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Leprosy 
 
 PRINCE A. MORROW 
 
 NEW YORK 
 
 REPRINTED FROM 
 
 Twentieth CENTrRY Practice of Medicine 
 Vol. XVIII. 
 
 NEW YORK 
 WII^LIAM WOOD & COMPANY 
 
 PUBLISHERS 
 1899. 
 
l?Ci^^ 
 
 or)<^-3 
 
 COLUMBIA UNIVERSITY 
 EDWARD G. JANEWAY 
 MEMORIAL LIBRARY 
 
LEPROSY. 
 
 BY 
 
 PRINCE A. MORROW. 
 
 >"EW YORK. 
 
 Vol. XVIII.— 26 
 
LEPROSY. 
 
 Syno77yms.—liGpTa; Elephantiasis Grgecorum; Leontiasis, Saty- 
 riasis; Frencli, Lepre; German, Aussatz; Norwegian, Spedalskbed; 
 Spanish, Elefantiasis de los Griegos; Italian, Elefantiasis dei Greci' 
 Lepra, Lebbre; Latin, Lepra vera. Elephantiasis; Hebrew, Zaraath 
 (Tsaraath); Sanscrit, Kushtha; Egyptian, Uchetu. 
 
 Z>e/?H7w«.— Leprosy (from Greek, /li-,o«) is a chronic infectious 
 disease caused by the bacillus leprae, characterized by erythematous 
 and pigmentary changes in the skin and the production of tubercular 
 nodules containing bacilli in the cutaneous tissues and mucous mem- 
 branes, and by irritative and degenerative changes in the nerves, 
 with implication of the lymphatic ganglia and internal viscera and 
 the supervention of a profound cachexia which leads to a fatal termi- 
 nation. 
 
 Types of Leprosy. 
 
 The bacilli of leprosy, like the germs of other infectious diseases, 
 when they have gained access to the organism, affect particular struc- 
 tures and spread from one organ to another along certain definite 
 tracts, producing changes in the tissues which are characteristic and 
 peculiar to the morbid process. These changes consist of diffuse 
 or circumscribed infiltrations, and the clinical picture varies accord- 
 ing to the localization of the lesions in the integument or in the 
 nerves. 
 
 Two principal forms of leprosy are recognized. When there is a 
 determination of the morbid process towards the cutaneous and mu- 
 cous membranes in the shape of macules and nodules, it is termed 
 tubercular or tegmnentary ; when it is centred upon the peripheral 
 nerves, it is termed ancesthetic, trophoneurotic, or nerve leprosy. These 
 two forms, although etiologically identical, exhibit marked differences 
 in their objective characters, mode of evolution, and duration. 
 
 In tubercular leprosy the predominating lesions are nodular infil- 
 trations, termed tubercles or lepromata, in the skin, mucous mem- 
 branes, and other organs; the course of this form is more rapid, and 
 the average duration of life is from five to fifteen years. 
 
 Anaesthetic leprosy is characterized by degenerative changes in 
 
404 MORROW — LErROSY. 
 
 the nerves, an?estliesia, atrophy, and mutilation of the extremities ; its 
 course is slower, and the duration of life may be prolonged to fifteen 
 or twenty years or longer. 
 
 As marks of differentiation it may be said that the development of 
 tubercles constitutes the distinctive sign of the tubercular form, while 
 insensibility and atrophy are the distinguishing features of nerve 
 leprosy. While both forms almost invariably proceed to a fatal ter- 
 mination, both are susceptible of spontaneous cure— the anaesthetic 
 form rarely and the tubercular form still more exceptionally. 
 
 The division of leprosy into two principal forms, according to the 
 most prominent symptoms exhibited by each, was recognized by the 
 early writers, and this classification is now practically universal. 
 Certain writers have attempted to differentiate still further the maui- 
 festations of the disease by the employment of terms indicating a 
 single symptom. Thus Kaposi and others describe a macular form. 
 This cannot, however, be recognized as constituting a distinct form 
 or type of leprosy. Macules simply represent a phase in the evolu- 
 tion of the malady common to both the tubercular and anaesthetic 
 forms and do not exist independently, but are always associated 
 sooner or later with tubercular or nerve manifestations. 
 
 That the above division of leprosy into two forms is to a certain 
 extent arbitrary is evident from the fact that the typical features of 
 both forms may coexist in the same individual, thus establishing their 
 pathological unity. In a certain proportion of cases there is a com- 
 bination of both tegumentary and nerve lesions, constituting what 
 is termed the mixed or complete type of leprosy. 
 
 ETIOLOGY. 
 
 At the present time there is a general consensus of opinion among 
 medical men that the vast array of functional disorders and organic 
 changes met with in leprosy are caused by the introduction into the 
 human body of a specific microorganism, the bacillus leprae. The 
 fact that this organism is invariably found in the body of lepers, and 
 nowhere else, would seem to establish the relation of cause and effect 
 between the presence of the bacilli and the production of the symp- 
 toms peculiar to the disease. It must be admitted, however, that the 
 chain of evidence which connects the bacillus with the causation of 
 leprosy is not so complete as in the case of certain other parasitic 
 diseases, as for example tuberculosis and anthrax. 
 
 The rigorous conditions demanded by the modern scientific mind 
 before we are authorized to affirm that the disease is of parasitic 
 origin, produced by the introduction into the organism of a patho- 
 
ETIOLOGY. 405 
 
 genie microbe, liave not been complied witli. These necessary con- 
 ditions are : 
 
 1 . Tliat tlie specific microbe should be found in the diseased tissues. 
 
 2. That the microbe should be capable of being cultivated outside 
 the human body. 
 
 3. That when the product of pure cultures is inoculated into the 
 same species from which it was derived, it should produce the iden- 
 tical disease. 
 
 Since the bacillus has not been successfully cultivated or inoculated 
 into animals, the scientific proof of its pathological role has not been 
 demonstrated. Nevertheless, it is generally conceded that the theory 
 of its pathogenic action is based upon sufficient histological and clini- 
 cal evidence. This evidence has been formulated by Neisser as fol- 
 lows : 
 
 The constant presence of the bacillus in all cases which exhibit un- 
 doubted clinical evidence of leprosy ; its localization in the diseased 
 foci of the organism, so that every symptom of leprosy may be cer- 
 tainly referred to the bacillary focus existing in situ or at a distance ; 
 the correlation which exists between the cellular alterations within 
 the cells and the bacilli; the fact that these bacilli present charac- 
 ters absolutely specific, and that leprosy possesses all the attributes 
 and joarticularly the mode of propagation of bacillary diseases pecu- 
 liar to the human race and transmitted from man to man. All these 
 considerations admit of no doubt that the bacillus of Hansen is the 
 unique and necessary pathogenic agent of leprosy. 
 
