CHAPTER 2: IS LEPROSY CONTAGIOUS?
ONE of the most debatable points in connection with the spread of leprosy is that of contagion, and amongst dermatologists there are rival schoolscontagionists and anti-contagionists. In the report of the Committee of the Royal College of Physicians, issued in 1867, thirteen were in favour of contagion, and thirty-four physicians and experts in various parts of the world were convinced that the disease was non-contagious. The chief authorities in Norway, including Boek and Danielsen, who had forty years experience, were opposed to contagion; and this is the prevailing view in Norway at the present time.
Dr. G. A. Hansen says : "If people wash themselves, and take the least care of themselves, when they come in contact with lepers, I do not think there is any danger whatever. It is a remarkable fact that not one of the nurses or servants in our Asylums (Norway) has caught the disease, although they daily wash and dress the patients."
In the pursuit of my investigation, I have been confronted on every hand by the most conflicting theories with regard to the causation of leprosy, and particularly with regard to this question of contagion. The contagionists, when pressed, I found invariably included inoculation, and interpreted the word in that sense. They admitted that the leprous discharge might be touched with impunity, when the integument is intact, but not otherwise. Every nurse, doctor, attendant or laundress, in the hospital, is bound to come in repeated contact with pus from ulcerated tubercles. It is only by the insertion of the leprous virus into the blood, through a sore, prick or abraded surface, that the disease is communicable. This view is now held by the highest authorities in all parts of the world. At the same time, there are others who hold that the disease is transferable in a lesser degree by inhalation, heredity and cohabitation.
From personal inquiries made at asylums and lazarettos in various countries where leprosy is endemic, I am convinced that, apart from the risk of inoculation, there is little or no danger of contagion, using the word to mean simple contact between unbroken surfaces of the body. So far as my investigations have extended, the only country where the belief in communication by simple contact prevails to a certain extent is Hawaii; but here also I found much diversity of opinion, not a few using the word contagion to include inoculation, both accidental, as in a cut or a sore, and by design, as in vaccination.
I believe that the instances of communication apart from inoculation of this disease (if they exist at all) are extremely rare, but the theory is opposed to the results of most inquiries.
A medical resident of sixteen years standing in British Guiana told me that the disease was being extensively disseminated in some unexplained and mysterious way, as the infected population had greatly augmented of late years; you encountered them in churches, at balls and public meetings, in the streets, and the market-place. Several leprous patients were pointed out to me at the Colonial Hospital, in close proximity to the other inmates, and I may observe that only the worst cases (and these belonging to poor families) are segregated at the Leper Hospitals. The lazarettos at Gorchum and Mahaica, British Guiana, at Trinidad and Barbadoes, were full to overflowing; new wings were in progress, or had recently been added, and the demand considerably exceeded the present accommodation in each establishment. No one appeared to be afraid of contagion, and I could not learn of a single case so communicated. After going through the various buildings of the Leper Asylum at Mucurapo, Trinidad, and seeing the unfortunate patients in every form of this hideous and mutilative disease, I said to the lady superintendent (of Dominican Sisters), who had been in charge of the institution for seventeen years, "Have you no fear of contagion?" "Not the slightest," she promptly replied. "And you and your assistants do all that conscientious nursing requires?" (This includes washing the sores and bandaging the limbs of the unfortunate inmates.) "Certainly, and feel it a joy and privilege to be of service to these afflicted people." "Has any case of infection by contact to doctor, nurse, attendant, or laundress ever been reported during your superintendence?" "Not one."
This experience was confirmed at the lazarettos in Barbados and elsewhere; and some of the nurses and attendants have been employed from ten to thirty-two years. At the leper asylum in Ceylon, I learned that the laundry work had been managed by one family for three generations, and no case of infection had ever been recorded of laundress, nurse, or doctor. Similar experiences were related to me in South America, South Africa, and at the leper asylums in Norway.
The officials connected with the leper settlements at Molokai, and the Hospital of Suspects, Kalihi, near Honolulu, where I saw some of the worst cases, have not the slightest fear of contagion. They told me that they had never known a medical attendant or nurse contract the disease by simple contact. Of inoculation through sores, or wounds in the skin, or the entrance into the blood through the minutest prick or abrasion, a wholesome fear is entertained, not only amongst the native population, but by the officials; and not without sufficient reason, as will be seen by the facts detailed in another chapter.
