CHAPTER 16: THE LEPROSY INVESTIGATION COMMITTEE.

CHAPTER 16: THE LEPROSY INVESTIGATION COMMITTEE.

By reason of the reports of the serious increase of leprosy in various countries, and the public interest excited by the self-sacrificing labours and death of Father Damien, an influential committee was convened for the purpose of investigating the causes of this recrudescence.

The first meeting was held on the 17th June, 1889, at Marlborough House, under the presidency of the Prince of Wales. On the 13th January, 1890, a subscription dinner was held at the Hotel Metropole, London, at which more than a hundred persons interested in the project sat down, and subscriptions amounting to over Ł2500 were announced.

This fund ultimately reached about Ł7000. The following resolutions were adopted at a meeting of the General Committee held at Marlborough House on the 30th June, 1889:—

(1) That a sum of Ł500 be appropriated to a memorial to be erected to Father Damien in some public place in the Hawaiian Islands.

(2) (a) That a fund be formed, the interest of which shall be devoted to the medical treatment and care of indigent British lepers in the United Kingdom. (b) And that a sum of money be set apart and placed under the control of trustees for the endowment of two student-ships, one student to make the United Kingdom and the remainder of Europe his field of investigation, and the other to go abroad and study the disease in China, the Colonies, and elsewhere. The studentships to be held for a period of three years, to be renewed by the trustees if thought desirable.

(3) That a Commission be appointed, for not less than one year, consisting of three members, one to be named by the Royal College of Physicians, one by the Royal College of Surgeons, and one by the General Committee of the National Leprosy Fund, to go out to India for the purpose of investigating the disease of leprosy there, and that the Indian Auxiliary Committee be requested to add two members to this Commission.

The following Commissioners were appointed :— Nominated by the Royal College of Physicians—

BEAVEN NEAVE RAKE, Esq., M.D. (London), M.R.C.S. (England), L.R.C.P. (London), Government Medical Officer and Medical Superintendent of the Trinidad Leper Asylum.

Nominated by the Executive Committee of the National Leprosy Fund— GEORGE ALFRED BUCKMASTER, Esq., M.A., B.Ch., M.D. (Oxford), D.P.H. (Diploma of Public Health, Oxford), M.R.C.S., L.R.C.P. (London), formerly Radcliffe Fellow Magdalen College, Oxford, Lecturer on Physiology, St. George’s Hospital, London.

Nominated by the Royal College of Surgeons— ALFRED ANTUNES KANTHACK, Esq., B.A., B.Sc., M.B., B. S. (London), F. R. C. S. (England), and L. R. C. P. (London), late Clinical Assistant Royal Ophthalmic Hospital, London, and Midwifery Assistant, St. Bartholomew’s Hospital, London.

Appointed by the Viceroy of India—

(The late) Surgeon-Major BARCLAY, Secretary to the Surgeon-General to the Government of India.
Surgeon-Major S. J. THOMSON, Deputy Sanitary Commissioner of the Second Circle in the North - West Provinces and Oudh.

The following order appeared in the Indian Government Gazette of the 21st November, 1890:— EXTRACT from the Proceedings of the Government of India in the Home Department (Medical), under date, Calcutta, the 21st November, I890.

RESOLUTION.

The Executive Committee of the National Leprosy Fund having determined to appoint a Commission for the purpose of investigating the disease of leprosy in India, it is notified for general information that Dr. Beaven Rake, Mr. Kanthack, and Dr. Buckmaster (their full titles and qualifications are set out in the resolution) have been appointed Commissioners. These gentlemen have now arrived at Bombay, and have been joined there by Surgeon-Major A. Barclay, M.D., Secretary to the Surgeon-General with the Government of India, and Surgeon-Major S.J. Thompson, Deputy Sanitary Commissioner, North-Western Provinces and Oudh, who have been appointed by the Government of India to co-operate with them. The Governor-General in Council will feel obliged if public bodies and individuals desirous of producing evidence before the Commissioners will address the Local Government of the Province to which they may belong, in order that arrangements may be made for the presentation of such evidence before the Commissioners. Each Local Government has already been requested to depute an officer to assist the Commission in collecting and arranging the evidence that may be procurable in the territories under its control, and instructions should be given to all the civil and medical officers to give to the Commissioners any aid which they may ask for in the course of their inquiries. The Government of India will, on learning from the Commissioners the programme which they intend to follow, notify it for public information.