 The etiological views of writers on leprosy before the discovery of 
 Hansen's bacillus have now only an historical interest. How various, 
 diverse, and even contradictory these views were is apparent from the 
 fact that at one time the origin of leprosy was attributed to divine 
 wrath as a i^unishment for sin, at another time to divine favor, secur- 
 ing for the sufferers religious honors. 
 
 Yiewed from the standpoint of our more advanced knowledge, we 
 look upon these various theories of the origin of leprosy as only the 
 speculations of human ignorance, and yet many of the theories which 
 had been advanced are not only interesting, but also extremely valu- 
 able, as they indicate clearly the conditions under which leprosy ordi- 
 narily occurs. 
 
 The causes of leprosy have been variously ascribed to malaria, 
 dampness and humidity, uncleanly habits, filth and overcrowding, 
 sudden changes of temperature, etc. Dr. Tilbury Fox, writing in 
 1868, says the cause of leprosy is probably a mixed one. It is a com- 
 bination especially of bad hygiene exhibited in damp dwellings, putrid 
 and innutritions food, and a malarial climate. While the pathogenic 
 
406 
 
 MORROW — LEPROSY. 
 
 agent of leprosj- escaped detection, there is no doubt that the causes 
 alleged by these observers favor the propagation of the disease and 
 to-day are recognized as powerful predisposiug factors. 
 
 The Bacillus Leprae. 
 
 The bacillus of leprosy, discovered by Hansen in 1874, is, as above 
 intimated, now generally regarded as the essential cause of leprosy. 
 In tubercular leprosy it is present in enormous numbers ; in lepra 
 
 Fig. 1.— Bacilli Leprae. (From a photograph by Dr. J. A. Fordyee.) 
 
 nervosa it is normally present in relatively small numbers. It has 
 been claimed by Kaposi, Petrini, and others that it may be absent 
 even in well-marked cases of tubercular leprosy. This paradox is 
 explained in various ways. It is a known fact that under certain un- 
 determined conditions the parasite stains very poorly and decolorizes 
 rapidly, so that the technique may still be regarded as faulty. The 
 failure of bacteriological researches to demonstrate the presence of 
 bacilli in two cases of tubercular leprosy instanced by Kaposi cannot 
 be considered proof that the organisms were absent, but rather that 
 the methods employed were defective. On the other hand, the absence 
 
THE BACrLLUS LEPE^. 407 
 
 of the parasite in lepra nervosa is regarded as evidence of spontaneous 
 cure ; at least of tliat particular attack. 
 
 Jlorphclogical Characters. — The bacillus leprae is believed to belong 
 to the Streptothrix family. It is a near congener of the bacillus tuber- 
 culosis, and a transition between the two is found in the bacillus of 
 fowl tuberculosis. The members of this group are also believed to 
 be allied to the actinomycetes, which are also pathological. 
 
 The parasite is slender and rod-like, in length from one-half to 
 three-fourths of the diameter of a human red blood corpuscle, and in 
 breadth about one-fifth of the length. The ends are usually pointed, 
 but in certain cases are clubbed, and then resemble the Edebs-Loffler 
 bacillus. Dichotomous division has occasionally been noted. Most 
 authorities believe that the bacillus is spore-producing and also en- 
 capsulated. The tendency to form colonies is a characteristic of this 
 parasite. Young bacilli are homogeneous, while the older are gran- 
 ular. 
 
 Analogies icith Koch's Bacillus. — The points of agreement and dif- 
 ference between the bacilli of leprosy and those of tuberculosis are 
 of more than passing interest. They show similar staining qualities, 
 although the lepra bacilli stain with more facility, and both occa- 
 sionally exhibit clubbing of the ends and dichotomy. The lepra 
 bacilli are more uniform in size and rectilinear. They may be distin- 
 guished by differential stains, by their greater number, and by their 
 tendency to form colonies. 
 
 The most striking point of aflinity, however, lies in the similarity 
 of their toxins. As the bacillus leprae cannot be cultivated, we know of 
 the leprous toxins only from their clinical results ; but the similarity 
 is shown by the fact that lepers react both locally and generally to 
 tuberculin — a fact of great practical significance as holding out a plan 
 for the rational treatment of the disease — a plan which, according to 
 Babes, leads to at least temporary improvement when vigorously car- 
 ried out over long periods. 
 
 None of the microorganisms cultivated from leprous tissues corre- 
 sponds to Hansen's bacillus, although one of them, the so-called diph- 
 theroid bacillus, much resembles it. 
 
 Methods of Examining for the Bacillus Leprce. 
 
 In the Serum. — The best method is to clamp the nodule with a pair 
 of forceps or a specially devised instrument for clamping and squeez- 
 ing the nodule. After the nodule becomes angemic from pressure it 
 should be freely incised at the apex, when a small quantity of serum 
 will escape. The clear fluid which exudes is to be placed upon a clean 
 
408 MOKROW — LEPEOSY. 
 
 cover glass, and if this is brought in contact with a second cover glass 
 a thin film of exudation will spread evenly between the two, when 
 they are to be carefully separated. The cover glasses are now passed 
 through the flame of a spirit lamp, which fixes the film and assists in 
 the process of staining. 
 
 The preparation is now to be stained in an aqueous solution of 
 fuchsin, or better, a three-per-cent. solution of carbolic acid should 
 be added to the fuchsin, which assists the staining-process. If now 
 the specimen be decolorized in a thirty-per-cent. solution of nitric 
 acid and counterstained with a methylene-blue solution, washed in 
 water, dried, and mounted in xylol-Canada balsam, it will show the 
 bacilli single and in clusters stained red, while the nuclei and ground 
 substance are stained blue. 
 
 In the Tissues. — After the section is properly cut with a microtome 
 it should be placed in a fuchsin-carbol solution for some hours. It 
 should be removed carefulh' and dipped in a thirty-per-cent. solution 
 of hydrochloric or nitric acid. This will decolorize everything excei)t 
 the bacilli. If the section is now stained with methylene blue, the 
 red-stained bacilli will appear under the microscope as pink rods 
 upon a blue ground. 
 
 Alvarez, of Honolulu, has proposed a rapid method of making a 
 positive diagnosis in doubtful cases. After the removal of a bit of 
 skin or other tissue to be examined it is washed in a normal salt solu- 
 tion and thoroughly triturated in a small mortar until a homogeneous 
 solution results. The skin or other tissue may be boiled, or digestive 
 ferments may be added, before it is submitted to the process of tritu- 
 ration. When the trituration is completed, a small quantity may be 
 transferred to a cover-glass, and the specimen is then fixed, stained, 
 decolorized, and counterstained in the manner described above. If 
 there are but few bacilli present, the triturated mass may be sub- 
 mitted to a centrifugal machine or placed in a conical glass, and the 
 sediment examined in twenty-four or forty-eight hours. 
 
 Alvarez claims that by this method we can spread upon the cover- 
 glass films thinner than any section that can be made with a micro- 
 tome, and by using the centrifugal machine we can gather bacilli in a 
 small place, where they are easier to find than in a section. More- 
 over, a diagnosis can be made in a few minutes instead of waiting for 
 the tissues to harden. 
 