The British Consul in Crete, in a memorandum to Baron Ferdinand de Rothschild, M.P., on the subject of leprosy in that island, concludes that the disease is not contagious, from the fact that there are "several cases of healthy women married to, and living with, lepers for years without being in the least affected. In fact, if the disease were decidedly contagious and hereditary, it would inevitably spread much more than it does, considering that the lepers are perfectly at liberty to marry among themselves or with healthy persons, and that their children remain with them like those of other people, without any precaution being taken on their behalf."
Dr. Arthur Mouritz, in his official report to the Honolulu Board of Health, dated Molokai, February, 1886, says :" The washerwoman for the hospital Kalowao (Molokai) has washed the soiled clothes of the worst cases, certainly many of them so, in the settlement for the past seventeen years."
In a communication by Dr. Van Deventer Director of the Suburban Hospital, Amsterdam, to the Hawaiian Government, the writer says :" Not one case of contagion has ever been recorded."
Dr. Trousseau, of Honolulu, who told me he devoted much attention to the causation of leprosy in Hawaii, says : " Is leprosy infectious or ever contagious in the proper sense of the word, that is, by contact mere and simple? I emphatically say No." I am supported in that opinion by the whole medical world, and by my personal experience."
Dr. Manget, formerly superintendent of the Leper Asylum, British Guiana, 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.
In the Leprosy Committee Report of 1887, signed by Dr. C. Handfield-Jones, chairman, it is stated "The committee believe that leprosy is not contagious in the conventional sense of the term, but, if at all, is only so in low degree and under exceptional circumstances."
Dr. Max Sandreczi, director of the Hospital for Children, Jerusalem, says :" I am obliged to declar that the result of my researches gives me the conviction that leprosy is by no means contagious, and that consequently the exclusion and isolation of the patients is both a useless and a cruel measure."Lancet Aug. 31, 1889, pg 423.
The Lancet, June 22, 1889, p. 1252, says :"There hardly an hospital in London that has not had within its walls cases of leprosy within the past decadein-patients, it is true, who have contracted the disease in countries where it is indigenous. Nor, so far as we know, has there ever been an instance of the communication of the disease from one of those subjects others in this country."
Mr. Jonathan Hutchinson, F.R.S., LL.D., in answer to the questions published in No. 1 Journal of the Leprosy Investigation Committee, "Is leprosy contagious?" suggests to inquirers into this subject the following important considerations :"A certain number of lepers arrive every year in England from abroad. They usually remain in England and are allowed to mix freely with their friends. Children are permitted to go to schools, married couples continue co-habitation, inmates of hospitals and workhouses are, unless specially loathsome, placed in the general wards; in brief, not a single precaution against contagion is ever taken, and yet the disease never spreads. Precisely the same statements are true of French practice. It is believed that there are six lepers in Paris at the present time, and I am told that two leading Paris surgeons have each a leper employed as a household servant. Yet the disease never spreads in Paris any more than in London.
"The officers of leper hospitals, surgeons, nurses, and students, hardly ever become the subjects of the disease. . . In Norway I believe that no instance of an official becoming a leper has ever been known, although the exposure has been most free."
And in a footnote to his article, page 74, Mr. Hutchinson adds:"Surgeon-Major Porteous, in 1855, published a list of servants who had been employed in the Leper Hospital, Madras. It included eleven servants who had been employed in the wards in periods varying from ten to fourteen years. None of them had become the subjects of leprosy."
Dr. Van Someron, who had charge of the hospital six years later, says :" There is no record of any of the medical officers connected with the lazarettos having become affected with the disorder, nor have I heard of its ever having attacked the attendants of those who in private families were its victims."
Dr. W. Munro, the author of a work on leprosy, explains his views of contagion as follows :" 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."
The Lancet of June 28, 1890, referring to the theory of contagion in connection with the spread of leprosy, says :" But there are conditions and limits to the contagion: probably it occurs only through inoculation." This opinion is supported, according to the British Medical Journal, October 11, 1890, in the despatch from the Government of India relating to the isolation of lepers. It particularly notes that many of the medical authorities in India consider that the evidence at present available goes to show that leprosy is contagious only in the sense that it is inoculable. The "Report of the Royal college of Physicians on Leprosy," issued in 1867, states "that the all but unanimous conviction of the most experienced observers in different parts of the world is quite opposed to the belief that leprosy is communicable by proximity or contact."
