through these reports we meet research, patient toil, and continued
with evidence
All
labour
on.
of
deep
the part of the
authors. The
first
chapters
of Drs. Lewis and
Cunningham's essay India; the
in British
deal with the distribution of
leprosy
body of the report is taken investigations in Kumaun, and and at the same time elaborate, The total number of lepers
up with the results of their at the close we have a succinct,
leS3
summary of the whole. in British India amounts to no
54 in every 10,000 of the populaor Bengal Presidency there are 5-2, in the Madras 4-4, and in the Bombay Presidency 8'5 lepers in every 10,000 of population. In the Bengal Presidency six districts contain a leprous population equivalent, or nearly so, to 20 per 10,000. They are Beerbhoom (41'2 per 10,000), Bancoorah, (300), Burdwan (22-G), Kumaun (211), Banda (19-6), and Dehra Doon (19 0). In the Bombay Presidency there are thi-ee districts, vie., Barsi (25*6), Sowda (25*0) and Rajapore (23 4). In the Madras Presidency the highest district is that of Madras itself, 10'5 per 10,000. In Bengal the lowest leper population is found in Assam (1*6 per 10,000), Chittagong (2 6), Orissa (2-4), &c. In the North-Western Provinces, Meerut, Agra, Jhansie, and Benares show from 2 to 3 per 10,000 ; in the Central Provinces, Jubbulpore, and Upper Godavari show only TO; in the Punjab the lowest numbers are found in Derajat (15), Peshawur (19) and Mooltan (3). In Madras the sea-coast districts give 4-9, while the inland districts give tion.
than
99,073,
In the
36 per 10,000.
The district in which the smallest number of
lepers exists is Coimbatore with 2 0 per 10,000. In the Bombay Presidency the districts in the Deccan give 11 6, in Konkan 8*4, in Gujerat 5'4, and in Sind 1*4 per 10,000. In British Burmah the leprous population amounts to 11-6 per 10,000. Dr. Vandyke Carter, in his exhaustive report of a tour in Kattiawar in 1876?" Modern Indian Leprosy,"?gives the ratios for the whole Bhaonagar State as follows :?l< 1 leper child to 3,000:
1
leper male
adult to
300,
and 1
leper female adult to infested districts of 1,100, Bhaonagar (which are all connected) these ratios rise to 1:1,800; 1 :200, and 1 :850 respectively." lie also found that the leprous disease is most predominant in populous coast areas, and less so inland, but lie asserts that mere proximity to the * * The sea has nothing to do with the disease. * Bhal is a as considerable, though rather barren, particularly noteworthy maritime area, where leprosy is quite absent. It might seem that scanty population, and limited movement of people, were the sole cause of this exemption; yet better peopled and flourishing districts on the west of the Bhal (Wala, &c.,) and to the North-West (Botad) are infested but very slightly indeed." Drs. Lewis and Cunningham write:?" It has been seen that in Madras the disease is more prevalent along the coast than in the interior ; the reverse, however, holds good for Sicily ; for, whereas the returns give 2 lepers to every 9,000 persons living along the^coast, there were 5 persons to a similar number in the interior. Many parts of India may be cited as * * * Norway contains testifying to a similar condition. of about double the number lepers that Kumaun does, but the population also of the former is more than three times that of the latter, so that the leprous population of Norway (12 per 10,000), is, in proportion, considerably lower than that of Kumaun." In Kumaun leprosy prevails to a far greater extent and
if
we
take the four more
"
CIjc JInUiait fttcUtrai (Sajcttc, OCTOBER 1, 1877.
LEPROSY IN INDIA. We recommend all tho3e who take
an
interest in this
subject
and valuable report on " Leprosy in India," by Drs. Lewis and Cunningham, which appears in the Twelfth Annual Eeport of the Sanitary Commissioner with the
to
read the
interesting
Government of India. The value of the report is enhanced of India and Kumaun showing by many statistical tables, maps the
of leprosy in each locality, and four excellently lithographic drawings from photographs which vividly
prevalence
executed
usual appearances of this loathsome disease. With the above we would couple a most excellent and ex-
display
haustive
the
Report?Modern
Indian
Syrian Leprosy, by
Dr.
Leprosy?of
a
Tour in
Norwegian, Cretan, and II. Vandyke Carter of Bombay.
Kattiawar in 1876, with Addenda
on
LEPHOSY IN INDIA.
1877.]
October 1,
along the eastern side of the district than along the western. In Pergunnah Sor the ratio is 59'4, and in Changarkha 47*4 per 10,000, while in Pergunnahs Johar and D&rma the ratios are 6 4 "As a rule, also, the most and 6 2, respectively. populous districts, and probably the most well-to-do, are those containing the largest ratio of lepers." Dr. Vandyke Carter remarks in his Summary :?" 1. Wherever found leprosy is most frequent in villages beyond the mean in size. 2. "When in much infested districts small villages abound, they are not infested beyond a certain proportion 3. When in like areas, small villages are fewer than the mean they are still affected to a similar extent. 4. Under all circumstances, the proportion of large villages which are affected exceeds that of small villages; and when leprosy is at its minimum, it attaches to a large village. 5. Hamlets are seldom the 1 ome of lepers. 6. Single leper-villages are every where more frequent than multiple leper-villages. 7- In much infested areas (whether coast or inland), single leper-villages maintain a nearly uniform proportion to the multiple. 8. They are commonly large villages, but not so in districts with many small villages. When small villages are few, the ratio of single 9. leper-villages remains nearly constant. 10. When leprosy becomes rare, the proportion of small single leper-villages is reduced. 11, Multiple leper-villages are always fewer than the Sjngle, but in much in12. They are fested districts their proportion is nearly uniform. commonly large villages, and may be so always in much infected Non leper-villages are not outwardly distinguishable areas. 3. from infested localities. 14. All leper-localities are connected, and they are universally arranged in groups or linear series." The preponderance of lepers in the eastern part of Kumaun Drs. Lewis and Cunningham ascribe to the influx of affected people from Nepal, in which country these unfortunate people disappear in the most mysterious manner; the supposition being that they bury themselves. They found that in the Almora asylum, one-fifth of all the lepers who have obtained shelter during the last 30 years came from Nepal. When the asylum was visited by Drs. Lewis and Cunningham there were 80 inmates, excluding a few spurious or doubtful cases. They write : "All the recognised forms of true leprosy are represented there among the inmates, although in very unequal proportion, ana3sthetic phenomena form the promiin which cases 49 being nent symptoms, 12 in which the tubercular element prevails, 4 in which eruption is very conspicuous, and 15 in which tuberculated and anaesthetic phenomena are so closely and equally associated that they may with propriety be regarded as cases This division of the of the " mixed" variety of leprosy. founded cases is, however, to be regarded as a relative one only, as classed cases The ana;sthetic, on predominance of symptoms. were invariably, or almost invariably, comparatively pure cases of this form; but in advanced cases of tuberculated leprosy, the ?