 Culture Uxpei'iments. 
 
 Experiments in the artificial cultivation of lepra bacilli in various 
 culture mediums have uniformly failed. The authenticity of cultures 
 claimed to be successful by numerous investigators have all been con- 
 
THE BACILLUS LEPK^. 409 
 
 tested, since iu no instance lias the x^athogenic nature of tliese cul- 
 tivations been established by inoculation experiments. 
 
 Possibly au explanation of the uniform failure of all culture exper- 
 iments is that due regard has not been paid to the element of time, 
 which is so essential a condition of the germinative capacity of the 
 lepra bacillus, and results may have been looked for too early. 
 
 Quite recently Carrasquilla, known as the originator of the serum 
 therapy of leprosy, claims to have made successful cultures of the 
 bacillus leprse. His method of procedure and results are de- 
 scribed in a communication to the National Academy of Medicine 
 of Bogota, February, 1899. He collects the serum by means of a 
 specialh' devised clamp or forceps applied to the tubercles, macules, 
 or infiltrations. The clear fluid collected is first examined under the 
 microscope to be sure that it contains Hansen's bacillus. Tubes of 
 gelatinized serum are then sown with a drop of the cle^r fluid on a 
 sterilized platinum wire and placed in a Eoux condenser at a tem- 
 perature of 37' C. 
 
 At the end of twenty-four hours he saw the development of the 
 first culture. Spots or macules had appeared all around the points 
 sown with the platinum wire, with rounded, irregular contours, some 
 yellow, others white with a certain refraction. Four days later he 
 examined under the microscope the colonies of the first tubes sown 
 and was able to demonstrate the presence of the bacilli, even with- 
 out coloration. Submitted to the ordinary coloring methods, all 
 the characteristics of Hansen's bacillus were displayed, while no 
 other microbe aj)peared in the preparation, showing that it was 
 a pure culture. Taking this first culture, he sowed other tubes of 
 gelatinized serum, and these produced exactlj^ the same develop- 
 ment as the first, which were sown directly from the lej^rous exuda- 
 tion. Later he used as a culture fluid the bouillon of beef with 
 identical results. One set of tubes was sown with the culture of pre- 
 ceding tubes, and the same series of phenomena was always produced 
 under identical conditions. A month later, in examining the cul- 
 tures, he was surprised to see the bacilli in movement, and in exam- 
 ining cultures there was always observed a mobility of the bacilli 
 after a certain stage of their development. He was also enabled to 
 identify different phases in the evolution of the microbes as shown by 
 differences in their morphological characters and movements. 
 
 Carrasquilla further claims that, when injected into horses, the 
 filtered liquid of the cultures produced precisely the same effect, al- 
 though the reaction was more intense, as the serum taken directly from 
 lepers. Furthermore, the serum of the horses which had received in- 
 oculations of the liquid from the cultures produced in patients the 
 
410 MORROW— LEPROSY. 
 
 same reactions and the same modifications in the manifestations of 
 the disease, only perhaps more pronounced, as the serum from horses 
 which had been inoculated with the serum of lepers. 
 
 Carrasquilla does not believe that the immunity of animals to 
 leprosy is so absolute as has been maintained, and since experiments 
 in inoculating human beings are not permissible, his further experi- 
 ments are to be conducted with a view of reproducing the disease in 
 animals by means of his cultures. 
 
 Until this final proof of the i)athogenic action of the cultures is 
 furnished Carrasciuilla's claims must be received with the same scep- 
 ticism as has been accorded b\' the i)rofession to those of Bordoni- 
 Uffreduzzi of Turin, Spronck of Utrecht, Byron of New York, and 
 others, who have announced successful results in cultivating the lepra 
 bacillus. 
 
 I) isi rib id ion, of the Bacilli. 
 
 Leprosy, according to Cornil, is the perfected type of bacterial 
 disease. By the extreme abundance of bacilli infiltrated everywhere 
 in the i^athological products of leprosy, by their persistence at all 
 periods, this disease gives us the most characteristic histological dem- 
 onstration of the role of the bacillus. No other disease is so rich in 
 bacilli. All leprous products contain colossal quantities of bacilli. 
 
 Like all specific microbes, the lepra bacillus has an elective aflinity 
 or predilection for certain tissues and fluids of the bodj-. The bacilli 
 are present in all forms and stages of tubercular leprosy ; they are 
 found in both the diffuse and nodular infiltrations of the skin and 
 mucous membranes, in the connective tissue of the peripheral nerves, 
 in the spinal cord (the anterior horns) and in the spinal ganglia, in the 
 cornea, the cartilages, and the liver, spleen, and kidneys, si)aringly 
 in the spermatic tubes and testicles, also in the ovary and the lemale 
 breasts. They are found abundantly in the lymphatic glands and 
 spaces, in the sebaceous glands, and in the hair and sebaceous follicles 
 of the body, but not of the scalp. The}' are not found in the blood, 
 except in the last stages of the disease. It is claimed that they 
 exist in the blood during the febrile or congestive attacks, but this 
 has not been determined. The blood would seem to serve as an 
 agent of transport for the dissemination of the bacilli through the 
 economy. The bacilli exist in a state of permanence in the lymph, 
 and this fluid is regarded as the natural culture fluid of the microbes. 
 
 Their in-esence in the pi/ t/siolog iced secretions, the tears, saliva, milk, 
 and semen, though formerly denied, is now attested by Babes ; they 
 have never been found in the urine, nor in the menstrual fluid. It is 
 probable that the jjhysiological secretions, unless pathologically 
 
THE BACILLrS LEPE^. 411 
 
 altered bv the presence of leprous deposits in the secretory structures 
 of the organs, do not contain leprous microorganisms. The bacilli 
 are, however, also found upon the skin and in organs which are to all 
 appearances perfectly healthy. 
 
 The 'pathological secretions from the surface of ulcerating lesions 
 of the integuments, of those of the mucous membranes of the nose, 
 mouth, and throat, the large intestine, and the rectum contain large 
 numbers of the bacilli, which are discharged through the nasal mu- 
 cus, the saliya, and dysenteroid excrement in vast quantity. 
 
 It is to be observed that individual cases may present the greatest 
 variations in respect to the lesions and secretions which contain 
 bacilli. Thus Weber found that bacilli were in one case present in 
 skin scrapings, lanugo hairs, blood from nodules, serum from vesi- 
 cles, semen, etc., and entirely absent in the saliva, nasal mucus, scalp 
 hairs, and in blood not taken from nodules. 
 
 The special reactions between the bacillus and iudividual tissues 
 are best treated of under particular headings. With regard to the 
 migration of the parasite within the body and the problem of its 
 preference for individual tissues, we are still in great obscurity. 
 
 EUminatioii of tlie Bacilli. 
 
