CHAPTER 3:  LEPROSY COMMUNICABLE BY INOCULATION

WHILE the preponderance of medical and scientific opinion is against the theory that leprosy is, in the ordinary sense of the word, a contagious disease, the evidence in favour of its being communicable by inoculation is overwhelming. Even those who strongly uphold the theory, of contagion invariably include inoculation as one of the principal means of communication. However widely authorities differ as to the other causes to which leprosy is attributed, such as climatic influences, unwholesome and putrid food, want of salt, a fish diet, malaria, heredity, contagion, syphilis. and insanitation, we may safely affirm that there is a practical consensus of opinion as to its inoculability.

To the question, Is leprosy inoculable? Sir William Moore, K.C.I.E., late Surgeon-General, Bombay Staff, Hon. Physician to the Queen, says :—"Professors Damisch and Kobner proved by an experiment that leprosy may be communicated to animals by inoculation. There is also the well-authenticated case of a boy, Miller, who pricked himself with a needle used by a leper, from which injury leprosy developed. Then there was a case of a medical student pricking himself when performing a post-mortem examination on a leper."

Sir William Moore has himself cited (Journal of the Leprosy Investigation Committee, No. .1, p. 28) a case of inoculation in a person with an injured hand who was employed to rub sulphur ointment on leprous patients, his family being quite free from the disease, and no history of previous association with lepers being obtainable. He considers that the sulphur ointment had no protective influence. "All that is required is the transmission of leprous discharge, which contains the microbe or germ of leprosy, to the healthy body. But in order that the poison may act it is necessary that it should come in contact with an abrasion or sore on a healthy skin. An infinitesimal portion of leprous discharge is quite sufficient."—Leprosy and Leper Houses, pp. 2 and 3.

In a communication to the secretary of the Leprosy Fund, dated June 2, 1890, Sir William says:—" Leprosy has been attributed to the following causes:--Climatic heat; (2) unsanitary conditions ; (3) want of salt; (4) vegetable diet; (5) fish diet; (6) lime in water; (7) malaria. But facts show that none of these are the causes." After giving the reasons for this conclusion, the writer adds :—"My views that leprosy is a phase of inherited syphilis, communicable, however, by inoculation, and the reasons for such views, have been expressed in my ‘Manual of. the Diseases, of India,’ 1887."

This view accords with the most eminent medical authorities in all countries where leprosy prevails. In a report on Leprosy in Cyprus, by Dr. Heidenstam, chief medical officer for the island, transmitted by the High Commissioner, Sir Henry Bulwer, to Lord Knutsford, and presented to both Houses of Parliament, March, 1890, the author, after dismissing various theories put forward to explain the spread of leprosy, such as heredity, the use of putrid food, salt pork, mal-hygiene, malaria, and miasma, says :—"My researches have led me to the conclusion that leprosy is what should be termed an inoculable disease, inasmuch as the virus is transmitted into the system in like manner as many other maladies, notably syphilis, anthrax, glanders, etc.; but it has not the same action in all constitutions, nor in all circumstances of life, and is of a long and slow incubation. My further researches and studies have not in any way altered the opinion I then expressed, and I am more than ever convinced that the direct cause of leprosy is simply and solely due to the inoculation of the virus of a person affected into another up to that time free.

"It has been advocated that instances of the communicability of leprosy have been rare, and so doubtful that it is impossible to rely on their authenticity. In this island, at least, I have met many cases where the slightest doubt could not be entertained."

Dr. Olavide, of Madrid, at the Paris Dermatological Congress of 1889, maintained that leprosy was evidently a parasitic disease, contagious, and inoculable. This authority refers to a curious fact, that it is observed by preference amongst the soldiers and monks who have resided previously in America and in the Philippine Islands. In Spain, while vaccination is not always carried out amongst the civil population, it is rigorously enforced in the army, as I was informed some years ago by the then British Consul; Mr. M’Pherson, of Madrid.

At the same Congress, Dr. Zambaco-Pacha, communicating the results of his inquiries concerning leprosy in the Isle of Mitylene, mentions that while he is an anti-contagionist, the discovery of the leprous bacillus has somewhat shaken his ideas. He records the curious fact that, of about 120,000 souls in Mitylene, 15,000 are Mussulmans, and amongst these there is not a single leper to his knowledge. Dr. Zambaco omits to note the fact that Mussulmans in most countries have a rooted aversion to, and distrust in, vaccination, and escape the ordeal whenever they can.*

*This repugnance was made known to me by means of’ personal investigations in Ceylon in 1890-91. "The First Triennial Report of the Working of the Vaccination Department in Bengal" mentions, amongst other races, the Mahomedan Ferazis, who display the utmost repugnance (as do also the higher classes in India) to vaccination.

Dr. Sutherland, of Patna, observes that :—"Another test of the prevalence of leprosy in this district was to ascertain the proportion of leprous persons in Patna gaol. Among Mussulmans, two were affected, or one in twenty-eight; while among the Hindoos there were seventeen persons affected, or one in every sixteen."

"This is certainly a startling assertion, one person in every sixteen affected with the taint of leprosy, and yet it comes from the pen of a careful observer."—Leprosy a Communicable Disease, by Surgeon C N. Macnamara, p. 15 and 16.*

*The Madras Times, Nov. 28, 1891, referring to the opposition to vaccination, which, the editor observes, is by no means confined to the ignorant populations,’ says :—"Official ‘reports show notably that the Lubbays and Mahomedans, as a class, resist vaccination, and do much to prevent the authorities from tracing the age of children over six months, with a view to enforcing the Act. Male vaccinators, it is remarked, are prohibited from entering their houses on the ground that these are gosha, and Hindu female vaccinators are unable to cope with the difficulty satisfactorily. It has been proposed to employ a Mahomedan female vaccinator, but a suitable woman who can read, write, and serve notices has not yet been found."