phenomena are very rarely, if ever, dissociated from more or less pronounced symptoms of anajsthesia, so that they might genercases. Still the ally be included under the heading of mixed one condition was so much more strongly marked than the other thi t it
appeared
them under those
a
classed
which cases is
warrantable and conducive to clearness to retain distinct heading. The same holds in regard to
'eruptive,'
as
iy>tewoithy,
and is
to be ascribed to the fact that
the very small proportion of probably, in part at all events,
patients
do net
generally present
themselves for admission until the disease has lasted for some
time,
and
until,
in
consequence,
eruptive symptoms have
disappeared,
267 have been
or
obscured by the development of
anaesthetic or tuberculated phenomena. This is the more probable as, in the vast majority of cases, the patients, suffering from advanced tubercular or anaesthetic symptoms, described commenced with the occurrence of an their disease a3
having
eruption."
examined in Kattiawar by Dr. Vandyke 44 per cent, were of the tubercular, and 137 says that or 56 per cent, of the anaesthetic varieties. alone were districts infested more in the (which "everywhere intermingled; and both forms of disease are Of the 262
Carter,
125
lepers
or
closely visited) inspected leper-localities, 36 had anaesthetic leprosy only, 28 had tubercular leprosy only, and 25 contained both varieties : on the whole, there is rather more tubercular leprosy inland, and rather more anaesthetic leprosy on and near the coast. Again, where there is but one leper in a village (wherever situate), commonor when there are 2 lepers, the anaesthetic leprosy is est : but where there are 3 to 5, or 6 to 8, lepers in a village tubercular leprosy predominates ; and where or town, then there are upwards of 10 lepers in a town, the milder form (anaesthetic) again becomes the more frequent, though there the inference is of modified value, because lepers are not
of 89
seldom
immigrants Taking the 49
from outside." of anaesthetic
cases
leprosy
in the
Almora, Drs. Lewis and Cunningham found that
"
asylum
at
in 36 there
complete anaesthesia of the face, that in 28 scalp, in 6 the neck, in 48 the upper, in all the lower extremities, and in 21 the trunk were affected. In two cases the ears were affected without there being any anaesthesia of the face, so that the cases in which the head and neck were more
was
or
less
the ears, in 12 the
Taking the regions of the entire affected amounted to 38. we find the lower of extremities number of in order cases, body occupying the first place, followed successively by the upper extremities, being only face."
little
and neck, and the trunk, the latter than half as frequently affected as the
more
The results of their careful
anaesthetic
tendency and
the head a
areas
to
of the several
peripheral over clearly demonstrate
also
according
analysis
"
illustrate the well-known central localisation of the affection,
in these cases
to nervous areas.
the distribution of anaesthesia One of the most interesting points
noted is that in reference to the ears,
apparently indicating tragi are less liable to suffer than the rest of the ears, implying a corresponding comparative exemption of the auriculo-temporal nerve as compared with the other nerves supplying the external ear. The distribution according to nervous areas is also illustrated by other phenomena?by the exemption of the upper lip and chin, by the sharp limitation of anaesthesia to the line of the lower jaw and to the gluteal regions on the trunk, by the greater liability of the extensor, as compared with flexor that the internal surfaces and
surfaces of the upper, and of the outer with the inner surfaces In one case of the lower extremities." the tongue was
anaesthetic to the touch, but the sense of taste another the reverse condition was present, but touch and cases
only.
as
retained ; in a
rule,
both
taste remained intact except in very advanced Only four cases complained of pain, either in the
toes, in the calves of the legs, of the soles of the feet.
or
in connection with
In 17 cases
The
commoner
forma
were
ulceration
there was more
decided alterations in the skin in some
the body.
was
or
or less other portion of
general shrivelling
and
THE INDIAN MEDICAL GAZETTE
268
puckering of the surface, which at the same time presented a dry aspect ; the occurrence of coarse folds of skin about the elbows and knees; the presence of fissures, more especially in the soles of the feet, and of various extent and
patches In
one
course
the occurrence of
or
two
cases
there
were
of the cutaneous nerves
discoloured
generally of a whitish hue. obvious thickenings along the
supplying
ancesthetic
areas.
In
marked enlargement of the inguinal glands. in most cases on both hands and feet, rarely situated ulcers, Open on the hands alone, but frequently on the feet alone, were present one case
there
was
Many of them were caused by injuries, and in " discharges, microscopic examination revealed no special cells or other morphological elements not common to any nonspecific ulcerating surface." In all but three cases there was loss of digits to a greater or less degree. " The blood of the patients was microscopically examined in 28 cases. In 17 of these it was to all appearance perfectly normal, in the remaining 11 it was characterised in five instances by a greater or less excess of normal white corpuscles and bioplastic fragments of small size, in three by such excess combine^ with a softened gelatinous condition of the red corpuscles causing them to adhere in irregular masses, and in three by the latter phenomenon alone. In two, specimens of blood could only be with difficulty obtained from the hands. One of these was a case in which the characters of the specimen were normal; the one in which the red corpuscles were softened. other, * As regards the initial symptoms of this variety (ansesthetic) of leprosy, Drs. Lewis and Cunningham state that " the commonest symptom attracting attention to the commencement of the disease is an eruption of some form, such having occurred, it is affirmed, in 31 of the 49 cases." Dr. Vandyke Carter t'ells us that in 137 cases of ancesthetic leprosy, 22 of them state that it commenced with an eruption and then neuritis followed ; 68, or one-half of the whole, referred it to vesicles or blebs, abscess or sore, and 35 to nerve symptoms from the first, such as heat, pain, tingling, numbness, &c. Of the tubercular form of leprosy there were 12 cases in the Asylum, or 15-0 per cent, of the total cases in which nodular appearances were by far the most prominent features of the disease. In all, the face and ears were the seats of tubercular deposit, and in five cases it was limited to these parts; in two the tongue was greatly invaded; in one the deposit was generally diffused over the body, and in one it was chiefly confined to the extremities. In some cases the deposit in the face and ears " was diffused, causing general thickening over wide areas, in others it occurred as isolated, sharply-defined, prominent nodules. The sites of chief deposit were those well known as those specially selected in the disease?the malar prominences, eyebrows, nose and ears. In some cases there were prominent tubercles on the upper eyelids, which added considerably to the deformity, due to the general thickening of the tissues and the forehead between the various areas coarse deep furrows on the of the deposit. The deposit when affecting the nose generally appeared to take origin around three centres, affecting the lip and in 35 cases.
their
"
alee
respectively.