 The bacilli leave the body by means of every natural secretion or 
 excretion, with the i^ossible exception of the urine — in saliva, nasal 
 mucus, conjunctival secretion, vaginal, urethral, and uterine dis- 
 charges, semen, milk, faeces, secretion of leprous ulcers, and the free 
 surface of the skin. They have not been found in the menstrual blood 
 (Babes). 
 
 The nodules and diffused infiltrations of the skin and of the mucosa 
 of the nose, mouth, and throat, the large intestine, and the rectum 
 contain immense numbers of bacilli which are set free on the break- 
 ing down of these tissues. Once freed from their nidus, their dissemi- 
 nation is a matter of chance. 
 
 Schaffer claims that lepers throw off fewer bacilli from the skin 
 than from the buccal and nasal mucosa in coughing and sneezing. 
 He was able to collect lepra baciUi on clean slides placed on tables 
 and the floor near to patients whom he had caused to read aloud. 
 Lepers who had been reading aloud only ten minutes projected from 
 forty to one hundred and eighty-five thousand bacilli. 
 
412 MORROW — LEPROSY. 
 
 The BacilH Outside the Body. 
 
 Bacilli have beeu found in the habitations of lepers, articles of 
 furniture, and objects surrounding^ the leper. They have also been 
 found sparingly in the dust and dirt of rooms where lepers have lived, 
 iu the soil habitually trodden by lepers' feet, and in the earth where 
 lepers have been buried. 
 
 From the fact that the leper discharges from his skin and nasal and 
 buccal mucous membranes, and with his breath iu talking, coughing, 
 sneezing, etc., myriads of bacilli, and that these bacilli must of neces- 
 sity come in contact with a large entourage of healthy people, none 
 of whom may be contaminated, it is evident that these bacteria are 
 either endowed with a very feeble contagious activity, or that they are 
 dead or cadaveric when discharged. This cadaverization of the bacil- 
 lus explains, according to Besnier, the negative results of cultures and 
 inoculations and enables us to understand why it is that leprosy is 
 wiped out when the leper dies, offering a new and fundamental dis- 
 tinction from Koch's bacillus which retains its vitality and virulence 
 through an incredible length of time and under various conditions. 
 The question whether the bacilli found outside the body are living 
 or dead is still ^nh judice, and cannot be decided either affirmatively 
 or negatively until we are able to show some comprehensible differ- 
 ence between living and dead bacilli by culture or inoculation. 
 
 Arning states that the bacilli seem to multiply in the bodies of dead 
 lepers months after they have been buried. He has also obser\'ed 
 that fragments of lepromata i:)laced in water for several months became 
 surrounded w'ith myriads of bacilli, ver}^ evidently multiplied, and 
 which proves to him that ihej are living. 
 
 Babes also concludes from certain characters of the bacilli, the 
 globi and the api^earances of sporulation, that some of them, at least, 
 are living. 
 
 Transmission of the Bacilli. 
 
 As the bacillus leprae has not been cultivated we have no certain 
 means of determining to what extent the bacilli which infest the 
 numerous secretions and discharges are lifeless, and for the same 
 reason we have no positive evidence as to how the disease is spread. 
 
 Since the bacilli are present in the semen at an earlj^ period of 
 the disease, although a condition of azoospermia soon supervenes, and 
 the milk of women with tubercular leprosy also contains the parasite, 
 Babes believes we are warranted in the assumption that bacilli may 
 pass between two individuals in the processes of generation and lac- 
 
THE BACILLUS LEPE^. 413 
 
 tation. This would not, however, necessarily indicate that the dis- 
 ease was inherited. The ovary also contains bacilli, but much less 
 frequently and to a less extent than the testicle. 
 
 Of other modes of transmission, direct and indirect, Babes thinks 
 that the aerial route from the germ-impregnated dust to the pores of 
 the face, especially when the pores are large and the subject unclean- 
 ly, has the most to recommend it. The reasoning to establish this 
 belief is not a priori, but is based upon the peculiar small perifollicu- 
 lar foci of infiltration which are so characteristic of tubercular leprosy 
 of the skin. Under the microscoj^e this iDhenomenon is suggestive of 
 the possibility of the penetration of the bacilli through the follicular 
 wall from without. The converse, namely, the penetration of the 
 follicular wall from within outwards in advanced cases of tubercular 
 leprosy, is well authenticated, and by this means the bacilli, which 
 appear to be unable to make their way through the epidermis, suc- 
 ceed in reaching the free surface of the skin when the latter is still 
 unbroken. 
 
 Babes himself warns against too hastily adopting this view. We 
 only know that the hair follicle is a predilection locality in leprosy, 
 and under these circumstances the parasite may be able to reach it, 
 no matter how it has entered the body. 
 
 With regard to other i:)ossible modes of transmission, we have no 
 guide but the analogy of other diseases. In addition to the lodging 
 of germ-laden dust in large pores and abrasions, the bacilli may find 
 ports of entry through the mucous membranes of the nose, tonsils, 
 conjunctiva, the deeper air and food passages, and perhaps the geni- 
 tals, since primary lepromata are occasionally seen in the latter local- 
 ity. When we come to lepra nervosa, the question of transmission 
 becomes even more obscure. 
 
 In connection with this whole question it is well to remember that 
 thus far there is absolutely no certain evidence of the disease being 
 conveyed by inoculation. 
 
 Resistance of the Bacilli. 
 
 The resistance of the bacilli to disintegration and decay -is most 
 remarkable. Thousands of bacilli have been found in a small frag- 
 ment of a leprous nodule which had become dried in an envelope of 
 paper, where it had been forgotten for ten years. Bacilli may re- 
 main almost indefinitely in tissues where they are developed, show- 
 ing no tendency to be eliminated or destroyed ultimately (Cornil and 
 Babes) . When introduced experimentally, bacilli have been found in 
 fragments of nodules which had been inserted under the skin of 
 animals one to two years previously. 
 
414 MORROW — LEPROSY. 
 
 "NVeseuer's experiments would go to show that, unlike the bacilli 
 of tuberculosis, lepra bacilli, if introduced in the living tissues, re- 
 main unabsorbed and susceptible of being impregnated by coloring 
 matter for an indefinite length of time. He found the results to be 
 identically the same, whether he introduced pieces containing bacilli 
 which had sojourned in alcohol for two years or fresh pieces. In 
 both cases the only manifest reaction was of a phlogistic nature, of a 
 purely local character, and similar to that which would have followed 
 the introduction of any inanimate matter, such as charcoal or cinna- 
 bar. The bacilli become incorporated with the cellular elements, and 
 their form persists intact. 
 
 Variations in the Bacilli. 
 