In the Archives de MÚdecine Navale et Coloniale, September, 1890, is an article by Dr. F. Forne on the "Contagiousness of Leprosy," of which theory the writer is a firm adherent. Dr. Forne says: —"One of the arguments invoked for the purpose of denying the contagious character of leprosy consists in saying that the persons attending on the lepers—religious persons, infirmary attendants, medical men —do not contract leprosy. It is important to refute that assertion by showing that it is contradicted by facts." The writer then proceeds to give details of the case of Father Damien, who, after sixteen years’ residence at the leper settlement at Molokai, succumbed to this disease, as Dr. Forne supposes, through contagion. Of this there is not the slightest proof, unless contagion is understood to include inoculation, and that this is intended would appear by the following reference to another case to illustrate the author’s theory:—"Dr. Hulin de Goden, medical officer of the leper settlement of Desirade (French Antilles), says that Sister A. became leprous after having pricked herself in the fingers of her hand with a sewing-needle while mending articles that had been used by lepers. Whether it was after having pricked her fingers matters little, since it is by the skin of the hands that the leprous contamination would have taken place in both cases. He observes that, in general, the washing of linen is habitually practised under the supervision of the Sisters, while sewing, on the contrary, is more often carried out by themselves.

"The accidental inoculation would have taken place before 1878, the date of the first leprous manifestations; in 1881 the affection had taken so considerable a development that Dr. Hulin de Goden decided to isolate the patient.

"An analogous fact has been observed in Tahiti, where leprosy has been transferred by passing from the native race to the white race, absolutely in the same manner as we have the fact produced in the Sandwich Islands, in New Caledonia, and in Guiana.

"A religious woman from Europe, free from hereditary taint, who was working at the linen-drapery of the hospital at Tahiti, inoculated into herself the terrible malady with a sewing-needle under the same conditions as the religious woman of Guiana, She was sent back to France in 1881 as being affected with leprosy."

Dr. Woods, cited by Dr. Hahn, expresses himself, thus:—"In the hospitals of Calcutta, and other districts of the East Indies, hospital attendants, positively free from all hereditary taint, have contracted leprosy by means of accidental inoculations undergone in the exercise of their functions; Dr. Robertson, Director of the Leper Settlement of Seychelles, became leprous during his period of service in that house."

Dr. FornÚ says: "Dr. Hillebrand cites the following case :—At Borneo a young European boy was in the habit of playing with a child of colour affected with leprosy. One day this latter plunged the point of his knife into an anaesthetised part of his body, an operation which was immediately repeated by his comrade with the same knife. Some time afterwards the European started for Holland, there attained his maturity, and, at the end of nineteen years, returned to Borneo fully affected with leprosy."

In a memoir read by Besnier before the Academy of Medicine, Paris, October 11th, 1887, Leloir, a high authority, is stated ‘to have pointed out that lepra would appear to be contracted by inoculation and not by contact, from the fact that the epidermis does not, as a rule, contain bacilli, and that the epidermo-dermic basal membrane apparently constitutes a barrier to the passage of the micro-organism in either direction.

One of the latest contributions to ‘this important subject is an able work entitled "Leprosy," by Dr. George Thin (London, 1891), in which the question of contagion is fully discussed. The author has succeeded in bringing together (pp. 139-166) the largest number of examples of alleged contagion of any writer I have met with. Some of these are distinctly traceable to inoculation by means of sores, pricks, gunshot wounds, abraded surfaces. The following are amongst the examples:—

No. 14.—Dr. Duncan, Civil Surgeon, Julpaiguri district, states that a healthy woman sustained a gunshot wound in the thigh. She had no leprous relations, but her husband was a leper with ulcerations on his hands. The woman became a leper.

No. 53.—A young coloured boy, while suffering from an eruption, played with a boy who was a leper; the previously healthy boy became a leper about a year afterwards, whilst his family remained untainted.

No. 67.—Dr. W. H. Ross cites a case which occurred in a European family without any leprous taint. J. K., while playing with leper boys, pricked himself with one of their fishing hooks, and became an undoubted leper.

On page 162 Dr. Thin remarks: "No one doubts that syphilis is a contagious disease, because surgeons, nurses, and attendants may fulfil their duties for many years in Lock hospitals without becoming infected; and it is a matter of every-day experience that a member of a large family may pass through all the infectious stages of syphilis, living in constant association with brothers and sisters, without the disease being transmitted; yet it is quite certain that in all those cases the disease could be communicated by an inoculation of the simplest kind." From this illustration we infer that Dr. Thin considers leprosy transmissible by inoculation, and sometimes uses the word contagion in that sense, as I have noticed with many other writers on leprosy.

On page 66 Dr. Thin quotes Dr. Donelan as authority for a case of leprosy due to inoculation.

Professor Cayley, F. R. C. S., says (Journal of the Leprosy investigation Committee, p. 36) that leprosy is directly inoculable.

Dr. John Murray, Inspector- General of Hospitals London, in a communication to Dr. P. 5. Abraham, Secretary of the National Leprosy Fund, June 9th, I 890, says: "I consider that it (leprosy) is communicable from the sick to those that are well, probably through a broken surface, as an ulcer or wound, and that it may be communicated by inoculation."

Dr. Liveing, physician to the Middlesex Hospital, in his Gulstonian Lectures for 1873, says:—"Facts, too, are slowly accumulating which tend to prove that the casual inoculation of leprous matter is one actual means of spreading this fell complaint." Dr. Hoegh, in his "Report on Leprosy" for 1855, quoted by Liveing, "suggests that the disease is communicable through the Itch Acarus (presumably the acarus scabici) which in Norway commonly infests the skin of lepers."

In his handbook on the "Diagnoses of Skin Diseases," 1880, p. 284-5, Dr. Liveing writes:—" Leprosy has within the last thirty years been imported and spread rapidly amongst natives of certain islands where it was before quite unknown. It is probable that in a certain stage of the disease it is inoculable. This appears to me the most reasonable explanation of its progress amongst a new population."

