California gional cility LIBRARY California' IViNF Sanitation in California. 155 carefully guarded against debasing influences. The public look to the medicaP^orofession for the conservation of their health interests, and it is^especially our fault if they go wrong or fall short of due measure I desire to state here^fchat one of my colleagues on this com- mittee, as well as in the S^ate Board of Health, suggests the utility of sanitary conventionsVto be held under the auspices of the State Board of Health. The\object is to arouse, in various parts of the State, an interest in\public hygiene among all classes of people. Such conventions have been held inN^ichigan, Ohio, Penn- sylvania, Kansas and other States, and "the proceedings, em- bodied in the reports of their State Boards 6 Health, indicate good work in the character of the papers read and the discus- sions upon them, and in the attendance upon the meetings. In my judgment this proposition is worth trial, and "I hope and believe that useful results would follow. _LEPROSY_ ITS EXTENT AND CONTROL, ORIGIN AND GEOGRAPHICAL DISTRIBUTION. By H. S. ORME, M. D., Los Angeles. The origin of leprosy, like the source of other specific mala- dies, is totally unknown. In its present form it has certainly prevailed for thousands of years long anterior to the dawn of authentic history. The earliest description of the disease was written by the Hindoo Atreya, who is supposed to have lived 2000 years B. G., but it is so vague and the symptoms so varia- ble that he may have included several different affections under the common term Kushta, as he attributed most of the morbid appearance to wind. Whatever this may mean, it is evident that both causes and symptoms were then very imperfectly under- stood. The same vagueness is found in the description of (sar- aath by Moses in Leviticus, and the fact that both considered certain forms curable indicates that several distinct pathological conditions were included under one term. Moses probably made no distinction between true leprosy and certain macular and scaly eruptions, since the weekly inspection of suspected casea would have no significance in leprosy, and the ceremonial observances of cleansing would be useless in this affection. All this is not strange when we consider that medical writers, until nearly the middle of the present century, made no clear distinc- tion between typhus and typhoid fevers; and that, until the middle of the 18th century, both measles and scarlatina were included under the common term morbilli; while the Arabian physicians some centuries earlier classed small-pox in the same category with the other two. We shall see later on that some individuals of our day regard leprosy and syphilis as variations of the same disease. It is probable that leprosy, as we now understand it, has not been absent from the most ancient seats of civilization, China, India and Egypt, since some undefinable period in the childhood of our race. Whether in these countries it was more or less Leprosy. 157 prevalent in remote ages than now, can only be conjectured; but its history in Europe during the Christian era is so well known that we are certain of its general ravages from the 12th to the 15th centuries, when it is estimated that there were as many as 1900 lazarettos devoted to the treatment of lepers at one time in the various countries of Europe. These establishments were instituted in France in the 8th century; in Ireland about the middle of the 8th; in Spain, at the beginning of the llth; in England, during the llth; in Scotland, and the Netherlands, during the 12th; and in the following century in Norway (1266). There is evidence of civil regulations touching lepers in Lom- bardy as early as the year 643, and in France in 757. The Church Council at Orleans in 549 imposed the care of lepers on the Gallic bishops, and this was confirmed by one held at Lyons in 583. Dr. Erasmus Wilson avers that it had reached En- gland in the 6th century. It seems strange that leper hospitals should not have been established there for four centuries. Since the beginning of the 16th century it has declined, and at the present time has mostly disappeared in that part of the world. Its introduction to Europe has been variously attribu- ted to the arrival of the Roman legions from Eastern conquests and the return of the Crusaders in the llth and 12th centuries. It is more than probable that leprosy had gained a foothold before the Christian era, that the returning Crusaders intro- duced it afresh and spread it over the land. The world's medi- cal history during the intervening ages is exceedingly scanty and vague. At the present time it lingers in some parts of Europe far separated from each other and nowhere in threatening propor- tions. In Spain, in the lazaretto, at Granada, there were 53 cases in 1860. Within the present decade there has been a much smaller number in a lazaretto at Barcelona. There are no legal restrictions on lepers in Spain, but it is probable that social ostracism here, as in most parts of the world, drives them as outcasts into seclusion, and it is also probable that many small groups of lepers remain undiscovered or unmen- tioned in various obscure communities.* *Sir Morell ]Y1 ackenzie, in a recent article on "The Dreadful Revival of Leprosy," sounds a loud warning note, and declares that unless prompt measures are taken, we have every prospect of seeing a great spread of this full disease through the countries which are to-day comparatively free. The contagiousness of leprosy he considers beyond question. Ind. Med. Jour 158 Leprosy. The history of leprosy in the Sandwich Islands is of surpass- ing interest, owing to its dreadful ravages and the recent date of its recognized appearance. Its introduction has generally been charged to Chinese immigrants or coolies, and this notion is connected with the vernacular term, "mai pake," Chinese sickness. The common agreement is that leprosy bad not made much headway previous to 1860. Dr. Hillebrand avers that it was brought by the Chinese in 1848. Dr. Saxe states: "Leprosy was unknown to the natives until 1848, when it was introduced by the Chinese, and