 Variations in Sfaininr/ Qualities. — In a communication to the Ber- 
 lin Leprosy Congress, 1897, on "The Bacillus of Leprosy in the 
 Human System at Different Periods of its Growth," Lawrence Her- 
 man has demonstrated that these variations are especially manifest in 
 relation to the staining reactions of the bacilli. He found in a mass 
 of bacilli which he extracted from tubercles and in sections that the 
 bacilli did not all color in the same manner. The bacilli from recent 
 nodiiles retained less carbol-fuchsin and took on a secondary colora- 
 tion of methylene blue. In preparations from older nodules there 
 are seen in the blue-stained masses, now and then, bacilli which have 
 retained the fuchsin and are stained red. He has encountered: 1. 
 Eed-stained bacilli which have remained well stained deep red; 2. 
 pale red-stained bacilli which have become decolorized to a greater 
 or less extent; 3. bacilli which have lost their fuchsin and become 
 stained more or less blue. 
 
 Herman concludes from his investigations that the bacilli which 
 are easily decolorized and have by contrast taken the methylene-blue 
 stain are the more recent and active bacilli, while those which have re- 
 tained the red stain and are more resistant to the decolorizing effect of 
 nitric acid rejiresent the older, possibly more stationary forms. 
 
 Further researches are necessary before it can be determined 
 whether the tinctorial differences between bacilli of different ages 
 indicate a modification in their infective virulence. 
 
 Variations in Virulence. — A priori it might be assumed that specific 
 bacilli possess the same character and degree of virulence irrespective 
 of the source from which they are derived. Experiment has shown, 
 however, that cultures of tubercle bacilli from bone tuberculosis are 
 more highly virulent than cultures of sputum bacilli, and it is also 
 claimed that different varieties of human tuberculosis exhibit marked 
 differences in their respective virulence. 
 
THE BACILLUS LEPE^. 415 
 
 Since successful cultures of the lepvsb bacilli have never been 
 made, the determination of their comparative virulence must be based 
 upon clinical evidence alone. Observation would seem to show con- 
 clusively that differences in the virulence of lej^rous germs are mani- 
 fest not only in respect to their contagious activity, but also in re- 
 spect to the intensity and severity of their pathogenic action when 
 introduced into the body. It is well known that leprosy is feebly 
 contagious in certain countries and ultracontagious in others, while 
 the virulence of the morbid process in the tubercular form contrasts 
 with its comparative benignity in the ansesthetic form. 
 
 The causes of the great diversity in the objective characters and 
 course of the two principal forms of leprosy, the rapid multiplication 
 of the bacilli and their predilection for the cutaneous tissues in the 
 one form, their comparative fewness and preference for the nerve 
 structures in the other, has been variously interpreted. It was a 
 subject of inquiry by the recent Berlin Leprosy Congress, and by cer- 
 tain leprologists the difference was attributed to the variable viru- 
 lence of the bacilli. 
 
 Hansen considers it a begging of the question to invoke a variable 
 virulence of the bacillus or a predisposition and a relative immunity 
 of the soil; he thinks that climate influences the form. 
 
 Blaschko thinks there is no essential difference between the two 
 forms, but only a difference in the quantity of the bacilli. 
 
 Arning, on the contrary, regards the difference as fundamental and 
 believes that the bacilli have a different action in the two forms. 
 
 According to Neisser, it is not a simple difference in the quantity 
 of the bacilli, but a qualitative difference in the morbid process, 
 besides a different localization, it being in the cutaneous form prolif- 
 erative and in the nerve form atrophic and retractive. 
 
 Impey thinks that there are either two very similar but not identi- 
 cal bacilli in leprosy, or that in pure nerve leprosy the poison secreted 
 by the bacilli acts in a more powerful manner upon the nerves, because 
 the nervous system of the patient is peculiarly susceptible to the ef- 
 fects of the ptomain. 
 
 In the writer's opinion the explanation of the difference in the two 
 forms must be sought for, not in a difference in the virulence of the 
 germs, but in the character of the soil. The type or form of the mor- 
 bid process is determined by the idiosyncrasy of the individual or by 
 some pathological predisposition which in the one case renders the 
 skin, in the other the nerves, more susceptible to the pathogenic 
 action of the bacilli. As regards the infective virulence of the bacilli, 
 it is claimed that the tubercular form is highly contagious, while the 
 other is comparatively innocuous. This may result not from a differ- 
 
416 MORROW— LEPROSY. 
 
 ence in the virulence of the germs, but simph' from the accident of 
 their localization, which in the one form permits of their abundant 
 and ready discharge, while in the other they are chiefly confined in 
 the nerve structures. 
 
 At the same time there can be but little doubt that the infective 
 virulence of leprous germs is modified by climate and conditions of 
 environment which render the system sterile or antagonistic to their 
 development. 
 
 Inoculation in Man. 
 
 Before the bacillary origin of leprosy was demonstrated and dur- 
 ing the i:)eriod when the theory of the non-contagiousness of leprosy 
 was in the ascendency, numerous attempts were made to inoculate 
 human beings. At the present day it would be difficult to find any 
 one who would dare attempt to inoculate leprosy. 
 
 In 1844 Dauiellsen, who was a firm believer in the non-contagious- 
 ness of leprosy, first inoculated himself with portions of a tubercle 
 from a leprous patient. He repeated this experiment on himself later 
 in the same jear without other result than the production of a septic 
 lymi)hangitis. Still later, he inoculated two helpers and one nurse in 
 St. George's Hospital in Bergen, all with negative results. In 1846 
 he inserted a small leprous nodule under the skin of his left forearm 
 and the wound was sutured. The sutures cut through, and after a 
 few days an ulcer formed which healed in a few weeks. 
 
 In 1856 Daniellsen, his assistant, Loberg, a farmer, two waiters, 
 and a servant at Lungegaard's Hospital were inoculated with por- 
 tions of tubercles, blood, and the pleural exudation from a leper. 
 In 1857 several syphilitic and favus patients were inoculated, and in 
 1858 Daniellsen and a waiter were again inoculated, with negative re- 
 sults. The inoculations were ordinarily made in the arm, and when 
 the leprous products were inserted the wound was sutured and covered 
 with plaster. There were ordinarily redness and swelling over the 
 sutures and after about fourteen days the individuals were all right. 
 
 Altogether Daniellsen inoculated twenty healthy individuals with 
 the blood of lepers, portions of tubercles, and blood collected from 
 the surfaces of the tubercles. There were observed a few cases of 
 lymphangitis, but in none of the twenty cases did he produce a 
 condition resembling leprosy. Some of these patients were kept 
 under observation many years, but all remained perfectly healthy. 
 The negative results of these experiments contributed largeh' to con- 
 firm the opinion that leprosy was neither contagious nor inociilable. 
 
 Profeta, between 1868 and 1875, inoculated himself, Cagnina, six 
 men, and two women, all with their free consent, but the results 
 
THE BACILLUS LEPE^. 417 
 
 were negative. Bargilli of Mytelene made two unsuccessful inocu- 
 lations. 
 
 Hansen inoculated the products of tubercular leprosy in persons 
 already suffering from aneestlietic leprosy without result. Both Han- 
 sen and Beaven Bake also found that the local lesions of leprosy were 
 not produced when the diseased tissues from a leper were inserted in 
 a healthy part of the same person, which would seem to indicate that 
 the bacillus does not grow in healthy tissues of the leper, but only in 
 a part made suitable for its reception and growth by a process of 
 preparation not yet determined. 
 