Sir Erasmus Wilson says leprosy is endemic, but not contagious.
Dr. William B. Atkinson, secretary of the State Board of Health, Philadelphia, in diagnosing the case of John Anderson, a Swedish leper, observes that there is no danger of contagion except by inoculation.
Dr. Shoemaker, of Philadelphia, says leprosy is only contagious through inoculation.
In a study on leprosy, based on personal observation, Dr. L. Duncan Bulkley has arrived at the conclusion that the disease is not in any proper sense of the word contagious, but there is reason to believe that under certain conditions it can be inoculated.Family Doctor, June 11, 1892.
Dr. H. MHatton, Macon, Georgia, concludes a paper "On the Propagation of Leprosy," published in the "Transactions of the Medical Association of Georgia," by stating that it is non-contagious, and quotes the report of the committee of the English College of Physicians to the effect that, out of sixty-six answers to their inquiries, only nine speak of it as contagious, forty-five as non-contagious, and twelve are silent.
Dr. John L. Mears, Medical Superintendent of San Francisco Board of Health, says" Although this disease (leprosy) may not be contagious in the ordinary acceptation of that term, we are satisfied that it is communicated by inoculation."
Drs. Fox and Graham report in the transactions of the American Dermatological Association for 1883, page 197, as a result of their combined investigations, that leprosy is contagious by inoculation, and there is no reason for believing that it is transmitted in any other way.
Dr. P. W. Farrar, Nevada, Iowa, W.S., in a communication to Mr. L. F. Andrews, Secretary, State Board of Health, February 21st, 1885, p. 205, says: "Leprosy is not contagious in the usual acceptance of the term. It requires actual inoculation of pus or blood into the circulation through open vessels or abraded surfaces, and there must be favourable cachectic condition to the action of the virus."
Dr. Bevan Rake in a communication to the Acting Surgeon - General, dated Maraval, 11th July, 1889, says :"In a paper received from St. Louis, Missouri, only the other day, I saw that Dr. Bockmann estimates that there must be in Minnesota about 100,000 persons of Norwegian descent whose ancestors were lepers; and yet leprosy never appears amongst them; all the leprous Norwegians in the State are imported, so that leprosy does not appear to have spread there either by heredity or contagion."
In an article entitled "Notes on Leprosy as observed in Antigua, West Indies, Mr. John Freeland, Government Medical Officer, observes :" On the subject of contagion I certainly agree with Mr. Hutchinson when he says that the profession divides itself into two camps, one asserting contagion and the other denying it; but I think that the contagionists, or those who believe that contagion takes an important share in the spread of the disease, are, in this part of the world at least, in a decided minority. No one, I imagine, would absolutely deny that contagion might be artificially effected by. inoculation; but the chances of such an event happening accidentally are so remote that it can hardly be taken into account."British Medical Journal, October 5th, 1889.
Dr. James H. Dunn, Professor of Dermatology in the Minnesota Hospital College, in a clinical lecture on leprosy, reported in the North - Western Lancet, March 1st, 1888, said : " The question, Is leprosy contagious? has been a source of much discussion and contention. At times and in some countries it has been looked upon as markedly contagious. Some writers still regard it so; but at the present day the great majority of dermatologists teach that it is not, at least not in the ordinary sense of the term. There is no evidence to show that the malady. has in any instance spread by contagion in a country where leprosy is not endemic."
Mr. T. H. Wheeler, the British Consul of Bogota, South America, in his Report for 1890 to the Foreign Office, No. 804, observes that although public opinion favours the belief prevalent in Colombia that leprosy is contagious, in the climates of Tocaima and Agua de Dios it is not so :" For . more than one hundred years that these places have been the chosen resort of lepers in all stages of the disease, who have mixed freely with the other inhabitants of the district, there is no case on record of the disease having been contracted by contagion."
Dr. Alfred Ginders, in a communication to the Inspector-General of Hospitals, etc., Wellington, New Zealand, on Leprosy among the Maoris, dated Rotorua, 4th July, 1890, states his opinion that the disease is not infectious or contagious in the ordinary sense, but "that, in all probability, the worst cases have arisen from direct infection of the blood by inoculation, either accidental or premeditated." The only premeditated form of inoculation in vogue is that induced by the lancet of the vaccinator.