Ahai, a Chinaman was the first leper recognized by the Hawaiian Board of Health." Dr. Emerson, President of the Board of Health of the Hawaiian Kingdom, says in his report for 1888: "Leprosy was first clearly made out to exist in this country about the year 1840 in the person of one Naea, a messenger of the chiefs, who died in 1852. The friends of Naea thought he had the disease for about ten years before his death. His case was reported by the Rev. D. D. Baldwin, M. D., of Lahaina, in a communica- tion to the Minister of the Interior, Hon. Chas. G. Hopkins, dated May 26th, 1864. In 1863, Dr. Baldwin obtained by reports from the deacons of his Church at Lahaina, the names of sixty people who were supposed to be affected with the dis- ease." Since the discovery of the Sandwich Islands in 1778, they have often been visited by ships manned by sailors from regions of the world where leprosy constantly prevails, and leprous sailors might have planted the disease by cohabitation with the native women. Besides, large numbers of Hawaiian seamen have sailed to all the shores of the Pacific and Indian Oceans, and they could easily have contracted it by intercourse with lepers abroad, and afterwards have communicated it to their countrymen at home. One indication that leprosy is not an ancient occupant of these islands, is the fact that the majority of the cases are of the tubercular form, and formerly the preponderance was still more marked; while in India and China, where it has existed many centuries, the anaesthetic type is the prevailing one. In 1886, of 652 cases at the Molokai settlement, 333 were classed as tubercular, 204 as anaesthetic and 115 as mixed. Leper population March 31, 1888, at Molokai, males 495, females 254, total 749. Leprosy. 159 By 1864, leprosy had increased among the natives to such an t extent that the authorities and people of intelligence became alarmed, and in 1865 a law was enacted providing for the isola- tion of all lepers. There has always been great difficulty in its execution,' not from open resistance, but from the hiding and secretion of lepers. Several characteristics, on the amiable side of human nature, obtain to excess among these simple people, which promotes in the highest degree the spread of contagious diseases, Christianity and civilization have failed to eradicate the indis- criminate sexual relations which have always existed, and inter- course with foreign ships' crews since 1779, the date of Capt. Cook's arrival, has saturated the population with venereal diseases, so that a great many of the people of both sexes are believed to be subjects of syphilis, either inherited or acquired. Again, these people are the most friendly and sociable creatures in the world, both with strangers and each other. Persons suffering with the most loathsome diseases are not to them objects of abhorrence, but rather of benevolent attention. In their homes and in their social relations they observe the closest habits of affectionate intercourse, eating from the fingers from a common dish, passing the pipe from one mouth to another, and sleeping together indiscriminately in their small, close habita- tions. The race distribution of leprosy in these islands is strik- ing. Nearly 90 per cent of the known cases have been among the native race. Though the Chinese are accused of introducing the disease, they have contributed very few to the leper popula- tion; and the President of the Board of Health in 1886 asserted that he had not known of an imported Chinese leper since the enactment of the anti-leprosy law. The unexampled spread of leprosy in these islands after 1870 may be attributed to several causes. There can be no doubt that the lowering of the vital stamina of the race by the great prevalence of syphilis, prepared them for the inroads of any disease that might threaten. During this period small-pox also scourged the people, and in 1868 there began a general vaccina- tion in which virus was taken indiscriminately from human sub- jects. This reckless practice doubtless contributed greatly to the spread of both syphilis and leprosy. 160 Leprosy. TABLE OP LEPERS AT THE MOLOKAI SETTLEMENT, HAWAIIAN ISLANDS 18661886. YEAR. LEPERS REC'D. PRESENT JAN. 1. Q 9 3 DISCHARGED. 3 . a SS 3~ < NATIONALITIES. M. 103 57 76 73 31 128 69 295 53 128 57 110 136 82 34 156 53 185 71 75 16 F. TOTAL. HA- WAI. WHITE CHI- NESE. OTH- ERS. 1866.. 1867 .... 1868.... 1869.... 1870.... 1871.... 1872.... 1873.... 1874.... 1875.... 1876.... 1877.... 1878.... 1879.... 1880.... 1881 .... 1882.... 1883.... 1884.... 1885.... 1886. 38 13 39 53 26 55 36 192 38 84 39 53 103 43 17 76 18 116 37 28 7 141 70 115 126 57 183 105 487 91 212 96 163 239 125 51 232 71 301 108 103 23 26 25 28 59 58 51 64 156 161 163 122 129 147 209 152 132 121 150 168 142 20 10 7 2 11 4 9 4 21 8 14 3 1 .... 10 is 10 7 25 139 68 113 126 57 183 105 483 90 207 95 162 238 123 50 229 68 300 99 99 2 105 143 228 284 279 402 439 749 671 706 677 710 802 717 606 706 643 784 717 653 1 1 1 1 6 5 8 14 8 16 5 13 27 37 41 51 60 149 93 96 23 3 1 1 3 1 1 1 1 1 1 1 2 1 1 1 2 1 6 3 2 1 1 Of the above there were : Full blooded Hawaiians 2,997 Mixed Hawaiians 37 Chinese 22 Whites 16 Other Nationalities 4 Male Hawaiians 1,903 Female Hawaiiaus 1,094 Dr. N. B. Emerson, President of the Board of Health, reported the inmates at the Molokai settlement present January 15, 1889, as follows: Males over 10 years of age 651 Males under 10 years of age 15 Females over 10 years of age 360 Females under 10 years of age 10 Total 1,036 Of the above there are eight Chinese and eight or ten whites (American, English, German, French, etc.). The number of lepers still at large is small and rapidly diminishing. March 31, 1888, they were estimated to be altogether 644. Leprosy. 