 In addition to these experimental inoculations, which were under- 
 taken with a definite scientific object in view, may be added accidental 
 inoculations, in cases of physicians or nurses who have pricked or 
 wounded themselves in dressing the open sores of lepers and in per- 
 forming operations or autopsies. In none of these cases has leprosy 
 developed. 
 
 Reference may also be made to cases in which leprosy is said to 
 have been contracted by thrusting a needle or knife which had pre- 
 ^iously been passed into the tissues of a leper into the tissues of 
 healthy individuals in a spirit of bravado, as in Hildebrand's case, 
 and to Blanc's case of leprosy following a razor cut in an English 
 nurse, etc. These cases are open to the possibility of doubt as to 
 whether the disease was inoculated in the manner alleged, as the pa- 
 tients were in more or less constant intercourse with lepers, afford- 
 ing abundant opportunities for infection in other ways. 
 
 The only experiment claimed to be successful in inoculating 
 leprosj^ in man was that of the convict Keanu of Hawaii, who was 
 inoculated by Arning in 1884 with pus laden with bacilli, and, in addi- 
 tion, a portion of a tubercular nodule was inserted subcutaneously. 
 This man developed leprosy from which he has since died. In 1889, 
 on a visit to the leper settlement of Molakai where Keanu had been 
 sent, I excised a small cutaneous nodule from his arm with a portion 
 of the overlying skin. Bacilli were found abundanth' in numerous 
 specimens of this section. The scientific value of Arning's experi- 
 ment has been nullified by the fact that Keanu came of a leprous 
 family, and it is not at all improbable that he had the seeds of the 
 disease in his system previous to the experimental inoculation. 
 
 Inoculation in Animals. 
 
 All attempts to inoculate animals with the products of leprosy 
 have been uniformly unsuccessful. Almost every species of animal 
 life has been subject to experimental inoculations. Hansen endeav- 
 VoL. XVIII. —27 
 
418 MORROW— LEPROSY. 
 
 ored to inoculate cats, rabbits, and monkeys. Kobner inoculated 
 monkeys, frogs, and various species of fisli. Hillairet and Gaudier 
 inoculated swine, but without results. Neisser, in inoculating dogs 
 and rabbits, and Damscli, in inoculating mice and cats, have produced 
 local manifestations of the disease in the tissues surrounding the 
 nodule of inoculation. 
 
 Leloir inoculated five rabbits with i)ieces of tubercular nodules, 
 introduced under the skin and into the jjeritoneal cavity. In one 
 case, after six months bacilli were found in the nodules, but none in 
 the surrounding tissues. In another case he found bacilli in the tis- 
 sues, but regarded them as bacilli coming from the nodule of inocula- 
 tion, and not as new bacilli which had been produced by the process 
 of growth and multiplication. 
 
 Beaveu Eake inoculated cats, introducing the lei)rous material 
 under the skin, in the peritoneal cavity, and in the anterior chamber of 
 the eye. These he kept under observation for four or five years, but 
 without finding an}' local growth or general dissemination of the ba- 
 cilli. Hansen inoculated animals with what he presumed to be pure 
 cultures of the bacilli with negative results. Melcher and Ortmann 
 reported that they succeeded in inoculating a rabbit by the insertion 
 of a i)ortion of a lej^rous tubercle in the anterior chamber of the eye. 
 The animal remained apparently health^', but suddenly died several 
 months later. The lungs, heart, and pericardium were found to be 
 the seat of an ai)parently fresh tubercular eruption. In the afi'ected 
 parts large round and oval cells were found containing bacilli which 
 the authors regard as lepra bacilli and not tubercle bacilli. Later 
 they reported that they had succeeded in inoculating two rabbits 
 which died four months after inoculation. The whole of the vis- 
 cera was the seat of a nodular eruption which they regarded as 
 leprous. The similarity of the tuberccle and lepra bacilli and the 
 difliculty of differentiating the nodules of tuberculosis from the nodules 
 of leprosy must be considered in appreciating the value of these experi- 
 ments. Feeding with leprous tissue has also failed to give results. 
 
 Dr. J. F. Dixon, medical superintendent of Robbeu Island, 
 Cape of Good Hojie, has contributed some curious facts illustrating 
 the immunity of animals to leprous infection. He says (Journal 
 Leprosy Investigaihuj Committee) "the domesticated animals of Eob- 
 ben Island have furnished additional evidence on the question under 
 consideration for many years past and may be almost sjDoken of as 
 having conducted an unsolicited series of exi^eriments on their own 
 persons which are of grave significance in this inquiry. 
 
 "Until quite recently the cows, and more especially the calves, 
 were in the habit of consuming large quantities of poultice recently 
 
SOUECES OF INFECTION. 419 
 
 taken from leprous ulcers and thrown out into the compound, and 
 rags and cloths that had been used in binding up leprous sores. 
 The poultry also used to eat discarded food and refuse thrown from 
 the leper wards. 
 
 " The water in which the soiled and filthy clothes and rags of the 
 lepers had been washed (in cold water only) was allowed to run down 
 an open gutter of considerable length and was drunk regularly by 
 the cows, calves, and i^oultrj^ of all kinds. 
 
 " This had been going on for many years, and all the time the flesh 
 of the animals and poultry, the hens' eggs, and the milk of the cows 
 had been freely and constantly used by all sections of the inhabitants, 
 who nevertheless remained healthy. The general health of the cattle 
 and poultry on the island is excellent, and the conclusion seems 
 inevitable that leprosy is not transferable through the medium of the 
 lower animals." 
 
 Sources of Infection. 
 
 Recognizing Hansen's bacillus as the active efficient cause of 
 leprosy, it may be assumed that all of the tissues of the body of the 
 leper containing this organism constitute possible sources of infec- 
 tion; the conditions of infection being that the bacilli should be dis- 
 charged from the bod}' of the leper, brought in contact with and be 
 capable of penetrating the tissues of a healthy organism in an oppor- 
 tune place favorable for its germination. 
 
 It is evident that the more numerous the bacilli and the greater 
 the facility of their discharge from the body of the leper, the more 
 active and virulent the source of contagion. The tubercular leper, 
 whose cutaneous tissues swarm with the bacilli and which are given 
 off in myriads from the open surface of the broken-down tubercles, has 
 undoubtedly a greater contagious activity than the ansesthetic leper in 
 whom the bacilli are comjDaratively few and embedded deeply in the 
 nerves from which they cannot readily find egress. It was formerly 
 believed that the tubercular ulcerations from which the bacilli are 
 discharged in myriads aft'orded the most prolific as well as the princi- 
 pal sources of infection. This view would imply a limitation of the 
 danger to the i^eriod of ulceration, also that the anaesthetic leper is 
 feebly or not at all contagious. 
 