This caused the formation of
irregular lobes,
advanced, ended in causing the nose to present a distinct trilobed extremity. The lobes of the ears were very greatly affected, becoming thickened, nodular and pendulous, whilst smaller masses of deposit caused irregular roughening and thickening along the rims." and when the condition was
In
only
one case
[Octobee 1, 1877. acute one of short
(an
thesia entirely absent; in the others more
"
les3 completely anaesthetic, but regions was much less common,
or
entire
duration) was anaesdeposit were general anaesthesia of complete, or extensive
the areas of
than in the form of the disease first described." there were open ulcer3
In five cases
hands, and in one there was a large on the right cheek. surface In one the tongue ulcerating was ulcerated, and in five cases the extremities were quite unaffected by ulceration, distortion, or absorptive changes of any kind. Pain was complained of in only one case, and was limited to the dorsum of the right foot, extending from a distorted and swollen fourth toe to the inner side of the ankle joint. The blood was examined microscopically in ten of the twelve cases. In eight of these the number of white corpuscles present in the specimens was excessive. In some this excess was very strongly marked, and the normal white corpuscles were accompanied by an abundance of smaller bioplastic fragments. In two cases, the only abnormal feature present was a soft and adhesive condition of the red corpuscles,?a condition which also occurred along with the excess of white corpuscles in one of the other * * * cases. In eleven cases a history of the initial symptoms of the disease was obtained. In seven the occurrence of patches of eruption is stated to have been the first symptom ; in one cracking of theskin of the heels followed by eruption; in twocracking on
feet
or
"
of the skin of the feet; in
one a
similar affection of the skin over
generally diffused pain in the Here, as in the case of the anaesthetic form of the disease, eruption seems to have been the most common [initial symptom." Dr. Vandyke Carter tells us that in 36 instances, or nearly one-third of the whole number he inspected, "tubercular leprosy began with symptoms of nerve disease, and this estimate may be below the truth. It commonly begins with an eruption of reddish spots on the face, hands, feet or trunk; also with swellings (the so-called 'tubercles'), bronzing or desquamation, which are all somethe ankle
joints
joints
;
in
and
one
of the extremities.
times attended with fever."
Age.?Of the 49 cases of anaesthetic leprosy Drs. Lewis and Cunningham found the average age of attack to be 26*18, and of the 11 cases of tubercular leprosy 18'90 years. The earliest date of attack was 9 years and the latest 30. Dr. Vandyke Carter writes:?" I have never met with leprosy in an infant, nor have I seen it in children under the age of 5. My tables show that 16'7 per cent, of lepers (girls proportionally oftenest) date their malady from childhood, in the more infested districts (specially coast): whilst elsewhere, about 9 per cent. : and that 39 per cent, acquire it between 16 and 30 years coast.ward, 45 per cent, inland ; where also 14 per cent, date the complaiut ^5 years, but only 11'8 per cent, in the infested coast areas. The instances of later origin I find to be chiefly of the form of anaesthetic leprosy, and some are possibly instances of simple neuritis. In both sexes tubercular leprosy commences at an earlier age than the anaesthetic form, yet this rule does not hold
good
for
Norway." of the disease
Duration
that,in
of attack until the years.
?Drs. Lewis and Cunningham inform
us
the anaesthetic form, the duration of disease, from the date
period
of examination,
ranged
The duration of sixteen was under 10
from 1 to 40
^ears,
of fifteen
between 10 and 20 years, of sixteen between 20 and 30 years, of In those cases of the tuberone 32 years, and of one 40 years. cular form the duration of the disease varied from 1 to 14 years,
Octobee
LEPEOSY IN INDIA.
1,1877.]
269
whilst men curiously name also their Of the cases eight had paternal grand-father, average of 8-27 for all cases. as being lepers, no woman naming father mother and mother's lasted for a period of under 10 years, and three for periods is taint Collateral given by 10 per cent, of males and between 10 and 20 years. Dr. Carter writes:?"I have no either. is it through paternal uncle, but 9 of females: chiefly cent, per data for ascertaining the mean duration of leprosy in Kattiawar, : one man names his mother s sister named also sister is father's as is it here as that but infer prolonged elsewhere, and may cent, of males, and 13 per cent, of xtend from 6 or 8 years for the tubercular form, and to 15 or as being affected. Eleven per and sisters. Altogether about * brothers females had * * leprous 20 years for anaesthetic leprosy. It appears direct or collateral taint, and that the mortality in asylums of tubercular leprosy is about 30 per cent, of all lepers have some Eleven per cent, have a brother * * * double that of anaesthetic. The mean age about 70 per cent, have none. evidence of a family taint. or other sister no but of lepers at death is, in Norway about 42 years, in the West leprous, in tubercular Indies about 32 years, and in Bombay about 37 ; those affected Hereditary taint proper is more strongly marked with tubercular leprosy dying at 32 '2, and those having anes- than in anaesthetic leprosy, viz., as 37 : 23 3 per cent. Drs. Lewis and Cunningham show clearly in their tables that thetic leprosy at about 50 years." have comparatively small families, and that amongst the lepers Sexes,?Of the 49 cases of anaesthetic leprosy which Drs. Lewis and Cunningham examined, 24 were females, and of the children there is a very high rate of mortality. It also appears 12 cases of tubercular leprosy 2 were females. Dr. Carter that the male leper is credited with a smaller number of children than the female leper, the absolute numbers in the Almorah Asy" as regards sex in the mild or severe forms of says that, disease, I find that of the former (anaesthetic), women are one-third of lum being 27 and 76 respectively, and the averages of children to families being 1'08 for the male lepers and 2-8 for the female the whole instances seen in and form with
an
Kattiawar, they only oneSo far as the evidence goes, the total number contributlepers. leprosy." to the ed population by the female lepers is about 70 per centHereditary Influences.?In the Asylum at Almorah Drs. Lewis the males. As a set-off to and Cunningham found that out of 80 lepers present, 28 or 35 in excess of that contributed by that 24 per cent, more of about table shows the Four had both this, however, per cent, had one or more leprous relatives. died to female than of the children born children the lepers parents affected, three the father, ten the mother, thirteen the Dr. Vandyke Carter's investigations do to male lepers." born the five the and two seven had other sisters, son, brothers, relations, as mother's brother, or father's brother, or sister's not bear out this observation, and the error probably arises from child, affected with leprosy. Many of the inmates, however, the number of cases examined into being too few on both sides. He says:?" 182 married of either sex had 430 children, or a had not for some years past heard anything of the indivimean of 2 4 children to each marriage, but if infertile marriages dual histories of the various members of their families. The figures seem to indicate that there is a strongly marked ten- be excluded there are nearly 3 children to one marriage?when is the leper the number of children is under this dency in the disease to follow the female line of descent. the female parent and vice versa, when the male." * * * Sixty-six married males, mean, all the cases in which parents Taking affected with tubercular leprosy, had 148 children (mean 2-24), or 10 cases parents' relatives are affected, we find fifth of all
"
of tubercular
cases
"
in which the father which the disease
or
was
father's relatives
present
on
are
leprous,
and 17 in
the maternal side."
Dr.
question of hereditary transmisjustice in these few pages, but on the whole the observations of Drs. Lewis and Cunningham are not corroborated by him. To a certain degree Dr. Carter believes in the contagiousness of leprosy, and it is difficult to eliminate this point when a number of lepers in one family Carter enters
so
fully
into the
sion that we cannot do him
the 106 males and 22 present themselves for examination. Of females examined by him in Kattiawar and affected with tuber-
leprosy, he found that in 19 per cent, of the males and 50 of the females there was taint in the direct or parental cent, per line?that through the father (most) and paternal grand-father cular
amounting to 15 per cent, of male, and 32 per cent, of female: leper-men had mother lepers in 4 per cent, of the whole, and kper-women had leper-mothers in 14 per cent. Ten per cent, of males and 22 per cent, of females showed taint in the collateral aunts : the father's brother is oftenest tho
line of uncles and
leper relative (8 and 18 per cent, respectively for males and females) ; the mother's brother is proportionally named oftener by women than by men. Of co-equal taint?brothers and sisters lepers?11 per cent, of males named a brother, 1 per cent, 9 per cent of the females had a leper brother, a sister leprous : and none of the 22 had a leper sister. Of the 133 cases of anaesthetic leprosy examined by Dr. Carter 14 per cent, of males and "
12 per cenf.