161 There is no apparent reason J,o suppose that leprosy existed in any part of the New World prior to its discovery by Colum- bus. At that date it prevailed throughout Europe, and followed the tide of immigration. Whether it was introduced independ- ently from Africa is conjectural, but it has certainly been found more among people of the African race than among all others in America. Their habits of life have always favored the pro- pagation of spreading diseases, and leprosy has ever found its victims chiefly among people and^individuals who live in closest social relations. With the advance of civilization, the enlarge- ment of habitations, abundance of clean garments and beds, and the use of separate table utensils, the disease has declined and nearly disappeared from the civilized world. In British Guiana leprosy is supposed to have come with African slaves. Negro lepers were isolated, and the disease was confined to them. In 1831, they numbered 431, and were then sent to a special establishment on the river Pomeroon. Near by were several Indian tribes, all of which withdrew except the Warrows, who associated with the lepers. In 1842, a census was taken of the Indians, and many lepers were found, but all were Warrows. In 1838 came emancipation, followed by the dispersion of the negroes and the introduction of coolies from India and China, some of whom were probably lepers. Now 2 in 1,000 of the population are lepers, including whites, negroes, Indians, coolies and the mixed races. (Pacif. M. and S. Jour., Jan., 1887.) There is good reason to believe that leprosy ap- peared in the West India Islands not long after their settlement by Europeans. Dr. Hans Sloan, who was in Jamaica in 1687, mentions a case and describes native plants used in the treat- ment of the disease. (Prof. Jones in N. 0. Med. & Surq. Jour., March, 1878.) In Jamaica at present there are said to be 700 or 800 lepers, negroes and mulattoes. In Barbadoes it is thought that the increase of lepers is four times as rapid as that of the population. On the Island of Trinidad, according to Dr. W. H. Park, there were three lepers in 1805; and in 1878 about 860. In the Brit- ish West Indies, as in most of the other British Colonies, there is no isolation of lepers. It is quite probable that leprosy exists on most, if not all, the other West India Islands , but its extent is unknown. In the American Colonies of the Netherlands lepers are 162 Leprosy. strictly segregated in Government asylums. The one in Suri- nam has 102 inmates, of whom, in 1883, 37 were Europeans, 56 natives and 9 immigrants from British India. In 1884, the asy- lum in Curacon contained 13 inmates; that in St. Martin 10; and that in St. Eustatius 19. Their isolation results from gen- eral belief in these colonies of the contagiousness of leprosy, which belief is not entertained in East Indian Colonies. I have no precise information upon leprosy in other South American States, except a denial of its existence in Chili to the inquiry of the Hawaiian Government. It is said to exist in Bra- zil, and probably is absent from few, if any, of those countries. Dr. Miguel Valladores, Physician to the lazaretto of Guate- mala, reports to the Hawaiian Government that leprosy is almost unknown among the aboriginal Indians of pure race. His patients have all been of mixed Spanish and Indian blood. He states that lepers are strictly segregated, and that he had under his care 9 men and 6 women. Isolation has only lately been put in force. Previously leprosy was on the increase. The Hawaiian Consul remarks: "Well-to-do families contrive to secrete an afflicted member of the family in some remote place; this is to my personal knowledge." I have no doubt that the practice of secreting lepers is general throughout the world, wherever the disease prevails, and it is not difficult in an early stage, for lepers to evade the authorities and go about their usual business. I have no particulars from other Central American States, but am disposed to believe that occasional cases of this disease might readily be found among the lowest class of people. Dr. Gomez, Director of the Lazar Department, Juarez Hos- pital, Mexico, reports that leprosy, called " Mai de San Lazaro," exists principally in the western regions of the Republic. Dur- ing his 13 years' service he has had no negroes under his charge, but observes no other race preferences. The disease has been known in Mexico since the conquest, and Cortez founded a lazaret. At the present time lepers in the city of Mexico are admitted to separate wards in a civil hospi- tal for each sex. The average number of patients is 30. The Su- perior Council of Health reported in 1886, that leprosy in Mexi- co existed prior to the conquest. There have been no special leper hospitals for more than 20 years, but the lepers are received in civil hospitals throughout the country. In early times seg- Leprosy. 163 regation in special hospitals was practiced. It is the belief of the Council that leprosy has decreased in Mexico in the last 75 years, but the fact is not accounted for. As to its ancient prevalence may not early observance have confounded true leprosy with elephantiasis Arabum, or Barbadoes leg? Sporadic cases of leprosy have been recognized in British Columbia within a few years. The most notable focus of the malady at present on this continent is at Tracadie, N. B., in that portion bordering on the Bay of Chaleurs and river of St. Law- rence. Its origin is not precisely known. Dr. W. H. Park states that it began with a woman named Ursale Landry in 1819. Prof. J. C. White (Am. J. Med. Sci., Oct., 1882) refers its source in 1815, to a woman named Benoit, whose mother came from Normandy. As no preventive measures were used, it gradually spread among different families, but mostly among the descend- ants of the first case. The first leper hospital was established in 1844, and 32 cases were received within five years. The hos- pital at Tracadie was founded in 1849, and between this date and 1882 more than 100 patients were received. None are admitted during the first year of the affliction, and very few defore the third year. Belief in its contagiousness is general among the people, and plainly recognized lepers are impelled by social ostracism to go into retirement. Nearly all the cases have been of French descent. So far no Indian has fallen a victim. The following table exhibits the vital movement for the period 1875-85: TABLE OF LEPERS IN THE PROVINCE OF NEW BRUNSWICK. 1875-1885. YEAE. IN LAZAKET. M. F. OUTSIDE. M. F. TOTAL. M. F. NKW CASES. M. F. DIED. M. F. TOTAL. 