 Eecent bacteriological investigations, especially of leprous lesions 
 of the mucous membranes, would seem to indicate the existence in 
 these structures of possible sources of leprous contagion, the impor- 
 tance of which has been entirely overlooked or at least not sufficiently 
 appreciated. The investigations of G. Sticker and of Jeanselme and 
 Laurens on leprous lesions of the mucous membranes of the nose. 
 
420 MORROW— LEPROSY. 
 
 mouth, and larynx, the results of which were submitted to the Berlin 
 Leprosy Congress (1897), must be regarded as among the most valu- 
 able of the recent contributions to our knowledge, as they tend to 
 throw light upon an obscure chapter in the etiology of the disease. 
 Notwithstanding the identification of the Hansen bacillus as the active 
 pathogenic agent in leprosy, our knowledge of the sources of infec- 
 tion and the channels through which bacilli gain entrance to the sys- 
 tem is by no means definite. 
 
 Several years ago before the above-mentioned investigations were 
 undertaken, I insisted upon the precocity of the mucous-membrane 
 manifestations of leprosy, asserting that in a majority of cases they 
 were first determined toward the upjier air passages, and I also main- 
 tained that the nasal and buccal secretions constituted the chief source 
 of infection in leprosy. 
 
 Jeanselme and Laurens found leprous alterations in the nasal 
 mucous membranes in sixteen out of twenty-six cases, or sixtj^ per 
 cent., of tubercular leprosy. These alterations, which were of the 
 nature of a rhinitis, attended with coryza, obstruction of the nostrils, 
 epistaxis, etc., constituted, the^^ claimed, the first signs of the disease. 
 The bacteriological examinations of the nasal secretions furnished 
 facts of the greatest interest from a semeiological point of view. In 
 the mucus of the leprous rhinitis, as in the blood of the epistaxis, 
 Hansen's bacillus was abundantl}^ found. In twelve cases it was i)os- 
 sible to detect the specific bacilli at the first examination. Some of 
 the cells were literally crowded with microorganisms having the mor- 
 phological and microchemical characters of the lepra bacillus. In 
 others the bacilli were extracellular and disseminated in the j^repara- 
 tions, but they were always agglutinated in great numbers. It is 
 worthy of note that the bacilli were also found in one case of anaes- 
 thetic leprosy. 
 
 These observers claim that : " The most important deduction to 
 be made from these bacteriological examinations is that the nasal 
 mucus of lepers is of very great virulence, and we do not believe 
 that we extend legitimate inductions in afiirming that rhinitis is one 
 of the most effective sources in the propagation of leprosy. The 
 contamination is effected all the more easilj^ as the leper discharges 
 a great number of bacilli in the initial period, when he does not sus- 
 pect the nature of the malady and persons do not protect themselves 
 from the disease. 
 
 " The same maj^ be said of the leprous lesions of the mouth and 
 throat, the nature of which is often not recognized, and which give off 
 almost continually a multitude of bacilli." 
 
 Schaffer, of Breslau, demonstrated that vast numbers of bacilli left 
 
SOUKCES OF IXFECTION. 421 
 
 the body by way of tlie diseased mucous membrane of tlie moutli 
 and throat of the leper when reading aloud or talking. The number 
 of bacilli projected would, of course, be still greater in the acts 
 of sneezing and coughing. The importance of these facts from 
 a prophylactic point of view is most interesting, and they coincide 
 with what the present writer emphasized in an article several years 
 ago : " In view of the fact that contamination probably takes place 
 from the nasal and buccal secretions, these should be disinfected, 
 etc., with the same scrupulous care as indicated in a case of tuber- 
 culosis." • 
 
 The investigations of Sticker show that in the 153 cases examined 
 by him evidences of the presence of bacilli in the secretions of the 
 nasal mucous membranes were found in a large percentage of all the 
 oases. Of these 153 cases, 58 were tubercular, 68 anaesthetic, and 
 27 mixed. Of the 58 tubercular cases, bacteriological examination 
 showed the presence of bacilli in all but 2. Of the 68 anaesthetic 
 cases, only 23 contained no bacilli, and of the 27 mixed cases, only 1 
 was free from bacilli. He concludes that the primary affection or its 
 neighborhood in the nose is chiefly the origin from which the bacilli 
 regularly and in enormous numbers are given ofl^ in the patient's 
 proximity. Only the purulent sputum of a few lepers (22 out of 153) 
 contained such enormous numbers of bacilli as the viscid or purulent 
 secretion from the diseased nasal mucous membrane. Not even the 
 suppurative nodules can compare with the above-named lesions in 
 the spreading of the bacilli. Sticker believes that the nose continues 
 to be an active focus for the projection of the bacilli during the entire 
 course of the disease, even during the periods when the cutaneous 
 manifestations have temporarily disappeared. 
 
 Physiological Secretions. — The physiological secretions may con- 
 tain bacilli when the secretory structures are the seat of leprous 
 changes, or they may serve as the vehicles of the virus. The saliva is 
 loaded with bacilli when the leprous lesions are situated in the bucco- 
 pharyngeal cavity. The bacillus has not been found in the urine, 
 although the Chinese, according to Arning, think the urine is espe- 
 cially pathogenic. 
 
 Pathological Secretions. — The altered secretions of the nasal mucous 
 membranes, the mucopus and blood, the discharges from broken-down 
 nodules and ulcerating surfaces contain the bacilli in vast numbers. 
 It is a question whether the pathological secretions in lepers of lesions 
 not produced by lejjrosy contain the bacilli. It is claimed that the 
 serous exudations of buUse provoked by vesicatories upon the skin 
 of lepers have been found to contain bacilli — a statement which is 
 contested by other investigators. In addition to the sources of in- 
 
422 MORROW — LEPROSY. 
 
 fectiou already described, it is probable that every open wound or 
 pathological break in the continuity of the skin may afford egress 
 to the bacilli. 
 
 In advanced cases of tubercular leprosy the bacilli arc able, ac- 
 cording to Babes, to penetrate the follicular wall from within outward 
 aud reach the surface of the skin when the latter is still unbroken. 
 It would appear that the opportunities for the escape of the bacilli 
 from the body of the leper, and their transference directly or medi- 
 ateh' to the bodies of healthy persons with whom he is brought in 
 contact, are almost innumerable. The only explanation of why con- 
 tamination takes place so rarely under such favoring conditions is 
 that many of the bacilli are dead when discharged. Moreover, the 
 bacillus leprjp seems to be a weak one, and, unless introduced in a tis- 
 sue soil favorable for its growth, it does not germinate. 
 
 Heredity and Contagion. 
 