The Medical Superintendent, Leper Asylum, Calcutta, Dr. Madhub Chunder Ghose, in his Report to the Honourable H. Beverly, President of the District Charitable Society of Calcutta, 27th August, 1889, says :" It seems to me, after an experience of fifteen years in the asylum, that leprosy is not contagious or infectious in the proper acceptation of the term. Recently I have taken the full history of all the lepers in this asylum, and, with one or two exceptions, the origin of the disease could not be traced to contagion; some acquired the disease from an hereditary taint, some from the effects of syphilis, and the indiscriminate use of mercury; but in most of the cases the origin of the disease could not be satisfactorily traced, but I have no doubt that the disease can be communicated by an abraded surface absorbing leprous matter."
Dr. Ghose adds :" To prove my assertion as to the non-contagiousness of leprosy, I beg to bring forward the following facts, that is to say, my own personal experience of the disease for over fifteen years. There is an inmate of the asylum, by the name of Doris, who is a non-leper, and who has been at the asylum for over twenty years, sleeping in the same ward, constantly mixing with the lepers, eating with them, etc., and he has not contracted the disease.
"There is also an idiot boy at the asylum, a non-leper, who has been an inmate for over ten years; he also sleeps, eats, and mixes freely with the lepers; this boy, also, has not the slightest trace of the disease.
"The dhoby attached to the asylum, with his father and grandfather before him, have washed the clothes of the lepers for more than thirty-five years; none of those showed any signs of the disease.
"The native doctor, Runchanun Dass, who lived with his family for over ten years in the premises of the asylum, neither contracted the disease, nor did any of his family.
"The dressers, Buddye and Narain, acted, the former for twelve years, and the latter for ten years: they did not suffer from the disease.
"The dressers, Rajjian and Jaddao, have been attached, off and on, the former for eight years, and the latter for ten years (this man is yet at the asylum as a dresser), and I have recent news regarding Rajjian, who has gone to his country: these men are unaffected. The dressers have, daily, to handle sores, wash unhealthy ulcers, apply ointment, etc., besides having to shave the lepers periodically. The present Christian cook and his father have been working at the asylum for over twenty years. The father died a non-leper, and the son is free of the disease.
"Other cooks, who work for a few years and then. go to their country, have never been attacked. The sweepers, Roohon and Bustee, have worked more than seven years without contracting the disease. Both the men have been discharged, and are yet living. Other sweepers, who have been working a short time each, also have not suffered.
"The Durwana have not contracted the disease. The present Durwan has been now over five years in service.
"I have myself been attached to the asylum now for over fifteen years, visiting the lepers daily, cutting and handling them, without having suffered.
"My predecessor, Dr. K. Stewart, was in medical charge of the asylum for over twelve years, and remained free of the disease till his death. My assistant, Dr. H. W. Mitnish, M.R.C.S., England, has been at the asylum for over eight years, and is healthy."Report presented to the Hon. H. Beverley, M.A., dated Calcutta, 27th August, 1889.
Dr. Vandyke Carter, of Bombay, says:" I have not met with any evidences of the contagious nature of leprosy that bear sifting."
Dr. Day, of Calcutta, who, according to Dr. Balehandra Krishna, L.M. and S. of Bombay, has made leprosy his special study, says, in the Indian Mirror, that he does not believe in the contagious nature, of leprosy.
Dr. J. Jackson, Bengal, in reply to a communication from the Royal College of Physicians, writes :" It is not contagious in the ordinary sense of the term. . .Leprosy Report, p. 202.
When Mr Commissioner Acworth, of the Bombay Municipal Corporation, paid an official visit to the Madras Leper Hospital, he was informed that the sweepers employed to wash the ulcers of the lepers did not contract the disease, although some of them had been doing the work for fourteen years.
Mr. A. Mitra, L. R. C. P., L. R. C. S. (Edinburgh), Chief Medical Officer, Kishmir, in an article in the American Journal of Medical Sciences, Philadelphia, 1891, observes :" Of course, contagion by inoculation is possible, and often takes place in various ways. In India, people usually have their feet and skin bare, and, therefore, there is every likelihood of inoculation."