1875 13 10 6 9 8 6 8 11 10 10 11 7 5 8 8 7 9 13 14 12 11 10 6 7 7 5 4 5 5 4 4 3 2 10 12 9 7 8 8 3 1 1 1 1 20 17 13 14 12 11 13 15 14 13 13 16 17 17 15 15 17 16 15 13 12 11 1 1 2 2 1 1 2 2 1 2 1 2 2 2 2 3 6 1 3 2 2 1 3 2 i 1 2 1 1 36 34 30 29 27 28 29 30 27 25 24 1876 1877 1878 1879 1880 1881 1882 1883 1 1 1884 1885 Dr. A. C. Smith, physician in charge in December, 1889, re- ported 20 inmates, 9 males and 11 females. Two were admitted 164 Leprosy. during the year, in which time there were no deaths. In Sep- tember, 1889, he reported about 18 lepers in Tracadie. It thus appears that the disease has steadily diminished since the plan of isolation was established, the apparent increase being ac- countable by discovery of cases previously concealed or not recognized. As will be seen hereafter, there have been some desertions . Prof. White gives a group of 11 cases of leprosy, which were traced out in the Island of Cape Breton, six of whom consisted of a woman and her five children. There was also a son-in-law and two children, and another son-in-1 aw whose wife was not a leper, but he used to sleep with one of his leper brothers-in- law. The other case waited on one of the sons and washed and laid him out after death. The first case became affected in 1852 and the last in 1870. All were dead before 1882, except the last, and he was far ad- vanced. It is worthy of notice that the mother of these chil- dren and first of the group was born on Prince Edward's Island in 1836, which island is not far from the New Brunswick seat of leprosy. Somewhat more than 25 years ago the discovery was made of the existence of leprosy among immigrants from Norway in sev- eral of the new Northwestern States of the Union. From that time to the present scattering cases have occurred, but the dis- ease shows no tendency to spread. It is easy to trace direct connection between them and the leprous population of West- ern Norway. In 1863 Dr. Holmboe, of Norway, visited his countrymen in those States and found 12 lepers among them, most of them diseased before emigrating. In no case had a native child of this country veloped the disease, and it was observed to pur- sue a milder and more prolonged course in this country than in Norway. (Prof. J. C. White in Am. J. M. Sci., Oct., 1882.) It has been asserted that Norwegian lepers have been advised at home to emigrate to this country, for the benefit of their health. In 1869-70 Prof. Wm. Boeck, Christiana, visited the N. W. States, and found 18 cases in Wisconsin, Iowa and Minnesota, all from Western Norway. Of these 9 were of the anaesthetic type, 3 tubercular, and 6 mixed. Four of them knew of no leprous relatives. (Report Minn. Board of Health, 1884-) Up to 1879 26 cases had been reported in Wisconsin, Iowa, Min- nesota and Nebraska among Norwegian and Swedish immigrants. Leprosy. 165 A child of a leprous father born in this country, was reported by Dr. Hyde in 1879, the only native leper of this group. (Dr. J. L. Babcock, N. Y. Med. Pec., Sept. 15, 1888.) In 1886, Dr. K. Hoegk. member of the Wisconsin State Board of Health, as the result of his investigation, stated his opinion that at least 160 Norwegian lepers (probably more) had come to this country since 1858. Norwegian records contain the names of 68. Many developed the disease after arrival, and some doubtless escaped notice. In 1886 he knew of three cases in that State. The State Board of Health of Minnesota in Oct., 1889, re- ported to me 7 cases known in the State. Only one was isolated. All the others were able to attend to their usual business. All were Norwegians and males, 35 to 73 years old, and affected with leprosy from 11 to 29 years. Five of them had developed before emigration to this country. Two of them have healthy children. The others have no living children. Between 1868 and 1889 there had been 19 deaths. Dr. G. A. Hansen, Surgeon of the Bergen (Norway) Leper Hospital, in a recent visit to the Northwestern States, estimates that there were only 16 or 17 lepers then alive. (Occi. Med. T., August, 1889.) In a book entitled "Concise Natural History of East and West Florida," published at New York in 1775 and quoted by Prof. Joseph Jones, of New Orleans, is found a description of a disease then prevailing among the negroes which was probably leprosy. The evidence that the malady then prevailed in the Spanish Province of Louisiana is stronger. Gayarre, in his history of Louisiana, volume 3, page 167, says: "One of the first measures of Miro's administration was one of charity. It is remarkable that leprosy, which is now so rare a disease, was then not an uncommon affliction in Louisiana. Those who were attacked with this loathsome infirmity ge,, > fee-ally congre- gated about New Orleans, where they obtained more abundant alms than in any other parts of the Colony. They naturally were objects of disgust and fear, and the unrestrained inter- course which they were permitted to have with the rest of the population was calculated to propagate the distemper. Ullon (whose administration began in 1766) had attempted to stop this evil by confining some of the lepers at the Belize (mouth of the Mississippi river), but this measure has created great dis- comfort and has been abandoned. Miro now determined to act with more efficacy in this matter, and on his recommendation 12 166 Leprosy. the cabildo, or council, caused a hospital to be erected for the reception of these unfortunate beings in the rear of the city. In the course of a few years the number of these patients gradually diminished either by death or transportation, the disease dis- appeared almost entirely, and the hospital went into decay." From this time leprosy appears to have attracted no public at- tention in Louisiana until about 1879, when the State Medical Society undertook its investigation. At that date Dr. Salomon had discovered six cases in New Orleans, and six more were re- ported in Vermillion Parish, near the Gulf of Mexico. This last group originated with a woman born in Louisiana, whose father came from the South of France. It does not appear that he was a leper, nor is there evidence of leprosy in the previous history of the family. The