In reply to a communication which I addressed to the superintendent of the Leper Asylum, Bergen (which institution I visited in 1889), Dr. G, Armauer Hansen, the Physician General of Leprosy in Norway, the discoverer of the bacillus leprae, says :—"I think leprosy to be inoculable; I, moreover, think that leprosy in most cases is transferred by inoculation."

Sir Erasmus Wilson, F.R.S., in his work on "Cutaneous Disease," 1864, says :—"Lepra is a blood disease. The origin of the disease is doubtless an animal poison, but the source and nature of the poison are unknown. One remarkable case lately under our observation has led to the belief that it may be communicated by inoculation."

INDIA

Dr. Balchandra Krishna, L.M. and S., in his pamphlet entitled "Leprosy in Bombay in its Medical and State Aspects," suggests a mode of reconciling the conflicting opinions as to the contagious nature of leprosy. He quotes the Lancet of June 29, 1889, "The discovery of the bacillus leprae by Hansen has greatly strengthened the belief in contagion. This bacillus has never been found in any disease or condition other than leprosy, while it has invariably been found by competent observers in the skin of tuberculated lepers from all parts of the world. In the non-tuberculated cases, on the other hand, it is invariably absent in all the sores in the diseased nerves. But, it has been found in the nerves themselves when the disease is not of too old a standing, and in those skin lesions of mixed nerve and skin leprosy not dependent upon disease of the nerve trunks. This goes far to explain the non-transmissibility of nerve leprosy. The evidence, on the whole, then, is strongly in favour of the disease being communicable; but all are agreed that it is only so in the ulcerating stage of the tubercular or the mixed form by inoculation of the pus on an abraded surface, either directly from the patient, or from the stained clothing or other objects contaminated by the secretions from the leprous sores. It is certainly not communicable by aerial infection in the same way as small-pox or other exanthemata."

"This seems to me," says Dr. Krishna, "to explain satisfactorily the reasons why some observers found cases which convinced them of the contagious nature of the disease, while others met with some which did not show any contagious nature. It also explains the three cases which I have mentioned above, as on no other hypothesis can they be explained."

In a paper on leprosy in the Times of India (Bombay), August 13, 1889, Dr. Balchandra Krishna says that the evidence in proof of the communicability of the disease from man to man is overwhelming.

Brigade-Surgeon H. V. Carter, of Bombay, referring to the spread of leprosy, says: "The direct communicability of leprosy is at least a good working hypothesis."

Surgeon-Major Pinkerton, in his evidence before the Royal Commission on Vaccination, testified that leprosy was increasing in the cities of India, and believed that it was inoculable.—Second R.C. Report, p. 6.

In a letter to the Times, June 12, 1889, Surgeon-Major Pringle, late of the Sanitary Department, Her Majesty’s Army, Bengal, refers to the danger of spreading leprosy by both inoculation and vaccination. "The fact is, the amount of the virus of leprosy with which Father Damien was unknowingly fatally inoculated might have been, and probably was, very minute. I am amply justified, from a careful study of smallpox inoculation and vaccination during the whole of my thirty years’ Indian service, in stating that, unless prompt and stringent measures are taken in Bombay, leprous inoculation will become far more possible, and hence probable, than it may appear at present."

Dr. Joq. Frank Periera, Medical Superintendent of the Leper Asylum, Bombay, India, in a communication to the Times of India, November 18, 1890, gives his opinion that the contracting of leprosy is mainly due to its inoculation by means of open sores from one person to another, and adds: "In most, if not in nearly all the cases treated by me, their previous histories have, almost without, exception, disclosed the fact of the disease being due chiefly to heredity and inoculation."

Dr. Cunningham, the special adviser to the Government of India, admits the principle of the inoculability of the disease.

As to the supposed cause of leprosy, "my experience," says Dr. S. M. Shircore, of Moorshedabad, India, "does not tend to the belief that this disease is contagious in its nature, unless by direct inoculation."

Dr. H. A. Ackworth, Municipal Commissioner, Bombay, who has devoted much attention to the leprosy question, writes to me from Bombay, 24th May, 1891:— "All the medical men that I have met have agreed ‘that in whatever of any other methods leprosy may be transmissible, it is certainly so by inoculation."

Dr. W. K. Hatch, M.B., Surgeon, Bombay Army, reports in the British Medical Journal, June 2 6th, 1886, p 1713, that on June 27th, 1885, a student, while making a post-mortem examination on the body of a confirmed leper, cut his left forefinger at the top, and received a small abrasion, which resulted in certain characteristics of leprosy. This writer has been promised further particulars.

Dr. Neve, of Kashmir, says that in leprosy the bacillus lepra is always present; that the period of incubation is so long, "that a few positive instances of inoculation or contagion outweigh an immense amount of negative evidence."—Leprosy, by Dr. George Thin, p. 62.

Dr. G. D. M’Reddie, Civil Surgeon, in his letter to Dr. Ghose, dated Hurdor, the 18th February, 1888, states:—" From observations I know leprosy is hereditary. It is also contagious in the sense that it is necessary for the discharge from a leprous ulcer to come into direct contact with the broken skin of the recipient, or the blood of a leper to be inoculated into the system, as in vaccination."—Report on Leprosy to the Hon. H. Beverley, MA., by Madhub Chunder Ghose, Leper Asylum, Calcutta, August 27th, 1889.

Surgeon C. N. Macnamara sums up the question of the communicability of leprosy as follows:—" The arguments, therefore, against the communicability of leprosy do not refute those in favour of it; consequently, I can arrive at no other conclusion than that leprosy is communicable; but it is necessary for the propagation of the disease by this means that the discharge from a leprous sore should enter the tissues of a healthy person, and, further, the disease may even then (unless under peculiar circumstances) remain undeveloped in the system for years."—Leprosy a Communicable Disease, p. 43.