ORDER

Ordered, that a copy of this resolution be forwarded to Local-Governments and Administrations, in continuation of the communication from this office, No. 11 Medical, 596-605, dated 15th September, I890, to the Surgeon-General with the Government of India, and to the Members of the Leprosy Commission for information. It will be convenient if the Commissioners will address the Surgeon-General with the Government of India on any point on which they may desire to receive further assistance or information.
Also, that the resolution be published in the supplement to the "Gazette of India." (True Extract). (Signed) C. J. YALL, Officiating Secretary to the Government of India.

The Leprosy Commissioners, who left England for India on the 23rd October, 1890, completed their inquiries in the autumn of 1891, and prepared their report; but its publication has been delayed, ostensibly on the ground that the Committee of the National Leprosy Fund were waiting the issue of the Indian census returns as regards leprosy. It appears, however, from the facts disclosed in the following circular, issued in June, 1892, that several of the most important conclusions arrived at by the Commission are strongly objected to.

NATIONAL LEPROSY FUND.

Memorandum on the Report of the Leprosy Commissioners.

Your Committee, having been instructed to consider and report to you upon the publication of the Report of the Leprosy Commissioners in India, in 1890-91, beg to submit the following considerations :—

I. They desire to place on record their sense of the ability with which the Commissioners conducted their investigations while in India, and of the comprehensive and valuable nature of their Report.

II. The conclusions at which the Commissioners arrived have been summarised by them at the end of their report as follows—the evidence upon which these conclusions rest being displayed at length in the earlier pages of the Report :—

(1) "Leprosy is a disease sui generis; it is not a form of syphilis or tuberculosis, but has striking aetiological analogies with the latter."

(2 "Leprosy is not diffused by hereditary transmission ; and for this reason, and the established amount of sterility among lepers, the disease has a natural tendency to die out."

(3) ‘Though, in a scientific classification of diseases, leprosy must be regarded as contagious, and also inoculable, yet the extent to which it is propagated by these means is exceedingly small."

(4) Leprosy is not directly originated by the use of any particular article of food, nor by any climatic or telluric conditions, nor by insanitary surroundings; neither does it-peculiarly affect any race or caste."

(5) "Leprosy is indirectly influenced by insanitary surroundings, such as poverty, bad food, or deficient drainage or ventilation; for these, by causing a predisposition, increase the susceptibility of the individual to the disease."

(6) "Leprosy, in the great majority of cases, originates de novo, that is, from a sequence or concurrence of causes and conditions, dealt with in the report, and which are related to each other in ways at present imperfectly known."

III. Thirdly, the Commissioners having been instructed to report upon the practical measures to be taken for the control or restriction of the disease in India, have suggested the regulation of lepers and leprosy by means of bye-laws framed by the various municipalities, which point they write as follows :—

(a) "The Commission are of opinion that the sale of articles of food and drink by lepers should be prohibited, and that they should be prevented from practising prostitution, and from following such occupations as those of barber and washerman, which concern the food, drink, and clothing of the people generally, quite apart from the dread a possible infection."

(b) "The Commission consider that the best policy in dealing with the concentration of lepers in towns and cities is to discourage it, and to this end would suggest that municipa1 authorities be empowered to pass bye-laws preventing vagrants suffering from leprosy from begging on or frequenting places of public resort, or using public conveyances."

(c) "The large presidency towns and the capitals of provinces in many cases already possess leper asylums, which might be enlarged by municipal funds or private subscriptions. Asylums should be built near towns where they do not already exist, and the authorities should have of ordering lepers infringing the regulations either return to their homes or to enter an asylum."

(d) "Competent medical authority should always be consulted before action is taken under such bye-laws."