Hero,
too, fathers
of females showed are
oftenest
taint in the direct line.
named,
and
by
women
the
and 13 married females affected with the same form had 28 children (mean 2-15). In the instances of anassthetic leprosy 70 married males had 187 children (mean 2 67) and 33 married
females had 67 children (mean 2'03). Dr. Carter saysUnproductive marriages are twice as frequent in tubercular as in anaesthetic leprosy : thus amongst leper fathers with anaesthetic leprosy in
a
ratio of 1: 12 was
marriage infertile, and with tubercular leprosy 1:6; amongst leper mothers with anaesthetic leprosy the ratio was 1 : 8, and with tubercular leprosy 1 : 4 ; so that tubercular leprosy, not only disqualifies for marriage, but has a tendency to render marriage infertile, and that most in women." Contagion.? Under this heading we have no trustworthy evidence. Drs. Lewis and Cunningham inform us that " the history of the Asylum (at Almorah) gives no support to the doctrine that leprosy is a contagious disease, but strong evidence to the con* * * We have no satisfactory evidence of trary. contagion and none of a rapid increase of cases due to hereditary influences." Dr. Carter, as a result of his investigation in Kattiawar, is inclined to believe that leprosy is somewhat contagious. He writes
:
?
myself, all these data may be said to point to transmission of the leprous disease by means of human intercourse." He does not bring forward any proof of the disease being so " propagated, but bases his view upon the fact that he found no' on the contrary, that all such leper village to be isolated, but, villages are connected with others immediately adjoining?the rare unaffected spots intervening, being temporary or incidental "For
THE INDIAN MEDICAL GAZETTE.
270
In another place he writes :?" My present exceptions." analysis of leper-localities in Kattiawar deserves particular notice, both in itself and as a datura to be further tested ; for regarded broadly, the peculiarly close connection and serial to some sequence of leper-villages moat obviously points method of transmission, and so far as has happened to me, there is no other agency at work than man and the surroundings he acquires." Occupation and Caste.?In the Asylum at Almorah of 72 cases of leprosy, 39 were Domes, 30 Rajputs, 1 Brahmin, 1 Buniab, and 1 Christian. Drs. Lewis and Cunningham write :?" As the inhabitants of Kumaun virtually consist of two classes only? Rajputs and Domes, the former representing an Aryan population, the latter the aboriginal people, whilst other classes are only very sparingly represented?the evidence, such as it is, is in favour of impartial distribution of the disease." Dr. "Vandyke Carter writes :?With reference to the influence of occupation in inducing the leprous disease, I have not detected any new * * * facts. In elucidation of the prime datum that leprosy first manifests itself upon exposed or unprotected integument? notably the face, ears, and limbs?nothing has suggested itself beyond the idea that hard manual or foot-work, constant contact with vegetation products and soil, pure and impure, contact with skin and excreta of ill-fed domestic animals, and incessant exposure to heat and dust, may be both predisposing causes and actual media for the conveyance of disease germs. The latter, if there be such, are an independent agency; and assuredly the hardest labour will not
produce neuritis?certainly not specific neuritis?without the super-addition of some sort of essential jnfluence. What this is can be ascertained Only by inspiration, untried. or by close enquiry on the spot?means yet failing or The occupation of fishing has no part in the production of As regards caste he writes:?"Whilst Kattiawar leprosy." leprosy attacks all castes and races, it yet probably does not attack them proportionately to their respective populations, preferring rather certain groups, large or small, in certain areas; and this doubtless in accordance with local events, which would have to be specially searched out." We now come to the
important question of segregation or lepers ? Drs. Lewis and Cunningham condcmn legal restraint or lepers' prisons. They are convinced that such, besides being tyrannical, could hardly be looked forward to as an efficient or practicable means of diminishing the prevalence of leprosy. " It would not be sufficient merely to confine those suffering from developed disease, but all those ?who might in any degree be supposed to be hereditarily disposed towards it, would also have to be secured. It would, in truth, be even more important to secure the latter, for, from the present evidence, there appears to be only a very small But had all number of children born to confirmed lepers. those predisposed to be secured, how and by whom could the what
can
be done for the
predisposition be determined? In the case of hereditary predisposition, it is quite uncertain for how long? for how many generations?the disposition may be transmitted existence
of
without giving any ostensible sign of its presence, but capable under certain circumstances of giving origin to the development of the disease. How, then, is the absence or disappearance
of
They
predisposition
to be determined ?"
advocate the estal I shment of free, charitable
wherever
practicable.
asylums
"iSuch institutions are, beyond doubt,
[October 1,
1877,
calculated to do very great good, and deserve all support and encouragement, so long as such support does not relieve the relatives of the diseased from the performance of their duties to the sick?so an
long
as
their existence does not afford
encouragement to people to profit by the misfortune of their
relatives at the expense of the community." Dr. Vandyke Carter, on the other hand, entertains the view-
segregation of the lepers would after generations be followed, if not by a total disappearance of the disease, at least by a diminution to a very small ratio. He, therefore, advocates legal enactments and compulsory imprisonment of lepers in asylums. He writes:?"The fir-^ consideration I take to be, separation of the infested from the healthy; and to a certain extent this might be done at home were distinct orders issued on the subject. Thus, it should be made incumbent on those families, who, being in fair circumstances, desire to keep their lepers with them, that these sick be altogether separately lodged, having had board and clothing quite apart,?the object being to isolate them as far as is possible. Too often, however, such regulations would be futile, on account of the poverty of the sufferer and his connections, who would not be able to provide the required that absolute and entire
a
few
I do not suppose that any other obstacle than expense would arise in attempting to enforce this isolation of the sick at their own homes, but even this
separate accommodation.
tolerant measure, when practicable, would need to bo maintained
by authority; and such being the case?namely, that legal provision is necessary?it becomes a question if it were not better at once to deal with the subject comprehensively. Two main objects being understood to be the protection of the community and the due care of the sick?objects which in practice become unique?I would suggest, first, that a convenient refuge be offered to all vagrant lepers, whose further wanderings should then be interdicted ; next, that a similar asylum be opened to the poorer classes of the peasantry, whose compliance with the wishes of the State is to be insisted upon; and, thirdly, that those persons who are willing to provide separate maintenance for their leprous sick should be permitted to do so only upon the condition that the isolation proposed be practically an efficient one. Segregation of the sick becomes an inevitable resultant, because it would be impossible to furnish individual separation for all; and hence a common Home for the large majority of lepers would be required." In a limited paper of this sort it is not possible for us to do justice to the authors of the excellent essays before us, so we must refer our readers to the reports themselves, and we promise they will well repay perusal.