SOUTH AFRICA.

In Appendix A to the "Cape of Good Hope Report of the Select Committee on the Spread of Leprosy," 1883, is an interesting communication from the Rev. Canon James Baker, dated Kalk Bay Rectory, August 10, 1883,, as follows:—"My own opportunities for investigation have been rather exceptional, and my advantages considerable. In early life I was a student of Medicine, and subsequently of Chemistry and Natural Philosophy, at University College, London. My appointment as chaplain to the Lunatic Asylum and General Infirmary on Robben Island, where I remained nine years, put me in the way of getting experience among lepers, and I commenced at once and continued to make the nature of this terrible disease a special subject of inquiry. In my present sphere of duty I see, unhappily, many cases for investigation. The increased spreading of the disease in many parts of the colony is now generally admitted; it is spreading among both the white and the , coloured races, especially in places near the sea coast.

"Leprosy is not to be compared with small-pox or scarlet fever, as to contagion, any more than typhoid fever, but this can be conveyed in excreta, finding its nidus, or seat of incubation, in one part of the body only; and so, while many will escape leprosy who handle patients as they may handle decomposing corpses, with the skin of their hands unbroken, others may have their blood-vessels or absorbents come in fatal contact with the active poison of the disease."

In the body of the same report I find the evidence of a number of witnesses of wide experience, who have given the subject much attention. Hon. Dr. Atherstone, Member of the Legislative Council, and F.R.C.S., Eng., who has practised in the Colony fifty years, chiefly in Graham’s Town, where he was District Surgeon for twenty-six years; also Consulting Physician of the Albany General Hospital, and President of the Leprosy Inquiry Committee of 1889, testified as follows :—" I have formed a very decided opinion as to the nature of the disease, and the manner in which it is transmitted from one to another, and spread all over the country. Recent microscopic investigation has established the fact that the diseased tissues and secretions are invaded by numerous parasitical, rod-like organisms called bacilli, always of the same form arid size, no matter from what part of the world the leper comes, or what part of the body is examined, whether the tubercles, lymphatic glands, cartilages, or suppurating sores. This specific bacillus of leprosy is no doubt the true cause, and it is. spread by inoculation, either by direct contact with the secretion, or suppurating sores of the leper, or transmitted by the clothes, utensils, pipes, etc., containing’ these parasitical germs of the disease."

Q. 345. "You are then of opinion that it is contagious?"—"Yes; in the mode I have described; not in the ordinary sense of the word."

On page 8 I find the following :—"Another result of our inquiry has been to remove any doubt that might previously have existed as to the contagiousness of the disease. Your committee are satisfied that where the disease has not been derived by heredity from one of the parents or grandparents, it has in every instance been contracted by means of contagion. It is quite possible that the disease may not be communicable except to a person having some wound or abrasion in the skin; but when it is borne in mind that the victims often suffer from a discharge of matter from the hands. or other limbs, it is not difficult to conceive how readily the disease may be communicated to persons coming in contact directly or indirectly with the sufferer."

Dr. Abercrombie, member of the Cape Town Medical Board, says (Answer 6a) :—" It would be communicated to a person who came in contact with a leprous person if he had a sore or an abrasion. For instance, if he were to touch a leprous person with a sore finger, use the same knife and fork, or drink out of the same glass."

Sir Samuel Needham, superintendent of the Old Somerset Hospital, says:—" I do not think it is contagious, except in cases of cohabitation, when persons are reduced to a low state of health, through being badly fed, or when they get a cut or wound inoculated by contact with a leprous patient."

Dr. W. H. Ross, twenty-two years Police Surgeon at Cape Town, in reply to Question 311, "Do you know the case of a little boy who contracted leprosy on the island?" said:—" I know the case. The boy had no leprous relations. He associated with lepers, and one day, being out fishing with them, he ran a fish hook into his finger. Leprosy shortly afterwards made its appearance."

In the "Report of the Select Committee of the Legislative Assembly on Leprosy," July, 1889, are the following answers from the same witness :—

Q. 346. "I know of several cases in which the disease was communicated by inoculation."

Q. 351. (1) "It has been conclusively shown that it is always accompanied, if not caused, by a specific bacillus or bacilli, distinctly recognisable under high powers of the microscope in all the stages, in the skin, tissues, glands, secretions, nerves, and bones of the parts affected, undergoing ulceration and destructive degeneration by the pressure of interstitial tubercular deposits. (2) These specific rod-like bacilli, like other fungoid growths of the lowest type of generative life, such as dry rot in old wood, etc., it appears, can only gain access to the system in persons in a low state of vitality, either from poverty and filth, defective nutrition, or depressed nervous energy or constitutional debility, from heredity, or other causes of enfeebled condition of health, admitting of the growth and reproduction of the germs of these low organisms.

(3) In such weakened state of the constitution, hereditary or acquired, these bacilli may be introduced into the system by direct contact with any abraded absorbent surface of the skin or mucous. membranes, as in wounds, sores, pricks, etc., or with the mucous surfaces of the lips, mouth, nose, eyes, etc., but chiefly in parts distant from the centre of circulation, as in the toes, fingers, etc., where they may find a lodgment from the diminished vitality of the part being insufficient to destroy them, although sufficient to prevent its rapid growth."

