. Ed., on leprosy in Norway, 13, 41, 65, 81. 
 
 L. 
 
 Leloir, Dr., on contagiousness of leprosy, 68 ; geographical 
 distribution of leprosy, 21 ; history, n ; inoculation of 
 leprous matter, 58; leprosy in Norway, 14 ; in Trini- 
 dad, 90. 
 
 Leprosy, Causes of, 48 ; diagnosis of, 44 ; duration of life in, 
 40; earliest accounts of, 2 ; forms of, 23 ; incubation 
 of, 62 ; " mixed," 40 ; morbid anatomy of, 47 ; muti- 
 lations due to, 35 ; paralyses in, 33 ; prevention of, 84 ; 
 prognosis of, 42 ; symptoms of, 23 ; treatment of, 75. 
 
 Locality as a cause of leprosy, 70. 
 
 M. 
 
 Marks, Prof., on leprosy among the Jews, 85. 
 Mercury in the treatment of leprosy, 76. 
 Mexico, Leprosy in, 21. 
 Middle ages, Leprosy in the, 6. 
 Morbid anatomy of leprosy, 47. 
 Mutilations due to leprosy, 35.
 
 I ' 
 
 N. 
 
 Neisser, Prof., on the leprosy bacillus, 48. 
 New Brunswick, Leprosy in, 92. 
 New Zealand, Leprosy in, 17. 
 Norway, Leprosy in, 12, 41, 81, 88. 
 Norwegian peasants, Diet of, 71 
 
 O. 
 
 Oceania, Leprosy in, 19. 
 
 P. 
 
 Paralysis due to leprosy, 33. 
 Pemphigus as a symptom of leprosy, 32. 
 Prevention of leprosy, 87. 
 
 R. 
 Russia, Leprosy in, 15. 
 
 S. 
 
 Sandwich Isles, Leprosy in, n, 19, 57. 
 Simpson, Sir J., on leprosy, 7. 
 Spain, Leprosy in, 15. 
 Sweden, Leprosy in, 14. 
 
 T. 
 
 Trinidad, Leprosy in, 21, 90. 
 Trophic disorders in leprosy, 32. 
 Tuberous leprosy, 23. 
 
 U. 
 Ulcers in leprosy, 26. 
 
 W. 
 West Indies, Leprosy, in, 21. 
 
 London: H. K. Lewis, 136, Gower Street, W.C.
 
 3 1970007367946 
 
 WC335 
 R781L 
 1890 
 Roose, Robs on. 
 
 Leprosy and its prevention 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664
 
 mS&m 
 
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