with evidence
All
labour
on.
of
deep
the part of the
authors. The
first
chapters
of Drs. Lewis and
Cunningham's essay India; the
in British
deal with the distribution of
leprosy
body of the report is taken investigations in Kumaun, and and at the same time elaborate, The total number of lepers
up with the results of their at the close we have a succinct,
leS3
summary of the whole. in British India amounts to no
54 in every 10,000 of the populaor Bengal Presidency there are 5-2, in the Madras 4-4, and in the Bombay Presidency 8'5 lepers in every 10,000 of population. In the Bengal Presidency six districts contain a leprous population equivalent, or nearly so, to 20 per 10,000. They are Beerbhoom (41'2 per 10,000), Bancoorah, (300), Burdwan (22-G), Kumaun (211), Banda (19-6), and Dehra Doon (19 0). In the Bombay Presidency there are thi-ee districts, vie., Barsi (25*6), Sowda (25*0) and Rajapore (23 4). In the Madras Presidency the highest district is that of Madras itself, 10'5 per 10,000. In Bengal the lowest leper population is found in Assam (1*6 per 10,000), Chittagong (2 6), Orissa (2-4), &c. In the North-Western Provinces, Meerut, Agra, Jhansie, and Benares show from 2 to 3 per 10,000 ; in the Central Provinces, Jubbulpore, and Upper Godavari show only TO; in the Punjab the lowest numbers are found in Derajat (15), Peshawur (19) and Mooltan (3). In Madras the sea-coast districts give 4-9, while the inland districts give tion.
than
99,073,
In the
36 per 10,000.
The district in which the smallest number of
lepers exists is Coimbatore with 2 0 per 10,000. In the Bombay Presidency the districts in the Deccan give 11 6, in Konkan 8*4, in Gujerat 5'4, and in Sind 1*4 per 10,000. In British Burmah the leprous population amounts to 11-6 per 10,000. Dr. Vandyke Carter, in his exhaustive report of a tour in Kattiawar in 1876?" Modern Indian Leprosy,"?gives the ratios for the whole Bhaonagar State as follows :?l< 1 leper child to 3,000:
1
leper male
adult to
300,
and 1
leper female adult to infested districts of 1,100, Bhaonagar (which are all connected) these ratios rise to 1:1,800; 1 :200, and 1 :850 respectively." lie also found that the leprous disease is most predominant in populous coast areas, and less so inland, but lie asserts that mere proximity to the * * The sea has nothing to do with the disease. * Bhal is a as considerable, though rather barren, particularly noteworthy maritime area, where leprosy is quite absent. It might seem that scanty population, and limited movement of people, were the sole cause of this exemption; yet better peopled and flourishing districts on the west of the Bhal (Wala, &c.,) and to the North-West (Botad) are infested but very slightly indeed." Drs. Lewis and Cunningham write:?" It has been seen that in Madras the disease is more prevalent along the coast than in the interior ; the reverse, however, holds good for Sicily ; for, whereas the returns give 2 lepers to every 9,000 persons living along the^coast, there were 5 persons to a similar number in the interior. Many parts of India may be cited as * * * Norway contains testifying to a similar condition. of about double the number lepers that Kumaun does, but the population also of the former is more than three times that of the latter, so that the leprous population of Norway (12 per 10,000), is, in proportion, considerably lower than that of Kumaun." In Kumaun leprosy prevails to a far greater extent and
if
we
take the four more
"
CIjc JInUiait fttcUtrai (Sajcttc, OCTOBER 1, 1877.
LEPROSY IN INDIA. We recommend all tho3e who take
an
interest in this
subject
and valuable report on " Leprosy in India," by Drs. Lewis and Cunningham, which appears in the Twelfth Annual Eeport of the Sanitary Commissioner with the
to
read the
interesting
Government of India. The value of the report is enhanced of India and Kumaun showing by many statistical tables, maps the
of leprosy in each locality, and four excellently lithographic drawings from photographs which vividly
prevalence
executed
usual appearances of this loathsome disease. With the above we would couple a most excellent and ex-
display
haustive
the
Report?Modern
Indian
Syrian Leprosy, by
Dr.
Leprosy?of
a
Tour in
Norwegian, Cretan, and II. Vandyke Carter of Bombay.
Kattiawar in 1876, with Addenda
on
LEPHOSY IN INDIA.
1877.]
October 1,
along the eastern side of the district than along the western. In Pergunnah Sor the ratio is 59'4, and in Changarkha 47*4 per 10,000, while in Pergunnahs Johar and D&rma the ratios are 6 4 "As a rule, also, the most and 6 2, respectively. populous districts, and probably the most well-to-do, are those containing the largest ratio of lepers." Dr. Vandyke Carter remarks in his Summary :?" 1. Wherever found leprosy is most frequent in villages beyond the mean in size. 2. "When in much infested districts small villages abound, they are not infested beyond a certain proportion 3. When in like areas, small villages are fewer than the mean they are still affected to a similar extent. 4. Under all circumstances, the proportion of large villages which are affected exceeds that of small villages; and when leprosy is at its minimum, it attaches to a large village. 5. Hamlets are seldom the 1 ome of lepers. 6. Single leper-villages are every where more frequent than multiple leper-villages. 7- In much infested areas (whether coast or inland), single leper-villages maintain a nearly uniform proportion to the multiple. 8. They are commonly large villages, but not so in districts with many small villages. When small villages are few, the ratio of single 9. leper-villages remains nearly constant. 10. When leprosy becomes rare, the proportion of small single leper-villages is reduced. 11, Multiple leper-villages are always fewer than the Sjngle, but in much in12. They are fested districts their proportion is nearly uniform. commonly large villages, and may be so always in much infected Non leper-villages are not outwardly distinguishable areas. 3. from infested localities. 14. All leper-localities are connected, and they are universally arranged in groups or linear series." The preponderance of lepers in the eastern part of Kumaun Drs. Lewis and Cunningham ascribe to the influx of affected people from Nepal, in which country these unfortunate people disappear in the most mysterious manner; the supposition being that they bury themselves. They found that in the Almora asylum, one-fifth of all the lepers who have obtained shelter during the last 30 years came from Nepal. When the asylum was visited by Drs. Lewis and Cunningham there were 80 inmates, excluding a few spurious or doubtful cases. They write : "All the recognised forms of true leprosy are represented there among the inmates, although in very unequal proportion, ana3sthetic phenomena form the promiin which cases 49 being nent symptoms, 12 in which the tubercular element prevails, 4 in which eruption is very conspicuous, and 15 in which tuberculated and anaesthetic phenomena are so closely and equally associated that they may with propriety be regarded as cases This division of the of the " mixed" variety of leprosy. founded cases is, however, to be regarded as a relative one only, as classed cases The ana;sthetic, on predominance of symptoms. were invariably, or almost invariably, comparatively pure cases of this form; but in advanced cases of tuberculated leprosy, the ?