Dr. J. C. Tache, Titular Professor, Laval University, Visiting Physician of the Tracadie Lazaretto, New Brunswick, Canada, reports to the Hawaiian Government ("Leprosy in Foreign Countries," 1886, p. 142-3):— "There is a case, the facts of which are established beyond the possibility of cavil, in which the disease appears to me, as well as it did to those who witnessed it, to have been produced by the absorption of liquid matter discharged from the body of a woman who had been in a cachectic state from leprosy. At the funeral of that woman, the body was carried on the shoulders of four strong. young men. The day was hot, and, on a sudden, liquid matter began to ooze out through a joint of the coffin, wetting the shoulder of one of the carriers. The wet, combined with the heat and the pressure of the sharp edge of the coffin, produced an abrasion of the skin of the young man. The contact of the liquid with the abraded surface lasted a part of the time of the procession, and the whole length of the service, as it was only on his way home that the young man washed his sore shoulder, and changed his clothes. Some months after, that man, whose health had always been robust, began to feel unwell. In a short time the symptoms of leprosy made their appearance, and he died of the disease eleven years after the occurrence. There had never been any case of leprosy in his family, whose ancestral genealogy is traced for several generations back. In fact, the disease was not yet known as leprosy, being of recent appearance in the locality, and among these people. He was the fourth case in that place, the other three being the woman spoken of, the husband and sister of the woman, in the ancestry of whom there had never been any trace of the disease. The fifth case in that locality was the sister of the young man." It is noticeable that the incubation of this disease was of comparatively short duration.

Dr. Manget, Surgeon-General, British Guiana, in the Report of the Royal College of Physicians on Leprosy," p. 45, observes:—" My own opinion is in favour of the contagiousness of leprosy, and that it may be propagated by the matter of ulcerated tubercles being applied to any raw surface; but I admit that I have met with cases which would seem to preclude the idea that the disease can be considered contagious in the ordinary sense of the term."

Dr. Charles W. Allen, attending physician to the North Western Dispensary for Skin Diseases, Surgeon to the Charity Hospital, in an article in the New York Medical Journal, March 3 1st, 1888, on leprosy, concludes that the disease is transmissible by inoculation from one individual to another.

In a remarkable article on "Leprosy, its Extent and Control," by Dr. H. S. Orme, published in the 20th volume of "Transactions of the Medical Society of the State of California" (1890), page 180, Dr. Saxe is quoted as giving the case of a physician’s son who acquired the disease after inserting a pin into his leg which a little Hawaiian leper had just previously thrust into an anaesthetic patch on his own leg.

Dr. S. Kneeland, of Boston, U.S., who visited Honolulu in 1872, says :—" There can be no doubt that it (leprosy) is spread by cohabitation, and inoculation of its diseased fluids, in the same way as syphilis."—Dr. Hillis on "Leprosy in British Guiana," p. 192.

Dr. J. C. Graham concludes an article in the Canada Medical and Surgical Journal, October 1883, as follows :—" In all probability the disease is communicated solely by means of inoculation; and opportunities for such inoculation are very few indeed, unless there has been a long and intimate contact with a diseased person."

Dr. Graham here omits from his purview the universal practice of vaccine inoculation, which sometimes carries with it the sources of leprosy and of other diseases.

In a leading article in the Philadelphia, U.S.A., Medical News on "Leprosy in its Relation to the State," the writer says:—" From time to time we hear of lepers reaching this country, either from Norway, the West Indies, or from China, and it becomes a very important question how to deal with such cases. Up to a few years ago, opinion was very strongly against the contagious nature of the disease, but since Hansen’s discovery of the bacillus lepra facts have been accumulating to show that the virus is a fixed contagion, communicable by inoculation, like syphilis and glanders."

Dr. William B. Atkinson, Secretary to the State Board of Health, Philadelphia, in his official report for 1890 of a case of leprosy (John Anderson, a Swede), observes: "There is no danger of contagion except by inoculation. The transmission of leprosy by inoculation or contact has been a debatable point with the profession for many years; but since the disease has been better studied, and the discovery of the bacillus leprae, a minute organism found in every case of true leprosy, opinion is gradually but surely coming round to the recognition that leprosy may be communicated by the unhealthy to the healthy to a much greater extent than has hitherto been considered probable."

The American Journal of the Medical Sciences, October, 1882, has a communication on "The Question of Contagion in Leprosy," by Dr. White, who remarks that heredity as the only, or as an important factor is out of the question. "It would have required several generations to have accomplished such results; we must look, then, to the customs of the race as exceptionally favourable to inoculation, and as the only possible explanation. It is probable that leprosy, like syphilis, may be communicated under all circumstances by which some of the fluids and other products of the infected foci of a diseased person come in contact with abraded or excoriated, possibly with the uninjured surface of a healthy person. It would be necessary that the diseased products should be at the surface of the skin, or mucous membrane, and this would generally be accompanied during the process of softening by which the impermeable layers were removed. Thus the nodular form in its ulcerative stage would necessarily be the most dangerous phase of disease, whereas the anaesthetic form might exist for years with little danger of communicating itself to its surroundings. In this sense we may conclude that leprosy is contagious, and in these ways, probably, the disease mostly spreads in a family, a community, a nation."

Mr. Plumacher, United States Consul at Maracaibo, Venezuela, observes in his official report for 1890 (p. 695) with reference to leprosy :—" I confess freely that I am not a believer in the theory of contagion properly so called. It will be easily understood that should matter from a leprous ulcer come into absolute contact with the blood of a healthy person inevitable infection would result, and leprosy be engendered, in the same manner that the surgeon at times meets his death through blood poisoning contracted in the dissection of a cadaver."

The United States Consul to Cape Colony, Mr. James W. Siler, in the official report on leprosy to his Government, dated March 24th, 1887, observes :—"This specific bacillus of leprosy is no doubt the true cause, and it is spread by inoculation by direct contact with the secretion or suppurating sores of the leper."

In a paper read before the State Medical Society by Dr. R. J. Farquharson, Secretary of the Iowa State Board of Health, Des Moines, and published in the New York Sanitarian, July, 1884, the author says:---

"Leprosy is not contagious in the ordinary acceptation of that term. It requires an absolute inoculation of pus or blood into the circulation through open vessels or abraded surfaces, and at the same time it is assumed that we must have the cachectic conditions favourable to the action of the virus."

Dr. Wood, of the United States Navy, in the Fourth Report, Navy Department, says that the dressers in the hospitals of Calcutta and other portions of the East, positively free from hereditary disease, have in many instances developed it, under circumstances connecting the inoculation with their duties.