IV. Upon the afore-mentioned conclusions of Commissioners, numbered 1, 2, 3, 4, 5, and 6, your Committee offer the following remarks :—

They desire to express their disagreement with the concluding words of No. 3—

"That the extent to which leprosy is propagated by contagion and inoculation is exceedingly small "—

not being satisfied with the evidence offered by the Commissioners for this opinion.

They cannot concur in the views expressed in No. 6,— namely, that

* "Leprosy, in the majority of cases, originates de novo, that is, from a sequence or concurrence of causes and conditions, dealt with in the report, and which are related to each other in ways at present imperfectly known,"

* See page 304

being of opinion that the evidence adduced does not justify such conclusions.

V. The Commissioners, in the section of their Report entitled "Practical Suggestions," pp. 45 2-7, as also in other parts of the Report, have expressed opinions strongly adverse to compulsory segregation, either complete or partial. For instance, they say on p. 258—

"No legislation is called for on the lines either of segregation or of interdiction of marriages with lepers."

And on p. 453— "For India, complete compulsory segregation of lepers may be considered to be absolutely impracticable. Neither do the conclusions given before as to the nature of the disease justify any recommendation for absolute segregation."

And on p. 454— "It is impossible, for the same reasons, to advise compulsory partial isolation. Voluntary isolation is therefore the only measure left for consideration."

And on p. 456—

"In no case would the Commissioners suggest an Imperial Act especially directed against lepers as such."

And again on p. 456—

** "In conclusion, the Commissioners believe, from the considerations and arguments adduced in the foregoing report, neither compulsory nor voluntary segregation would at pro effectually stamp out the disease, or even markedly diminish leper population, under the existing conditions of life in India."
* *see page 304

Your Committee, having already expressed inability to accept the reasoning upon which Commissioners have based the above conclusions, equally unable to accept the corollary that in any case of leprosy in India is either impracticable or undesirable. They entertain a precisely opposite opinion, and would be sorry if the Government of India encouraged by the report of the Commissioners to from taking the necessary steps in the direction of such segregation of lepers as may be found possible. opinions upon segregation are in accord with expressed in the following extract from a by Dr. Vandyke Carter :—

MODES OF SEGREGATION.

I. "By erecting plain asylums at certain centres, each of which would be a refuge common to several districts, and a place detention, tinder due management and supervision."

II. "By founding leper colonies, or village communities of the affected, who, while allowed more liberty of movement, should yet be prevented from mingling with the peasantry around: hence still the need of strict supervision. Many spots would serve—such as deserted forts, decayed villages, and places waste, yet not far from other sources of supply, or not without resources easily resuscitated."

III. "By requiring the strict isolation of leprous subjects retained in their homes at express wish of friends. Suitable separate lodgment would be indispensable; unsuitable shelter is even now sometimes supplied. Joining of such home-isolation with more public measures should not be overlooked, for to it experience in Norway seems to point as a means essential to complete success within a moderate period of time; and in India it would have to be still more largely resorted to."

IV. "For carrying out the above, in addition to funds, legislative authority is needed to take up the vagrant sick, to remove the sorely diseased who is insufficiently guarded at home, and at times to enforce continued isolation of the infected until medical sanction of liberty be granted."

VI. Reserving their opinions as expressed in the foregoing paragraph and extract, your Committee give a general approval to the minor recommendations of the Commissioners, numbered above as (a) (b) (c) (d), for the regulation of lepers and leprosy in India, which they consider might with advantage be carried out; though they do not concur in the opinion that municipalities will be necessarily or universally the best means of effecting that object.

Nominated by the Executive Committee of the National Leprosy Fund—
GEORGE N. CUEZON (Under-Secretary for India), Chairman.
EDWARD CLIFFORD.

Nominated by the Royal College of Physicians—
DYCE DUCKWORTH, M.D., LL.D.
G. A. HERON, M.D., F.R.C.P.

Nominated by the Royal College of Surgeons—
JONATHAN HUTCHINSON, LL.D., F.R.S. (With the exceptions noted below.)
N.C. MACNAMARA, F.R.C.S.