phenomena are very rarely, if ever, dissociated from more or less pronounced symptoms of anajsthesia, so that they might genercases. Still the ally be included under the heading of mixed one condition was so much more strongly marked than the other thi t it
appeared
them under those
a
classed
which cases is
warrantable and conducive to clearness to retain distinct heading. The same holds in regard to
'eruptive,'
as
iy>tewoithy,
and is
to be ascribed to the fact that
the very small proportion of probably, in part at all events,
patients
do net
generally present
themselves for admission until the disease has lasted for some
time,
and
until,
in
consequence,
eruptive symptoms have
disappeared,
267 have been
or
obscured by the development of
anaesthetic or tuberculated phenomena. This is the more probable as, in the vast majority of cases, the patients, suffering from advanced tubercular or anaesthetic symptoms, described commenced with the occurrence of an their disease a3
having
eruption."
examined in Kattiawar by Dr. Vandyke 44 per cent, were of the tubercular, and 137 says that or 56 per cent, of the anaesthetic varieties. alone were districts infested more in the (which "everywhere intermingled; and both forms of disease are Of the 262
Carter,
125
lepers
or
closely visited) inspected leper-localities, 36 had anaesthetic leprosy only, 28 had tubercular leprosy only, and 25 contained both varieties : on the whole, there is rather more tubercular leprosy inland, and rather more anaesthetic leprosy on and near the coast. Again, where there is but one leper in a village (wherever situate), commonor when there are 2 lepers, the anaesthetic leprosy is est : but where there are 3 to 5, or 6 to 8, lepers in a village tubercular leprosy predominates ; and where or town, then there are upwards of 10 lepers in a town, the milder form (anaesthetic) again becomes the more frequent, though there the inference is of modified value, because lepers are not
of 89
seldom
immigrants Taking the 49
from outside." of anaesthetic
cases
leprosy
in the
Almora, Drs. Lewis and Cunningham found that
"
asylum
at
in 36 there
complete anaesthesia of the face, that in 28 scalp, in 6 the neck, in 48 the upper, in all the lower extremities, and in 21 the trunk were affected. In two cases the ears were affected without there being any anaesthesia of the face, so that the cases in which the head and neck were more
was
or
less
the ears, in 12 the
Taking the regions of the entire affected amounted to 38. we find the lower of extremities number of in order cases, body occupying the first place, followed successively by the upper extremities, being only face."
little
and neck, and the trunk, the latter than half as frequently affected as the
more
The results of their careful
anaesthetic
tendency and
the head a
areas
to
of the several
peripheral over clearly demonstrate
also
according
analysis
"
illustrate the well-known central localisation of the affection,
in these cases
to nervous areas.
the distribution of anaesthesia One of the most interesting points
noted is that in reference to the ears,
apparently indicating tragi are less liable to suffer than the rest of the ears, implying a corresponding comparative exemption of the auriculo-temporal nerve as compared with the other nerves supplying the external ear. The distribution according to nervous areas is also illustrated by other phenomena?by the exemption of the upper lip and chin, by the sharp limitation of anaesthesia to the line of the lower jaw and to the gluteal regions on the trunk, by the greater liability of the extensor, as compared with flexor that the internal surfaces and
surfaces of the upper, and of the outer with the inner surfaces In one case of the lower extremities." the tongue was
anaesthetic to the touch, but the sense of taste another the reverse condition was present, but touch and cases
only.
as
retained ; in a
rule,
both
taste remained intact except in very advanced Only four cases complained of pain, either in the
toes, in the calves of the legs, of the soles of the feet.
or
in connection with
In 17 cases
The
commoner
forma
were
ulceration
there was more
decided alterations in the skin in some
the body.
was
or
or less other portion of
general shrivelling
and
THE INDIAN MEDICAL GAZETTE
268
puckering of the surface, which at the same time presented a dry aspect ; the occurrence of coarse folds of skin about the elbows and knees; the presence of fissures, more especially in the soles of the feet, and of various extent and
patches In
one
course
the occurrence of
or
two
cases
there
were
of the cutaneous nerves
discoloured
generally of a whitish hue. obvious thickenings along the
supplying
ancesthetic
areas.
In
marked enlargement of the inguinal glands. in most cases on both hands and feet, rarely situated ulcers, Open on the hands alone, but frequently on the feet alone, were present one case
there
was
Many of them were caused by injuries, and in " discharges, microscopic examination revealed no special cells or other morphological elements not common to any nonspecific ulcerating surface." In all but three cases there was loss of digits to a greater or less degree. " The blood of the patients was microscopically examined in 28 cases. In 17 of these it was to all appearance perfectly normal, in the remaining 11 it was characterised in five instances by a greater or less excess of normal white corpuscles and bioplastic fragments of small size, in three by such excess combine^ with a softened gelatinous condition of the red corpuscles causing them to adhere in irregular masses, and in three by the latter phenomenon alone. In two, specimens of blood could only be with difficulty obtained from the hands. One of these was a case in which the characters of the specimen were normal; the one in which the red corpuscles were softened. other, * As regards the initial symptoms of this variety (ansesthetic) of leprosy, Drs. Lewis and Cunningham state that " the commonest symptom attracting attention to the commencement of the disease is an eruption of some form, such having occurred, it is affirmed, in 31 of the 49 cases." Dr. Vandyke Carter t'ells us that in 137 cases of ancesthetic leprosy, 22 of them state that it commenced with an eruption and then neuritis followed ; 68, or one-half of the whole, referred it to vesicles or blebs, abscess or sore, and 35 to nerve symptoms from the first, such as heat, pain, tingling, numbness, &c. Of the tubercular form of leprosy there were 12 cases in the Asylum, or 15-0 per cent, of the total cases in which nodular appearances were by far the most prominent features of the disease. In all, the face and ears were the seats of tubercular deposit, and in five cases it was limited to these parts; in two the tongue was greatly invaded; in one the deposit was generally diffused over the body, and in one it was chiefly confined to the extremities. In some cases the deposit in the face and ears " was diffused, causing general thickening over wide areas, in others it occurred as isolated, sharply-defined, prominent nodules. The sites of chief deposit were those well known as those specially selected in the disease?the malar prominences, eyebrows, nose and ears. In some cases there were prominent tubercles on the upper eyelids, which added considerably to the deformity, due to the general thickening of the tissues and the forehead between the various areas coarse deep furrows on the of the deposit. The deposit when affecting the nose generally appeared to take origin around three centres, affecting the lip and in 35 cases.
their
"
alee
respectively.