The New Orleans Medical and Surgical Journal 1880, published a communication from Dr. T. H. Bemiss, Lahaina, Hawaii, on the introduction and spread of leprosy in these islands. "Alarmed," says the writer, "by an invasion of small-pox in 1853, a general vaccination of the whole population was ordered, and physicians being at that time very few on the islands, non-professionals aided in the work. It is charged by some that, as a natural result of the labours of the heterogeneous force so appointed, not only syphilis but also leprosy was greatly increased. In my last circuit trip in my district, I found very few adults who had never been vaccinated. This involves the question of inoculability, in my opinion the main, if not the only means of propagation, other than inheritance."

The same journal, 1888, says that "leprosy may be communicated from a leprous to a non-leprous person by means of a specific virus, which acts somewhat like the specific poison of syphilis, depending upon thin or denuded surfaces for its absorption, and which remains potent, very probably for an indefinite period of time."

Dr. R. Hall Bakewell, formerly Superintendent of the Leper Asylum, Trinidad, testified before the Select Committee of the House of Commons in 1871, that the inoculation of leprosy was proved as much as any fact in medical science.

In a paper read before the Auckland (New Zealand) Institute, July 20, 1891, and printed in vol. xxiv. of the "Transactions of the New Zealand Institute," Dr. Bakewell says :—" That bacilli exist in both leprosy and tubercle is beyond all dispute; that the bacilli of these diseases may be grown and cultivated in suitable media is ascertained as a fact respecting one of them—tubercle— and, although not experimentally proved as regards the bacillus of leprosy, yet is almost beyond doubt. Artificial nutrient materials have hitherto failed, and it is not allowable to try the only natural medium—the blood and tissues of a person living under conditions likely to develop leprosy. I have no doubt, from seeing the origin of leprosy cases, and studying several hundred cases of the disease, that it is not only inoculable, but that it spreads by inoculation or absolute contiguity, and I have no hesitation, after twenty years’ consideration of the subject, in affirming again the opinion given before the Committee of the House of Commons."

Dr. N. B. Emerson, President of the Honolulu Board of Health, says :—" The great problem that confronts the Board of Health is the leprosy question, and the medical profession in the Hawaiian Islands are, I believe, unanimous in the belief that leprosy is a communicable disease, and a transplantable disease, communicable by inoculation."

In a communication to the Secretary of the National Leprosy Fund, dated Dublin, 6th October, 1890, Dr. John D. Hillis, F.R.C.S.I., late Medical Superintendent, Leper Asylum, Demerara, says :—" My views on leprosy are explained in my work, ‘Leprosy in British Guiana,’ published by Churchill & Son. A further experience of ten years has convinced me more firmly than ever that leprosy is a communicable disease, most probably by inoculation. In tropical climates, many suffer from ulcers, excoriations, etc., which may render them more susceptible when brought so much into contact with lepers."

Dr. Arthur Mouritz, who occupied the position of physician to the Leper Settlement, Kalawao, Molokai, in 1886, says :—" The contagium of leprosy enters the system by inoculation at broken surfaces of the skin, fissures, or chaps, on external mucous surfaces, and possibly by punctures of insects, or the presence of parasites, scabies, etc." In his report to the President of the Board of Health, Honolulu, dated February, 1886, the doctor says:—" Some weight must be attached to the views of the foreigners themselves. They, one and all, such as are now alive, emphatically declare their belief that the disease is contagious. Some give evidence of contact (immediately followed by local symptoms—direct inoculation), infection of the whole system speedily following, this again succeeded by external manifestations of leprosy within a comparatively short period."

In his "Biennial Report to the Legislature of the Hawaiian Kingdom," session 1890, Dr. T. H. Kimball considers the fact of the inoculation or transplantation of leprosy to have been proved in those islands, and that the bacillus lepra carries the infection.

Dr. Ginder, who investigated cases of Maori leprosy at Taupo and Rotorua, New Zealand, in his "Report to the Inspector-General of Hospitals, etc., Wellington," dated 4th July, 1890, concludes "that in all probability the worst cases have arisen from direct infection of the blood by inoculation, either accidental or premeditated."

From inquiries made from those who were intimately acquainted with the late Father Damien, I have no doubt that in his case the disease was induced by means of inoculation of leprous virus from other patients, when he resided in Molokai, through sores on the skin. While possessed of many noble traits, this worthy and self-sacrificing missionary was conspicuous for neglect of ordinary hygienic precautions.

Dr. W. Munro, in his work on leprosy, quotes a series of cases to show that leprosy is spread by contagion, but explains in page 80 the wide interpretation he gives to this much misunderstood word. He observes "that by using the word ‘contagion’ I do not pretend to express any distinct belief as to the probability of the disease being conveyed by simple contact, being more inclined to believe that it is carried by inoculation in most cases, though long-continued contact even of unbroken healthy with diseased skin may be sufficient."

The doctor gives particulars (p. 84) of several cases of inoculation, all of which, he says, tend to show that inoculation is the chief, if not the only, manner by which the disease is propagated, such propagation taking place quickly only when some special circumstance, as the person being wounded, makes inoculation easy and certain. This writer does not believe there is any evidence of its being communicated in food or drinks, and the only danger from association with lepers is "when the healthy person has any cut or sore about his hands by which he might be inoculated."