* Upon this paragraph Mr. Hutchinson appends a dissentient opinion, as follows :—

"I understand the Commissioners to mean by the expression ‘de novo’ in reference to the origin of leprosy, that they believe that the disease may begin independently of personal contagion and in connection with climatic and dietetic causes. In that belief I entirely share. I also agree in the main with the rest of the statements in the Commissioners’ Report to which exception has been taken in our Committee. I feel convinced that if leprosy be contagious at all, it depends but to an almost infinitesimal extent upon contagion for its spread." JONATHAN HUTCHINSON, LLD., F.R.S.

** Upon this paragraph of the Report, Sir Dyce Duckworth and Mr. Hutchinson append independent or dissentient opinions, as follows :—

     "I am in agreement generally with the recommendations of the Commission respecting voluntary isolation, and the issue of Municipal Bye-Laws regulating the habits of lepers. I know of no trustworthy evidence to prove that a leper in any community is a source of greater danger than is a consumptive patient, and I know that a person suffering from syphilis is a real and very positive source of danger anywhere. It would therefore be absurd on the face of it to adopt stringent laws for the leper and to let the syphilitic person go free.
    "The intelligent layman now imagines that because bacilli are an essential feature of leprosy, therefore the disease must be readily contagious. This is simply quite contrary to fact. The same thing holds good exactly for consumption.
    "I think a well-empowered and vigorously-supported Government Medical Executive Officer should be appointed in every large town, and in certain districts, to supervise the leprous populations and report regularly upon them. It should be his business to see that the local regulations are fully carried out, and on his requisition only should any action be taken when necessary.
    "Suitable asylums should be provided, and those now existing be sufficiently enlarged to meet the needs that will arise under suitable bye-laws.
   "The project of leper-farms is, I think, a good one. More than this is, I believe, not within any practical scheme for amending the condition of lepers, and for diminishing the spread of the malady."   DYCE DUCKWORTH, M.D., LL.D.

"I am strongly in favour of the maintenance (by Government or otherwise) of voluntary homes for lepers, but do not believe that segregation would effect anything in diminishing the prevalence of the disease. Compulsory segregation would I think involve injustice and entail much social misery. I believe that our Commissioners Report well expresses not alone the opinions of those who have signed it, but, in a general way, those of the educated classes of the present day throughout India." JONATHAN HUTCHINSON, LL.D., F.R.S.

ADDITIONAL REPORT.

"Your Committee having also been instructed to report upon the disposal of the balance of Ł800 still remaining to the account of the Executive Committee, recommend that a sum of Ł250 should be set apart for the prosecution of further investigations and the continued half-yearly publication of the journal for a period of five years, or until such time as this sum is exhausted; and that the remaining Ł550 should be devoted to the. encouragement of local research in countries where there. is reasonable evidence for believing that leprosy has recently originated, or where it exists under very exceptional circumstances—with the view of tracing the disease to its alleged origin."

It may be observed that for the Commissioners to have allowed that leprosy is easily inoculable (as is shown in this volume upon the evidence of accepted authorities in all parts of the world) would have been equivalent to the admission of the danger in all leprous countries of the invaccination of leprosy. Such an avowal would have been inconsistent with the course adopted by the Commissioners and by the Committee of the National Leprosy Fund during the whole of this important inquiry, both of whom have practically ignored the evidence bearing upon the subject. When visiting Calcutta, for example, nothing would have been easier than for the Commissioners to have investigated the cases circumstantially reported by Dr. Roger S. Chew, which will be found in another chapter of this book. Having ignored these cases, one of the Commissioners, Dr. Beaven Rake, immediately on his return from India, gave evidence before the Royal Commission on Vaccination to show that leprosy was not communicable by vaccination, or, if so, only to so slight a degree that the danger might be disregarded. How far Dr. Rake’s testimony has stood the test of cross-examination will be gathered by reference to the evidence in the Blue Book which had not been issued at the time of this writing.