woman developed the malady in 1866 and died in 1870. In 1880, Prof. Joseph Jones, then President of the State Board of Health of Louisiana, visited the parish of La Fourche and there found another group of twelve cases. There was strong evidence that the disease had existed for sev- eral generations. These cases in the two country parishes (counties) were all French Creoles and of the humblest class of white people. It therefore appears that at least eighteen lepers were found in Louisiana in 1880, with a strong probability that a considerable additional number remained undiscovered. A report from the Louisiana Board of Health in May, 1889, gave twelve cases in the before mentioned parish of La Fourche, three positive and three doubtful cases at St. Martinsville, and forty-two known cases at New Orleans. It is remarked: " The cases in St. Martinsville are all descendants of one man, who died some years ago of leprosy, he having inherited the disease after it had skipped one generation. " The compiler of the accompanying table of cases in New Orleans, being the clinical lecturer on Dermatology at the Medical College and Polyclinic, and Dermatologist to two hos- pitals, has unusual opportunities for observation, of which he has fully availed himself. It is probable that hardly a case in that city has escaped his notice, and that the majority in the State have come under his eye. It is to be noted that only ten had relatives similarly affected, and Dr. Blanc remarks: "Some of the patients have had perfectly healthy children after the dis- ease began, but the rule seems to be in females for pregnancy to end in miscarriage, or in a weak, delicate child." To this it might be added that lepers generally lose the procreative f unc- Leprosy. 167 tion. It remains to say that there are no legal restrictions over lepers in Louisiana, and that they are received into the New Orleans Charity Hospital, and placed in the ordinary surgical wards with other patients. This practice, however, has not the approval of medical men, but is adopted for want of other provision. TABLE OF LEPERS IN NEW ORLEANS, 1889 DR. H. W. BLANC. i o a a < NATIVITY. COLOR. X K CO VARIETY NATIVITY OF PARENTS. DURA- TION. RELATIVES WITH LEPROSY. 1 60 Germany w f Anaes. Germany 1 year 2 16 35 New Orleans Germany w \v in f Tub. M. A. Germany 2 years 5 years 4 2 writers say from five to ten years, but it is often less. In the case of a man inoculated by Dr. Arning there were manifest symptoms of leprosy within three years, and the young man mentioned by Dr. Tache began to complain within a year but lived about eleven years. It is not improbable that there was a mistake in the period of incubation given for the first com- munication of the malady at the little village in Spain, pre- viously mentioned as only a few months; it might have been longer. Dr. Hansen mentions the case of a Hollander who became a leper ten years after his return from the West Indies. I have already mentioned a case in this paper in which the latent period was supposed to be forty years, but this seems incred- ible. As to sex, the common opinion is, that males are considerably in excess of females. This is probably correct, though females in the seclusion of home would be more apt to escape observa- tion. But it is plain that men and boys, being more away from home, in all sorts of company, would be more exposed to conta- gion. With heredity as the prevailing cause there should be no such marked sexual selection. It is agreed that the majority of cases begin between the ages of fifteen and forty years, which is the period of greatest activity and exposure. Under three years of age it is extremely rare. Dr. Fitch has not known a case before the commencement of second dentition, but Arning in the Sandwich Islands, and 13 182 Leprosy. Kynsey in Ceylon, have seen it at three years. Dr. Torrens has observed it in infancy in the Canary Islands, but the precise age is not given. We may safely conclude that there is always time for a reasonable incubation after exposure. The natural duration of leprosy varies with the type and cir- cumstances influencing progress. Lewis and Cunningham give the average duration of the tubercular form in India as six years shorter than that of the anaesthetic, and fourteen years for cases in general. Dr. Graham (Wood's Hand Book) states that leprosy usually proves fatal in seven or eight years. Danielson and Boeck, of Norway, give the average duration as eight or nine years for the tubercular type, and eighteen or nineteen for the anaesthetic, but sometimes prolonged to forty years. Dr. Arning in 1888 gave the duration from five to ten years, but Dr. Hillebrand whose experience in the islands dated fifteen years earlier, put it at three to five years. It is always under- stood that cases of mixed type have a progress slower than the tubercular and faster than the anaesthetic. The circumstances modifying leprosy are numerous and vary- ing in effect. Any causes which lower the standard of health, like previous sickness, deficiency or bad quality of food, expos- ure to bad weather, excessive exertion, sexual excesses; intem- perance, living in close and crowded apartments, deficiency of clothing for change, neglect of ablutions, all favor both the contraction and rapid progress of the disorder. Improvement in all these respects accounts for the development of new cases among Norwegian immigrants, and, with a single exception, of the exemption of their progeny in the United States. Admitting the contagiousness of leprosy, it is probable that it varies greatly in degree among different individuals and races, as is true of other diseases. Dr. Mouritz concludes that about eighteen per cent of the islanders resist contagion totally, judg- ing from his experience at the Molokai settlement. It is doubt- ful whether one per cent would resist intentional inoculation. Where the disease has prevailed for thousands of years, as in Egypt, India and China, and where the anaesthetic is the pre- vailing type, the principle of natural selection and survival of the fittest would gradually increase the resistance^of the people and in time those races might become exempt. In the absence of effective repressive measures, the population must otherwise have greatly diminished. The same seasoning for ages of the Leprosy. 