Dr. John Freeland, Government Medical Officer, Antigua, in a communication dated Antigua, Sept. 15, 1890, says :—"When I wrote to the British Medical Journal in October last that no one would deny that contagion might be artificially produced by inoculation, I meant, of course, inoculation by means of the actual introduction of secretion from the leper’s sore into the skin of the healthy, effected either directly by the lancet, or accidentally conveyed through the broken surfaces of the leper and the healthy coming in contact." Dr. Freeland relates how that "T. S., a healthy and robust lad, who was denied board and lodging by his relatives on account of his irregular and late hours, sought accommodation and residence in an out-room situated in a leper’s yard. After a time, he received rather a severe wound on one of his feet, and I was called upon to attend him, when I naturally protested against his surroundings, and wished him to go into hospital, not only that he might have every comfort and care, but that he might also be at once removed from his diseased neighbours. He would not, however, consent to leave his house, and I continued attendance long enough to discover that my patient had, since his accident, been systematically using the same basin, the lotion, and even the very rags and bandages that were, perhaps, but a few hours removed from the ulcerated surfaces of his leprous companion. I need not tell you that the healthy wound soon developed into an intractable and sloughing sore, and was, after some time, followed by those general, but unmistakable, symptoms of leprosy, which went on progressing until the disease was fully formed, and the lad died, an ulcerated and necrosed leper." — The Lazaretto, St. Kitts, West Indies, October 6, 1890.

THE INOCULATION OF THE CONVICT KEANU.

Whatever doubts have heretofore existed as to the inoculability of leprosy, there can hardly be any after a dispassionate consideration of the facts connected with the experiment on the condemned convict at Honolulu. The prisoner Keanu was inoculated with leprosy by Dr. Edward Arning on the 30th September, 1884, and again in November, 1885, after previously making a most searching inquiry as to any leprous taint in his family, and a dose examination of his own body. This examination satisfied Dr. Arning that no trace of the disease could be found in him. Every precaution was taken to secure his isolation from contaminating surroundings, and means were adopted to ensure that he was not employed outside the prison walls. On the 2nd September, 1888, Dr. N. B. Emerson, then President of the Board of Health, and Dr. T. H. Kimball, Government Physician, examined the prisoner and signed the following certificate :— "This is to certify that we have this day carefully examined Keanu, who was inoculated in November, 1885, and we find his condition as follows:— "Ears tubercular and considerably hypertrophied; forehead the same; face, nose, and chin show flattened tubercular infiltration; mouth clean, no tubercles; face generally presents a leonine aspect.

"Hands puffed, fingers swollen at proximal phalanges, tapering to distal phalanges; tips of forefinger and thumb of left hand are ulcerated from handing hot tin cups of tea or coffee, indicating anaesthesia.

"Body—Back thickly mottled with flattened tubercles and the surface uneven to feel, colour of the same—a yellowish brown; front of the body, chest and abdomen, presents plaques of tubercular infiltration of larger size than back, separated from each other by wider intervals and of a brighter colour, in some cases a ruddy pink, especially over upper part of sternum.

"Legs—The infiltration thins out as far down as the knees, there being one large bright patch on the inside of the left thigh ; legs below knees quite clean and skin smooth and even to touch.

"Feet — (Edematous; have poor circulation; bluish colour; soles of feet clean.

"Seat of inoculation, outer aspect of left forearm, upper third, shows a dark purplish scar, about one-and-a-half inches long by five-eighths of an inch wide, irregular in shape, keloid in aspect, dense and inelastic.

"The tests for anaesthesia were not made. Eyes with sclerotitis, muddy and infected.

"No signs of palsy about muscles of face, orbiculares palpebrarum, hands, or forearms.

"It is our decided opinion that this man is a tubercular leper.

"N. B. EMERSON, M.D., President of the Board of Health.
"J. H. KIMBALL, Government Physician, Honolulu."

In the spring of 1890 Dr. D. W. Montgomery, Professor of Pathology, California University, microscopically examined a piece of Keanu’s skin, and discovered the bacillus leprae both singly and in groups. This bacillus has been found, according to the Lancel, by competent observers in the tuberculated form of leprosy in all parts of the world, and has never been found in any other disease or condition. Keanu has since been sent to the lazaretto, Molokai, a confirmed and incurable leper—a punishment ten times more severe than the death penalty, and, in my judgment, utterly unjustifiable. In a letter on "Leprosy" in the British Medical Journal, September 24, 1887, Dr. William Jelly observes :—" I daresay the poor Kanaka convict (Keanu), had he known what leprosy is, would, without hesitation, have preferred the guillotine, the garotte, or the hangman’s rope."

Regarding this official declaration, Dr. C. N. Macnamara says:— "This report establishes unequivocally the fact that the inoculated man has become leprous; and, as he had been inoculated three years previously, there is every reason to believe that the disease is the result of the inoculation. This is very much borne out by the fact that at the seat of inoculation there is what is described as a dark, purplish scar of about one inch wide, keloid in aspect, dense and inelastic.

"The importance of a positive result like this cannot be outweighed by a considerable number of negative experiments; although, so far as we know, this is as yet the only direct experiment that has been made from a leper to a sound individual, and we do not believe that its importance is lessened by the fact that inoculations made from a diseased part of the body to an apparently unaffected part of the body of the same person have, in some cases, not led to development of the disease in the inoculated part within a comparatively short lapse of time.

"The communication of leprosy in this case confirms the views generally entertained by those who hold that the disease is contagious, the idea being that it can only be conveyed from one person to another by a direct communication of leprous tissue into the moist, living tissue of the person infected; in short, that when it is contagious, it is contagious in the same way that syphilis is understood to be centagious."—Leprosy a Communicable Disease, p. 45.

In an article in the April (1890) number of the Occidental Medical Times, Dr. Sidney Bourne Swift,. Resident Physician, Leper Settlement, Molokai, reports the present condition of Keanu as follows :—"Age 70 years; weight 178 pounds; leprous infiltration beneath integument of face and forehead; tubercular enlargement of lobes of both ears, the right more than the left; ulceration of palate, and extensive ulceration of pharynx; tubercular enlargement of uvula; tubercular enlargement of alae of nose; partial occlusion of nasal fossae, due to leprous infiltration beneath pituitary membrane; chronic conjunctivitis and phyrigium-like growth on both eyes; almost deaf; voice hoarse, and with a nasal inflection. Anaesthesia of both hands and feet,. although no pronounced enlargement of ulnar or tibial nerves; numerous tubercles distributed over the entire body, but most marked on the upper and lower extremities; three small but angry-looking ulcers on outer aspect of left leg; softened tubercle on dorsum old age."