On the subject of inoculation, the Commissioners conclude :—" The extent to which leprosy is propagated by contagion and inoculation is exceedingly small." It is a pity that the Commission should have bundled these two dissimilar sources of alleged causation together, as they cannot consistently be so treated. Nor have they defined the word "contagion," which many authorities, as I have shown, habitually use to cover inoculation. The dissemination of leprosy by contagion, using the word in its proper sense—i.e., by simple contact—has been disproved by eminent authorities, including superintendents of leper asylums of wide experience in all countries, as will be seen by reference to the chapter in this book entitled "Is Leprosy Contagious?" On the other hand it is conclusively established by a similar weight of evidence that leprosy is inoculable, and like other transmissible diseases can be propagated through a cut, sore, wound, or abraded surface, or be inoculated by flies and mosquitos, or spread by vaccination. Another point in which the Committee dissent from the views of the Commissioners is that of compulsory segregation or compulsory isolation, which they consider uncalled for by the evidence collected during their tours of investigation, or by the nature of the disease, and are of opinion that it would be impossible to stamp out the disease by either voluntary or compulsory segregation. The Committee of the National Leprosy Fund do not accept either the reasoning or conclusions upon which these recommendations of the Commissioners are founded. On the contrary, they are of the opinion that the segregation of lepers should be encouraged as far as possible in the interest both of the lepers and of the public. The Committee conclude by declaring that they can give only "a general ‘approval to the minor recommendations of the Commissioners" on this point. Both the Committee and the Commissioners accept the important fact that leprosy is not diffused by hereditary transmission.

Setting aside the alleged leading causes of leprosy, such as heredity, contagion, and inoculation, as contributing little or nothing to the spread of this disease, the Commissioners resort to a theory which, up to the present time, has received but little countenance from the medical profession, that "leprosy in the great majority of cases originates de novo, that is from a sequence or concurrence of causes and conditions, dealt with in the Report." The present writer considers it highly probable that leprosy as well as other diseases may in numerous instances be accounted for in this way, but it must be observed that the factors, which are various forms of insanitation, have been in operation time out of mind, and do not in any way account for the remarkable recrudescence of the disease shown in this volume. On the contrary the danger from malaria, overcrowding, impure water, unwholesome food, filthy deposits, has, under the instructive teachings of the late Dr. Southwood Smith, Sir Edwin Chadwick, and their followers, been gradually and sensibly diminishing, and it is triumphantly claimed that various diseases due to these causes have been decreasing also. It is obvious, therefore, that some other factor or factors, peculiar to this century and previously unknown, are at work. This factor, as high authorities now reluctantly avow, has been omitted by the Commission from the list of causations in their summary of conclusions—the latest and most daring official effort, to use a classic phrase, "to preserve vaccination from reproach."

Amidst this divergence of opinion between the conclusions of the Leprosy Commissioners and those of the Committee, the public will want to know what useful object has been realised by the large expenditure of time and money in promoting this lengthened inquiry. Will the authorities accept the conclusions of the Leprosy Commission, when they affirm that "the extent to which leprosy is propagated by contagion and inoculation is exceedingly small ;" or the opposite views entertained by the eminent members of the Committee of the National Leprosy Fund, who declare their disagreement with these amongst others of their conclusions?

The Leprosy Commissioners (all ardent supporters of the Jennerian practice) have searched far and wide for a rational theory that will account for the recent spread of leprosy in certain countries, but have utterly failed to discover one, and are almost driven to the conclusion that touches closely upon the facts collected in this volume. Under the head of "Transmission through an Intermediary Host," one of their number, Dr. Beaven Rake, says :—" There is at present no direct evidence to support this hypothesis, but it seems that some such theory might explain the alleged rapid increase of leprosy in Hawaii and New Caledonia."—Journal of the Leprosy Investigation Committee,. No. 1, Aug., 1890, pp. 50,51.

To the present writer, vaccination seems to be the only intermediary host that passes direct into the blood (except in rare instances of accidental inoculation), and which covers all the facts of the case.

It appears that of the Ł7000 collected Ł800 remains, part of which it is suggested should be devoted to further investigation. It is to be hoped, if this is adopted, that less prejudiced and more competent inquirers will be appointed, and that in the future numbers of the Journal the accumulation of evidence, so shamefully ignored, showing how leprosy has been spread at the point of the vaccinator’s lancet will find a place.

Index