183 natives of those countries likewise explains the protracted course of the disorder. Without such acquired resistance, and in the absence of repressive measures, its ravages would equal what was experienced in Europe in the twelfth, thirteenth and fourteenth centuries. Without apprehending a high degree of contagiousness for leprosy, or great risk in ordinary intercourse, it is clear that serious danger often lurks in unexpected quarters. Two priests and one physician, Dr. Edward Hoffman, undoubtedly con- tracted it on the islands, while pursuing their ordinary avoca- tions; also a priest at New Orleans. What might have hap- pened indeed may already have been incurred here in Califor- nia from the Marysville barber who continued to shave men's faces for years after he became a leper; from the San Francisco teamster who escaped and pursued his regular business more than two years; from a far advanced case lately found in a Chinese laundry at Sacramento; from an escaped leper sup- posed now to be engaged in fishing in the river, from two Chi- nese cooks and a Mexican dishwasher sent to the San Francisco Pest-house within the past year ! Probably not one of these individuals could point out the particular source of his own taint; more than possible other mysterious cases may follow them, like lengthened shadows to a hopeless doom. In fact, an instance has actually occurred in California of a white boy, now a leper, whose father has employed Chinese both on his ranch and in his house, some of whom are said to have had a cutaneous disorder. BACILLUS LEPB.E. The credit of first discovery of the Bacillus Lepree is given to Hanson, of Bergen, of date varying from 1869 to '74, according to different writers. In 1879 Neisser announced an independent discovery. The latter has inoculated rabbits and dogs with leprous matter and so produced inflammatory nodes corresponding to human lep- rosy. He supposes that the spores enter the system and develop wherever they find a suitable nidus, especially in the lymphatic glands. Thence they invade the entire body. Eichhorst states that artificial inoculation of animals has failed, and this has been Arning's experience in the Hawaiian Islands. Neisser, Damsch and Vossins have succeeded in the culture of the bacilli at the infected spots. The bacilli are found in the skin, mucous membranes, peripheral nerves, lymph-glands, testes, liver, 184 Leprosy. spleen and eyes, also in the blood, usually enclosed in white blood corpuscles. From the Annual of Universal Med. Sci. for 1888 (Sajous) I condense the following. The bacilli leprse have never yet been found in the blood. When introduced into the circulation these organisms probably are rapidly carried to the capillaries and thence by diapedesis to lymph spaces, where they set up the characteristic changes. Lymph may contain bacilli. Glandular secretions and excretions, notably the urine, are almost entirely free. Tears, the nasal secretion and the saliva swarm with them whenever the ocular, nasal or bucco- pharyngeal surfaces are lepromotous; also the alvine discharges in leprous diarrhea. When the testes are involved, the semen contains bacilli. The uterine mucus and vaginal secretions never do. Vaccinal lymph from lepers contain them. Leprosy may almost certainly be conveyed from venereal sores. The lymphatic and ganglia are characteristic and constant foci of the bacilli. The central nervous system is not affected by lep- rosy, as it is by syphilis. There are two methods of conveying disease through bacteria: 1. By direct contact or inoculation. 2. Indirectly through soil, air, water or food. Arning has suc- ceeded with the former mode, but failed with the latter in his experiments with leprosy. (This indicates that leprosy is con- tagious but not infectious.) Dr. Edw. E. Arning, by invitation of the Hawaiian Govern- ment, pursued the study of leprosy in the islands from 1883 to '85. The following is a brief abstract of his observations in its bacteriology. He found B. in the trunks of nerves supplying anaesthetic patches, but not in the patches themselves, nor in chronic sores resulting therefrom. No B. in blood or urine. They were found in the nodules of the tubercular form. Cul- ture experiments failed to reproduce B. Inoculation failed to prove the disease in the lower animals. (It had failed in the convict Keanu up to the date of his departure. The animals should have been kept under observation at least three years.) He considers leprosy peculiar to mankind, and transmission from one person to another directly through the bacilli, or through the intermediate stage of spores. Arning found B. lep. in leprous corpses, even after the appearance of bacteria of putrefaction; but could not aver that they were alive. B. are not found in the red maculae of the face, which usher in many cases. Excision from the point of inoculation of Keanu Leprosy. 185 showed B. under microscope for fourteen months, but in dimin- ishing numbers. After vaccination of lepers he found B. lepree in the lymph and crusts. Dr. Prince A. Morrow (N, Y. Med. Jour., July, '89) states that he had failed to find B. lep. in any part of a still-born child at full term. (Repeated observations would throw light on the heredity of leprosy, and no opportunity should be lost.) Dr. J. H. Stallard, of San Francisco, has kindly given me a report of his studies in the bacteriology of leprosy, and slides prepared by himself for microscopic observations. He finds that the bacilli persist in water and other fluids; notwithstand- ing the presence of putrefactive bacteria, for at least eighteen months. As they are motionless and inoculation is inadmissi- ble we have no positive evidence of activity; but the slides show that the bacilli continue in every possible form: as spores, more or less aggregated ; as bacilli of various lengths and diame- ter, plain or beaded, single or in closely woven zo-ogloeses. His experiments indicated wafer to be the vehicle of contagion. After immersion of leprous tissue in absolute