This caused the formation of
irregular lobes,
advanced, ended in causing the nose to present a distinct trilobed extremity. The lobes of the ears were very greatly affected, becoming thickened, nodular and pendulous, whilst smaller masses of deposit caused irregular roughening and thickening along the rims." and when the condition was
In
only
one case
[Octobee 1, 1877. acute one of short
(an
thesia entirely absent; in the others more
"
les3 completely anaesthetic, but regions was much less common,
or
entire
duration) was anaesdeposit were general anaesthesia of complete, or extensive
the areas of
than in the form of the disease first described." there were open ulcer3
In five cases
hands, and in one there was a large on the right cheek. surface In one the tongue ulcerating was ulcerated, and in five cases the extremities were quite unaffected by ulceration, distortion, or absorptive changes of any kind. Pain was complained of in only one case, and was limited to the dorsum of the right foot, extending from a distorted and swollen fourth toe to the inner side of the ankle joint. The blood was examined microscopically in ten of the twelve cases. In eight of these the number of white corpuscles present in the specimens was excessive. In some this excess was very strongly marked, and the normal white corpuscles were accompanied by an abundance of smaller bioplastic fragments. In two cases, the only abnormal feature present was a soft and adhesive condition of the red corpuscles,?a condition which also occurred along with the excess of white corpuscles in one of the other * * * cases. In eleven cases a history of the initial symptoms of the disease was obtained. In seven the occurrence of patches of eruption is stated to have been the first symptom ; in one cracking of theskin of the heels followed by eruption; in twocracking on
feet
or
"
of the skin of the feet; in
one a
similar affection of the skin over
generally diffused pain in the Here, as in the case of the anaesthetic form of the disease, eruption seems to have been the most common [initial symptom." Dr. Vandyke Carter tells us that in 36 instances, or nearly one-third of the whole number he inspected, "tubercular leprosy began with symptoms of nerve disease, and this estimate may be below the truth. It commonly begins with an eruption of reddish spots on the face, hands, feet or trunk; also with swellings (the so-called 'tubercles'), bronzing or desquamation, which are all somethe ankle
joints
joints
;
in
and
one
of the extremities.
times attended with fever."
Age.?Of the 49 cases of anaesthetic leprosy Drs. Lewis and Cunningham found the average age of attack to be 26*18, and of the 11 cases of tubercular leprosy 18'90 years. The earliest date of attack was 9 years and the latest 30. Dr. Vandyke Carter writes:?" I have never met with leprosy in an infant, nor have I seen it in children under the age of 5. My tables show that 16'7 per cent, of lepers (girls proportionally oftenest) date their malady from childhood, in the more infested districts (specially coast): whilst elsewhere, about 9 per cent. : and that 39 per cent, acquire it between 16 and 30 years coast.ward, 45 per cent, inland ; where also 14 per cent, date the complaiut ^5 years, but only 11'8 per cent, in the infested coast areas. The instances of later origin I find to be chiefly of the form of anaesthetic leprosy, and some are possibly instances of simple neuritis. In both sexes tubercular leprosy commences at an earlier age than the anaesthetic form, yet this rule does not hold
good
for
Norway." of the disease
Duration
that,in
of attack until the years.
?Drs. Lewis and Cunningham inform
us
the anaesthetic form, the duration of disease, from the date
period
of examination,
ranged
The duration of sixteen was under 10
from 1 to 40
^ears,
of fifteen
between 10 and 20 years, of sixteen between 20 and 30 years, of In those cases of the tuberone 32 years, and of one 40 years. cular form the duration of the disease varied from 1 to 14 years,
Octobee
LEPEOSY IN INDIA.
1,1877.]
269
whilst men curiously name also their Of the cases eight had paternal grand-father, average of 8-27 for all cases. as being lepers, no woman naming father mother and mother's lasted for a period of under 10 years, and three for periods is taint Collateral given by 10 per cent, of males and between 10 and 20 years. Dr. Carter writes:?"I have no either. is it through paternal uncle, but 9 of females: chiefly cent, per data for ascertaining the mean duration of leprosy in Kattiawar, : one man names his mother s sister named also sister is father's as is it here as that but infer prolonged elsewhere, and may cent, of males, and 13 per cent, of xtend from 6 or 8 years for the tubercular form, and to 15 or as being affected. Eleven per and sisters. Altogether about * brothers females had * * leprous 20 years for anaesthetic leprosy. It appears direct or collateral taint, and that the mortality in asylums of tubercular leprosy is about 30 per cent, of all lepers have some Eleven per cent, have a brother * * * double that of anaesthetic. The mean age about 70 per cent, have none. evidence of a family taint. or other sister no but of lepers at death is, in Norway about 42 years, in the West leprous, in tubercular Indies about 32 years, and in Bombay about 37 ; those affected Hereditary taint proper is more strongly marked with tubercular leprosy dying at 32 '2, and those having anes- than in anaesthetic leprosy, viz., as 37 : 23 3 per cent. Drs. Lewis and Cunningham show clearly in their tables that thetic leprosy at about 50 years." have comparatively small families, and that amongst the lepers Sexes,?Of the 49 cases of anaesthetic leprosy which Drs. Lewis and Cunningham examined, 24 were females, and of the children there is a very high rate of mortality. It also appears 12 cases of tubercular leprosy 2 were females. Dr. Carter that the male leper is credited with a smaller number of children than the female leper, the absolute numbers in the Almorah Asy" as regards sex in the mild or severe forms of says that, disease, I find that of the former (anaesthetic), women are one-third of lum being 27 and 76 respectively, and the averages of children to families being 1'08 for the male lepers and 2-8 for the female the whole instances seen in and form with
an
Kattiawar, they only oneSo far as the evidence goes, the total number contributlepers. leprosy." to the ed population by the female lepers is about 70 per centHereditary Influences.?In the Asylum at Almorah Drs. Lewis the males. As a set-off to and Cunningham found that out of 80 lepers present, 28 or 35 in excess of that contributed by that 24 per cent, more of about table shows the Four had both this, however, per cent, had one or more leprous relatives. died to female than of the children born children the lepers parents affected, three the father, ten the mother, thirteen the Dr. Vandyke Carter's investigations do to male lepers." born the five the and two seven had other sisters, son, brothers, relations, as mother's brother, or father's brother, or sister's not bear out this observation, and the error probably arises from child, affected with leprosy. Many of the inmates, however, the number of cases examined into being too few on both sides. He says:?" 182 married of either sex had 430 children, or a had not for some years past heard anything of the indivimean of 2 4 children to each marriage, but if infertile marriages dual histories of the various members of their families. The figures seem to indicate that there is a strongly marked ten- be excluded there are nearly 3 children to one marriage?when is the leper the number of children is under this dency in the disease to follow the female line of descent. the female parent and vice versa, when the male." * * * Sixty-six married males, mean, all the cases in which parents Taking affected with tubercular leprosy, had 148 children (mean 2-24), or 10 cases parents' relatives are affected, we find fifth of all
"
of tubercular
cases
"
in which the father which the disease
or
was
father's relatives
present
on
are
leprous,
and 17 in
the maternal side."
Dr.
question of hereditary transmisjustice in these few pages, but on the whole the observations of Drs. Lewis and Cunningham are not corroborated by him. To a certain degree Dr. Carter believes in the contagiousness of leprosy, and it is difficult to eliminate this point when a number of lepers in one family Carter enters
so
fully
into the
sion that we cannot do him
the 106 males and 22 present themselves for examination. Of females examined by him in Kattiawar and affected with tuber-
leprosy, he found that in 19 per cent, of the males and 50 of the females there was taint in the direct or parental cent, per line?that through the father (most) and paternal grand-father cular
amounting to 15 per cent, of male, and 32 per cent, of female: leper-men had mother lepers in 4 per cent, of the whole, and kper-women had leper-mothers in 14 per cent. Ten per cent, of males and 22 per cent, of females showed taint in the collateral aunts : the father's brother is oftenest tho
line of uncles and
leper relative (8 and 18 per cent, respectively for males and females) ; the mother's brother is proportionally named oftener by women than by men. Of co-equal taint?brothers and sisters lepers?11 per cent, of males named a brother, 1 per cent, 9 per cent of the females had a leper brother, a sister leprous : and none of the 22 had a leper sister. Of the 133 cases of anaesthetic leprosy examined by Dr. Carter 14 per cent, of males and "
12 per cenf.