Mr. A. Mackenzie, Secretary to the Government of India, writing from Simla to the Minister of Foreign Affairs, Honolulu (October, 1885) says:"On the whole, it is believed that the medical evidence tends to show that the disease is not contagious. In support of this view, it may be mentioned that not a single servant of the asylum at Almora, in the Kumaun District of the North-Eastern Provinces, appears to have contracted the disease during the thirty-one years for which there is information."
Dr. W. A. Kynsey, the Surgeon-General, Ceylon, says:"It (leprosy) is not considered contagious in Ceylon, and lepers are not generally shunned by their relatives or friends for fear of infection, but are often maintained by them in their own houses. It is, in my opinion, not contagious as syphilis, Parangi, the exanthematous diseases. There is no conclusive evidence in the hospital records of, communicability by direct contact with, in close proximity to, diseased persons. ,The attendants of the hospital have for years been in close association with lepers in all stages of the disease, the head-servant for more than twenty years; and the washing of the establishment has been performed by a family in the neighbourhood for four generations; but not a trace of the disease, as I have reason to know, has been observed among them."Leprosy in Foreign Countries, p. 9.
Dr. Dixon, Medical Superintendent of Robben Island, Cape of Good Hope, in a report published in the Journal of the Leprosy Investigation Committee, No. 3, July, 1891, says :"The evidence gathered from officials and patients long resident on Robben Island shows that there is no authentic instance, with possibly one exception, of any non-leprous person on the island having contracted the disease, either direct or indirect, with the leper residents."
Dealing first with the possible exception, the circumstances were as follows :A lad, son of the shoemaker, constantly associated with the lepers; he ate of food given to him by them, and was in the habit of fishing with their tackle; it is stated that on one occasion, when using the lepers tackle, he had a wound on his finger. For about ten years he exhibited symptoms, said .to be those of leprosy. He died in 1888, having suffered for about ten years. It cannot be held that there is conclusive proof that this solitary case originated by contagion.
The evidence of the older officers goes to show that, until about the year 1884, all the lepers soiled and filthy linen was washed by the female lunatics in cold water only, and was often mixed with the underclothing of the lunatic patients in the process of washing. This practice was probably in vogue for upwards of thirty years, yet there is no alleged or recorded instance of any lunatic patient contracting leprosy on Robben Island.
Dr. W. H. Ross, Police Surgeon in Cape Town, was asked
Q. 252. "You are aware that the bacilli have been in the saliva of lepers, would not that render the disease liable to be spread by the act of kissing?"" Not unless there was some cracked surface on the lips or mouth. I have never known of a case of leprosy having been contracted on the island, although they mix there freely." Report of Select Committee on the Spread of Leprosy, Cape of Good Hope, July, 1889. Minutes of Evidence.
Mr. Davidson of Madagascar says : " Leprosy is contagious by inoculation only."
Dr. W. V. M. Koch, the Acting Superintendent of the Leper Asylum, Trinidad, writing on the subject of contagion, explains that "the entrance of the (leper) germ into the system will take place if it is brought into contact with an absorbing surfaceany abrasion of skin or mucous membrane being sufficient for this purpose." Surgeon Generals Report for 1891, pg. 71.
Dr. Alexander Abercromby writes to me from Cape Town, April 20th, 1892, that after thirty years experience he holds that leprosy is partly contagious, and explains that he does not use the word contagion in the strict sense, "but when there is a discharge from a leprous sore, and this coming .in contact with the tissues of a healthy person will develop the disease; or the saliva of a person coming into contact with a slight abrasion of cuticle, or healthy mucous surface."
Under the head of "Leprosy in Havana," the British Medical Journal, June 18th, 1892, says that the number of cases in the Real Casa Hospital de San Lazaro at the present time averages 8o to 90, but seldom reaches 100. In 32 cases (40 per cent.) no family history of the disease could be obtained. In no single case could leprosy be traced to contagion, and of the 25 persons employed in the hospital, only one (a chaplain) contracted the disease during the last 12 years. Dr. Arango, the present medical superintendent, has never known any case in which the disease could be distinctly traced to contagion, and he knows persons who have lived twenty-eight or thirty years in the hospital without contracting it."