alcohol for over a year, he found that subsequent treatment with water would not remove the bacilli, though they could still be seen in situ. Dr. J. E. Graham (Wood's Eef. Hand Book) remarks: " It is probable that the spores or bacilli themselves find their way into the body through some lesion in the epithelium, and thus by their growth the system is affected. Nodules and infiltra- tions are thus the result of specific irritation -due to presence of bacilli." The mechanical action of these microbes seems to me a cor- rect supposition. Their growth and pressure on blood vessels and nerves satisfactorily explains the mutilations and anaesthe- sia, and pressure on solid tissues accounts for the ulcerations characteristic of the disorder. The morphological resemblance of the bacilli of leprosy to those of tuberculosis has been observed by bacteriologists, like- wise the slow growth of both microbes. The analogies in the natural history of the two disorders are equally striking; their slow progress, their frequent arrest and occasional retrogression; the usual relapse and final determination, unless anticipated by a fatal intercurrent attack of another disease; the prolonged period of incubation; and probably in both cases a necessary solution of continuity for admission of the microbes to the 186 Leprosy. internal organism. Moreover, it may be found, in time, that heredity figures about as much in one as in the other. The uniform presence of the bacilli in lepers, whenever looked for, and their absence from non-leprous subjects, demon- strate their connection with the disease. Successful inoculation demonstrates their causative agency and its contagiousness. Even without the evidence of specific bacteria, proofs of the communicability of leprosy are, in my judgment, satisfactory: with it there is no escape. It is improbable that these microbes should find access through sound mucous surfaces of the respi- ratory or alimentary tract, for then the disease would be infectious, like measles and typhoid fever, and vastly more prevalent. It is apparent, however, that individuals affected with lesions of any tract, whether external or internal, accessible to the air or to food and drink, might offer an avenue to leprous matter, either in the moist or pulverulent state. The morbid intestinal discharges and external ulcerations of lepers are known to abound in the specific bacilli, and are doubtless the general sources of contagion. Who knows the antecedents of old rags, of the cast-off clothing that goes to the shoddy factory, of the second hand clothing which many people handle and wear? The persistency of leprous bacilli has been demon- strated. Such considerations give a creditable explanation of some mysterious cases and a warning of danger lurking at unex- pected moments. THE CONTROL OF LEPROSY. This subject naturally falls under two heads: a, curative; b, preventive. a. It is not my intention to make even the most superficial review of the various remedies and modes of treatment in this malady, but only to notice a few agents lately approved. Dr. Arning found that the use of ointments having ten per cent strength of salicylic and pyrogallic acids destroyed the tubercles, softened the infiltrations and sometimes restored sensibility to anaesthetic patches. Salicylic acid was tried also internally with apparent benefit. Hypodermic injections of corrosive sublimate, 160 in the course of two years, were followed by amendment in one case; in another, eighty injections were fol- lowed by retarded rate of progress. He found electricity bene- ficial to the anaesthesia. Potassium iodide failed of good results. With apparent improvement from certain agents, as Leprosy. 187 above, he does not claim lasting cures. Dr. C. J. Peters of Bombay has used the following course. 1 : Carbolic oil (1 in 40) is rubbed over the whole body to promote healthy action of the skin. This is followed by soap aud water ablution. 2: To the ulcerated spots an emulsion of gurgin oil and lime water (1 in 3) is applied by friction or on cotton with a bandage. 3: To the anaesthetic patches and tubercular growths cashewnut oil is applied with a brush or feather. 4: Internally five minim doses of Chaulmoogra with five grains of sodium bicarbonate in one ounce of peppermint water are given. In some cases three grain doses of potassium iodide. The results obtained were healing of ulcers, dispersion of tubercles, restoration of sensi- bility and relaxation of contractions. The general testimony, however, is to the effect that any mode of treatment is in the end disappointing. Arrest of progress is only temporary, being usually followed by suspension of treat- ment. Indeed it is not certain that long perseverance would be attended by permanent relief. At the Tracadie Hospital patients have been discharged apparently cured, but they gen- erally returned to die. The results are even less encouraging than in the treatment of pulmonary consumption. Doubtless some have improved enough to be discharged, have gone out and died of other diseases, and have been considered cured of their leprosy; but there is no proof , and it is rather probable that in time it would have returned. The health authorities of the Hawaiian Islands consider leprosy practically incurable, though they acknowledge that life may be prolonged by certain medical treatment, by good food and favorable sanitary condi- tions. 