Hero,
too, fathers
of females showed are
oftenest
taint in the direct line.
named,
and
by
women
the
and 13 married females affected with the same form had 28 children (mean 2-15). In the instances of anassthetic leprosy 70 married males had 187 children (mean 2 67) and 33 married
females had 67 children (mean 2'03). Dr. Carter saysUnproductive marriages are twice as frequent in tubercular as in anaesthetic leprosy : thus amongst leper fathers with anaesthetic leprosy in
a
ratio of 1: 12 was
marriage infertile, and with tubercular leprosy 1:6; amongst leper mothers with anaesthetic leprosy the ratio was 1 : 8, and with tubercular leprosy 1 : 4 ; so that tubercular leprosy, not only disqualifies for marriage, but has a tendency to render marriage infertile, and that most in women." Contagion.? Under this heading we have no trustworthy evidence. Drs. Lewis and Cunningham inform us that " the history of the Asylum (at Almorah) gives no support to the doctrine that leprosy is a contagious disease, but strong evidence to the con* * * We have no satisfactory evidence of trary. contagion and none of a rapid increase of cases due to hereditary influences." Dr. Carter, as a result of his investigation in Kattiawar, is inclined to believe that leprosy is somewhat contagious. He writes
:
?
myself, all these data may be said to point to transmission of the leprous disease by means of human intercourse." He does not bring forward any proof of the disease being so " propagated, but bases his view upon the fact that he found no' on the contrary, that all such leper village to be isolated, but, villages are connected with others immediately adjoining?the rare unaffected spots intervening, being temporary or incidental "For
THE INDIAN MEDICAL GAZETTE.
270
In another place he writes :?" My present exceptions." analysis of leper-localities in Kattiawar deserves particular notice, both in itself and as a datura to be further tested ; for regarded broadly, the peculiarly close connection and serial to some sequence of leper-villages moat obviously points method of transmission, and so far as has happened to me, there is no other agency at work than man and the surroundings he acquires." Occupation and Caste.?In the Asylum at Almorah of 72 cases of leprosy, 39 were Domes, 30 Rajputs, 1 Brahmin, 1 Buniab, and 1 Christian. Drs. Lewis and Cunningham write :?" As the inhabitants of Kumaun virtually consist of two classes only? Rajputs and Domes, the former representing an Aryan population, the latter the aboriginal people, whilst other classes are only very sparingly represented?the evidence, such as it is, is in favour of impartial distribution of the disease." Dr. "Vandyke Carter writes :?With reference to the influence of occupation in inducing the leprous disease, I have not detected any new * * * facts. In elucidation of the prime datum that leprosy first manifests itself upon exposed or unprotected integument? notably the face, ears, and limbs?nothing has suggested itself beyond the idea that hard manual or foot-work, constant contact with vegetation products and soil, pure and impure, contact with skin and excreta of ill-fed domestic animals, and incessant exposure to heat and dust, may be both predisposing causes and actual media for the conveyance of disease germs. The latter, if there be such, are an independent agency; and assuredly the hardest labour will not
produce neuritis?certainly not specific neuritis?without the super-addition of some sort of essential jnfluence. What this is can be ascertained Only by inspiration, untried. or by close enquiry on the spot?means yet failing or The occupation of fishing has no part in the production of As regards caste he writes:?"Whilst Kattiawar leprosy." leprosy attacks all castes and races, it yet probably does not attack them proportionately to their respective populations, preferring rather certain groups, large or small, in certain areas; and this doubtless in accordance with local events, which would have to be specially searched out." We now come to the
important question of segregation or lepers ? Drs. Lewis and Cunningham condcmn legal restraint or lepers' prisons. They are convinced that such, besides being tyrannical, could hardly be looked forward to as an efficient or practicable means of diminishing the prevalence of leprosy. " It would not be sufficient merely to confine those suffering from developed disease, but all those ?who might in any degree be supposed to be hereditarily disposed towards it, would also have to be secured. It would, in truth, be even more important to secure the latter, for, from the present evidence, there appears to be only a very small But had all number of children born to confirmed lepers. those predisposed to be secured, how and by whom could the what
can
be done for the
predisposition be determined? In the case of hereditary predisposition, it is quite uncertain for how long? for how many generations?the disposition may be transmitted existence
of
without giving any ostensible sign of its presence, but capable under certain circumstances of giving origin to the development of the disease. How, then, is the absence or disappearance
of
They
predisposition
to be determined ?"
advocate the estal I shment of free, charitable
wherever
practicable.
asylums
"iSuch institutions are, beyond doubt,
[October 1,
1877,
calculated to do very great good, and deserve all support and encouragement, so long as such support does not relieve the relatives of the diseased from the performance of their duties to the sick?so an
long
as
their existence does not afford
encouragement to people to profit by the misfortune of their
relatives at the expense of the community." Dr. Vandyke Carter, on the other hand, entertains the view-
segregation of the lepers would after generations be followed, if not by a total disappearance of the disease, at least by a diminution to a very small ratio. He, therefore, advocates legal enactments and compulsory imprisonment of lepers in asylums. He writes:?"The fir-^ consideration I take to be, separation of the infested from the healthy; and to a certain extent this might be done at home were distinct orders issued on the subject. Thus, it should be made incumbent on those families, who, being in fair circumstances, desire to keep their lepers with them, that these sick be altogether separately lodged, having had board and clothing quite apart,?the object being to isolate them as far as is possible. Too often, however, such regulations would be futile, on account of the poverty of the sufferer and his connections, who would not be able to provide the required that absolute and entire
a
few
I do not suppose that any other obstacle than expense would arise in attempting to enforce this isolation of the sick at their own homes, but even this
separate accommodation.
tolerant measure, when practicable, would need to bo maintained
by authority; and such being the case?namely, that legal provision is necessary?it becomes a question if it were not better at once to deal with the subject comprehensively. Two main objects being understood to be the protection of the community and the due care of the sick?objects which in practice become unique?I would suggest, first, that a convenient refuge be offered to all vagrant lepers, whose further wanderings should then be interdicted ; next, that a similar asylum be opened to the poorer classes of the peasantry, whose compliance with the wishes of the State is to be insisted upon; and, thirdly, that those persons who are willing to provide separate maintenance for their leprous sick should be permitted to do so only upon the condition that the isolation proposed be practically an efficient one. Segregation of the sick becomes an inevitable resultant, because it would be impossible to furnish individual separation for all; and hence a common Home for the large majority of lepers would be required." In a limited paper of this sort it is not possible for us to do justice to the authors of the excellent essays before us, so we must refer our readers to the reports themselves, and we promise they will well repay perusal.