In an article on "Personal Observations of Leprosy in the New York Medical Journal for July 27th, 1889, Dr. Prince A. Morrow, after describing the results of the inoculation by Dr. Arning and the development of tubercular leprosy in the convict, observes that, during his visit to Molokai, he excised a small sub-cutaneous tubercle and a portion of the underlying skin. Numerous sections of this specimen were made by Dr. Fordyce, and in all of them the presence of bacilli was exhibited under a microscope. Dr. Morrow estimates that in the Sandwich Islands "about one half the cases are tubercubus, about one-third are anaesthetic, and the remaining sixth represent the mixed form; the tubercular type is the most rapidly fatal."

Dr. F. B. Sutliff, who spent four years studying cases of leprosy in Maui, Hawaii, says, referring to Keanu’s inoculation :—" This case will always stand alone; I suppose no other man will ever be purposely inoculated with leprosy. The facts in the case that point towards the inoculation as having been the direct and only cause of the disease are many and strong. Still they will be attacked by those who would rather maintain their own ideas than discover the truth.*

*In an article on Keanu's inoculation, the the Occidental Medical Times, April, 1892, Dr Sidney Bourne Swift intimates that the case made out by Dr Arning is inconclusive, inasmuch as other members of Keanu's family have been found to be affected with leprosy.  Keanu's own son, Eokepa, aged about 23 years, and his first cousin, Maleka, on his mother's side, are lepers, living in the leper settlement. Eokepa left school in 1873 on account of this affliction. These cases are by no means inconsistent with the facts contained in the reports above quoted, and it must not be forgotten that the lepra disease was first discernible at the points of inoculation. Nor can they be considered remarkable, knowing how the disease had been propagated by the vaccination lancet. In one instance reported to Queen Liliuokokalani, an entire school in Hawaii was swept away, with the exception of a single survivor, by this means. However, the case for inoculation does not rest upon Dr. Arning’s experiment, but on the un impeachable evidence of numerous reputable witnesses in all parts of the world, and on the fact admitted by pathologists that, given suitable conditions, all bacterial diseases are inoculable.

A well-known medical practitioner at Honolulu gave me a photograph of Keanu, which distinctly shows the appearances peculiar to inoculated tubercular leprosy at the point of insertion in the arm, as well as in other parts of the body. And he considered the experiment an absolute demonstration of the inoculability of the disease. He also unhesitatingly expressed the opinion that the dissemination of leprosy in Hawaii was largely due to inoculation by the lancet of the public vaccinator, a most serious matter not only for Hawaii, but for all other countries where the repulsive and destructive disease is endemic. Dr. Arthur Mouritz, Medical Superintendent of the Leper Settlement, Molokai, says it is doubtful whether one per cent, of the Hawaiians would resist intentional inoculation.

LEPROSY COMMUNICATED BY INSECTS.

Both in the West Indies, and in British Guiana, I found the belief prevailing amongst the people, as well as, to a certain extent, amongst medical practitioners, that leprosy was inoculated into the blood by mosquitos.

Nor is there anything improbable in the idea. Sir William Moore, late Surgeon-General, Bombay Staff, "is of opinion that one of the chief sources of danger is due to flies and mosquitos. These pests of Indian life may carry enough leprosy discharge to communicate the disease to a healthy person. None of us can make sure that the fly or mosquito, which irritates by its persistent attention, has not come from a leper. A fly investigates a leprous sore or discharge, carries a particle of poison in its proboscis, or feet, and next settles on some abrasion of the skin of a healthy person !" Dr. Manson, in China, says that elephantiasis has been conveyed by a mosquito. (The "elephantiasis" conveyed by mosquitoes apperas to have been another kind of disease than leprosy).

In Dr. Wilson’s communication on leprosy in The Lancet, Nov. 13, 1880, p. 779, the writer says:—" Dr. Manson received some reward from the Chinese Government a few years ago, for the discovery that leprosy was caused through the introduction of a poison into the blood by the bite of the mosquito, and although little has been heard of this discovery since, the idea seems to receive support from many facts, and explains the curious occurrence of that dreadful malady in the arctic regions, where the mosquito abounds."

Dr. Albert S. Ashmead has an article on "Leprosy in Japan" in the Journal of Cutaneous and GenitoUrinary Diseases, vol. viii. page 220, copied into the Journal of the Leprosy Investigation Committee for July, 1891, in which the danger of minute inoculation by insects is referred to as follows :—" The Japanese guard carefully against mosquitos and other insects, and wherever insects most abound the most endemic leprosy is found. In addition, those parts exposed to insect foraging are the seat of primary skin lesions of leprosy, as also mucous membranes most exposed to germs in food and water."

And it may be remarked that, if leprosy may be communicated by means of mosquitos and other insects, where the inoculated virus is infinitesimal in quantity, how much greater in proportion is the danger of such contamination in vaccination? In’ the latter case the vaccine lymph may, and often is, taken from children where the disease lies dormant, in the incubating stage, without declaring itself by the smallest signal to the eye of the most experienced physician. In all countries where leprosy is endemic, Europeans resolutely object to be vaccinated with lymph from native sources; and, notwithstanding the law, when imported lymph cannot be obtained they and their children remain unvaccinated. As a consequence, the population of Europeans attacked with leprosy is comparatively small and, indeed, of rare occurrence, except in the case of soldiers who are subject to the military regulation of revaccination. This repugnance to native lymph on the part of Europeans in the West Indies was pointed out by Dr. R. Hall Bakewell, Vaccinator - General, Trinidad, in his remarkable evidence before the Select Parliamentary Committee of 1871, and has been referred to by Dr. Castor, of British Guiana, and other authorities.

Index