6. Since, then, so little is to be expected of curative treatment there is no question of the necessity of vigorous preventive measures. In the earliest stages recognition of the disease is difficult and generally impracticable, but then the danger is small. As soon as diagnosis can be reached without risk of making a mistake, there should be no hesitation or failure about enforcing segregation. Long ago the people of California rec- ognized the danger of planting leprosy on this coast through Chinese immigration, and for more than fifteen years legislation has given abundant authority for its exclusion and repression. Inasmuch as the control of leprosy within the national borders belongs to the separate States, it is highly desirable that they 188 Leprosy. should enact substantially uniform laws. The subject is a suitable one for the consideration and action of the Conference of State Boards of Health, and this body could frame a bill suitable as a model for all the states. It would then be the duty of each State Board of Health to procure the passage of an act for that purpose. This part of the subject would be incomplete without noting some necessary precautions in disposing of leprous corpses. Bacteriologists have shown that the bacilli of leprosy, unlike many others, withstand the bacteria of putrefaction. We know that the soil is poisoned for many years by the bacilli of anthrax, for the rapid contagiousness of the disease has proved it. The contagion of leprosy is so slow that proof may never be made satis- factory how long the virus persists; but danger is to be appre- hended and it is easy to obviate it. The law should direct some effective method or methods of disinfection. Cremation would certainly be effectual, but could not be made compulsory in the nineteenth century. Whoever lives to the second half of the twentieth century will probably witness the cremation of bodies dead of dangerous disease. For the present we might be con- tent with burial in quicklime, and might, perhaps, obtain legal authority to enforce it. The full extent of this fearful malady no one knows. Few writers name even half the countries where it may be found. Though the civilized world has substantially won the victory, the enemy returns casually and carries off one or more victims from the best regulated communities. In all the four quarters of the globe it retains a foot-hold. In its ancient seats of Asia and Africa it holds undisputed sway, almost without exception stationary, or perhaps slowly declining, because the races are growing resistant by survival of the fittest. In Europe it has a strong-hold in Norway, from which it may be dislodged and, perhaps, quite expelled within half a century. It holds ill- defined territory in Southern and Central America, the West Indies and Mexico, and a small tract in British America. In Australia it is occupying new territory.* In the Sandwich Islands there is a struggle for life between the newly civilized people and the destroyer. In our own country the portions *The President of the Board of Health for New South Wales, "reports at present twelve cases in Sydney; ten Chinamen, one Japanese and one English- man. Thus it is clearly, as in so many other places, almost exclusively a disease of Chinamen." British Medical Journal, February, 1890. Leprosy. 189 once dominated by the Spaniards, have had the earliest and latest experience, even to the present hour. South Carolina has not escaped, Wisconsin, Iowa and Minnesota have received it with Norwegian settlers, Utah with Mormon converts, and the Pacific States with Chinese. New York City is seldom without specimens brought in ships from queer ports in foreign lands, and the other commercial cities are frequently startled with strange visitors. Occasionally, as at Charleston in the past and New Orleans in the present, alarming numbers come to light. Just now the point most threatened is New Orleans, for no legal barrier stands to protect the great city, which, after a long and dreadful struggle, has lately gained the mastery of tropical yellow fever by quarantine. The successful method of Ulloa and Miro is forgotten or unheeded by the authorities, and must be rediscovered to save the people from the fate of the Hawai- ians. Here in California the enemy, few and scattered, are in our midst, and others are liable to come on every ship from China and the Islands; but we have been fully warned, and are armed with lawful weapons. It is our own fault if they do not protect us. One other provision is needed a State hospital for lepers. Our statute enables local authorities to act for themselves, but not one of the counties has a suitable lazaretto. San Francisco has always had more than half the lepers in the State, but its only accommodation is the pest house, where lepers and small- pox cases are lodged in the same house. That the lepers escape small-pox and the small-pox patients escape leprosy is rather good luck than good management. At least one leper has died of small-pox, and some lepers of the future may be reminded of a former residence at the same institution for the other com- plaint. Apart from such improper association of subjects of the two diseases, the pest-house is an insecure place. Only lately a leper, in a far advanced stage, has been recommitted, who escaped two and one-half years ago, and was at large in the city during the whole interval. A small island near San Francisco would be the proper site for a lazaretto, and accommodations for twenty-five lepers would be large enough for present and prospective needs, inasmuch as most have hitherto been sent back to China. It has also been suggested that a contract be made if possible with the Hawaiian Government to have all lepers cared for at 190 Leprosy. the leper settlement on Molokai. In Louisiana there is impera- tive need of such an institution, and of legislation equivalent to the act of California. As to the other States ib would be suf- ficient to pass the necessary isolation act and leave its execution to the State Board of Health, with power to draw warrants upon the treasury, not to exceed a fixed amount, for the expenses. I would not be understood as encouraging any alarm on this subject, even in Louisiana or California. Our State needs only faithful enforcement of existing laws with a suitable lazaret; while Louisiana would be saved by a revival of the forgotten plan of Moro, which was successfully in operation just a century ago. In conclusion, I would not be unmindful of courtesies and assistance rendered in the collection of data for this paper from a large number of correspondents at home and abroad. They are too numerous for individual mention, further than is already indicated. Among them officers of Health Boards have rendered especial service. To all I tender sincere thanks. MAY 1 6 1979 R Tom which it wasborrowed. 3 1970 00475 rv I" UCSOUTHERNRE ON LIBRARY AC LTV A 001350452 7 LFniversit; Southe Libra