 A belief in the contagiousness and hereditary nature of leprosy 
 has generally prevailed from the earliest ages until tlie present cen- 
 tury. The earl}' writers among the Arabians, Greeks, Hindoos, and 
 others have recorded their belief in the contagiousness of leprosj^ 
 though differing as regards the manner in which it occurs. All the 
 proscrij)tive measures for the suppression of leprosy formulated in 
 the Levitical code, as well as measures for the isolation of lepers in 
 leper houses enforced in mediaeval times, were based upon the doc- 
 trine that the disease was contagious. The segregation of lepers in 
 special hospitals and communities practised in many countries at the 
 present day is based upon the conviction that every leper is a source 
 of possible danger to those with whom he maj' come in contact. 
 
 The traditional belief that the disease was susceptible of hereditary 
 transmission has never l)een questioned until comparatively recently. 
 In all ages marriage between lepers has been jirohibited or discoun- 
 tenanced by church and state. In mediaeval times not only was it 
 prohibited, but the development of the disease in one partner was re- 
 garded as a sufficient pretext, and even as an urgent argument, for the 
 dissolution of the marriage tie. At the present day, in many coun- 
 tries where leprosy is endemic, the separation of the sexes in leper 
 asylums and the interdiction of marriage between lepers is enforced 
 b}' government authority. 
 
 Within the past half-century the doctrine of the contagiousness of 
 leprosy began to be seriously contested. Daniellsen and Boeck, who 
 were non-contagionists and were strong believers in heredity as the 
 principal factor in the propagation of the disease, were largely' influ- 
 
HEKEDITY AND CONTAGION. 423 
 
 ential in bringing about tliis change of opinion. In this view they 
 were supported by the prestige and high authority of Virchow. 
 
 In 1867 the Royal College of Physicians of London promulgated 
 the dogma that leprosy was non-contagious. " The all but unanimous 
 conviction of the most experienced observers in different parts of the 
 world is quite opposed to the view that leprosy is contagious or 
 inoculable by proximit}^ or contact with the disease. The evidence 
 derived from the experience of attendants of leper asylums is espe- 
 cially conclusive on these points, the few accidents that have been 
 reported in a contrary sense usually rest upon imperfect observation 
 or they are recorded with so little attention to the necessary details as 
 not to afled the above conclusion." 
 
 This opinion was generally accepted by the profession in Europe. 
 As an evidence of how complete was the overthrow of the doctrine of 
 contagion, it may be said that in 1885, when the famous discussion of 
 the contagiousness of leprosy took place in the Paris Academy 
 of Medicine, it appears that only three physicians in France upheld 
 the doctrine of contagion. 
 
 With the elimination of what had been regarded as the principal 
 factor in the acquisition of leprosy, it is not strange that the other 
 factor was proportionately magnified in importance until it came to 
 be believed that heredity was the principal agency in the propagation 
 and production of the disease. According to many leprologists the 
 influence of heredity was manifest not only in the direct line from 
 parent to offspring, but collaterally as well. It was also held that it 
 might skip over one or two generations and reappear in the descend- 
 ants of lepers and that it might reappear in the second and fourth 
 generations with greater force than in the first and third. 
 
 The sweeping assertion formulated by the Royal College of Phy- 
 sicians, that leprosy was non-contagious, was based largely upon 
 negative facts of contagion while ignoring the equally numerous posi- 
 tive facts wdiich testified to the contrary. Although the doctrine of 
 contagion was generally abandoned in Europe, it was still upheld 
 by many observers in countries where leprosy was endemic. A 
 great amount of clinical evidence was accumulated showing a vast 
 number of instances of individual and epidemic contagions. The de- 
 velopment of new centres of lejjrosy in various parts of the world, the 
 positive evidence that the disease never originated spontaneously, 
 but was always imported by lepers, the insufficiency of heredity to 
 explain the rapid spread of the disease, the observation of a large 
 number of Europeans whose ascendants were free from all possible 
 leprous contamination and in whom there could be no specific con- 
 genital predisposition, but who nevertheless developed the disease 
 
424 MORROW — LEPROSY. 
 
 after sojourning in countries where leprosy was endemic — all con- 
 tributed to foster a growing scejiticism in heredity as an important 
 factor until professional opinion gradually came again to regard con- 
 tagion as the principal factor in the propagation of the disease. 
 
 In 1887 the Eoyal College of Physicians modified its former de- 
 cision by stating " the committee is quite aware that there is much 
 difference of opinion respecting the communicability of leprosy, and 
 that many colonial practitioners and inhabitants do not concur in the 
 views expressed by the College in their report of 1867." 
 
 In 1889 the College reconsidered the whole (question and practi- 
 cally recanted its earlier opinion in the statement " that there is 
 undoubtedly, as the committee now admits, increasing evidence re- 
 specting the communicability of leprosy." It is worthy- of note that 
 in Norway and Sweden many of the former opponents of the doctrine 
 of contagion have now become its most ardent advocates. From this 
 review of the changes which medical opinion has undergone in refer- 
 ence to the mode of communication of leprosy, we can now examine 
 more particularly into the question of the hereditary nature of the 
 disease. 
 
 Is Leprosy Hereditary ? 
 
 It is scarcely conceivable that a disease of so serious a nature and 
 which so profoundly- impresses the system should not exercise some 
 influence ujion the offspring. One recognized effect of leprosy, es- 
 pecially in the tubercular form, is its inhibitory influence upon the 
 procreative power. This is doubtless due to the azoospermia which 
 is especially marked in the advanced stage of the tubercular form, al- 
 though the sterility of leprous marriages is not so pronounced as has 
 been generally assumed. Clinical evidence would seem to show that 
 the influence of leprous progenitors upon the offspring is scarcely 
 appreciable in the early stage, but becomes manifest at a more ad- 
 vanced stage in the production of abortion, or of delicate children 
 who die of infantile diarrhoea or succumb to various slight causes of 
 disease. Abortion usually occurs at the third or fourth mouth, often 
 without other assignable cause than foetal cachexia, or the infant may 
 be still-born at full term. In other cases the child is l)orn living, but 
 small, ill-developed, cachectic, and may succumb to athrepsia or de- 
 generative changes. 
 
 It has been generalh' admitted that the leprogenic capacity of 
 progenitors msLX be manifest in the transmission to the offspring 
 of a constitutional protoplasmic state, expressed in a feeble organiza- 
 tion and diminished capacity of resistance to the germs of disease in 
 general. It is not settled, however, that there is transmitted a spe- 
 
HEREDITY AND CONTAGION. 425 
 
 cific congenital predisposition to the germs of leprosy in particular. 
 In an article already quoted I wrote : " As in the case of tuberculosis 
 with which leprosy j)resents so many analogies, the influence of 
 heredity is probably limited to the creation of a predisposition to the 
 disease. This may be expressed in an abnormal susceptibility to the 
 admission and pathogenic action of the bacilli due to a weak consti- 
 tution and diminished capacity of resistance of the organism inherited 
 from the leprous progenitor." 
 
 A more careful study of the question would seem to indicate that 
 even this measure of influence accorded to leprous progenitors is a 
 concession not warranted by the facts, since, as will be seen later, 
 there would seem to be in the children of lepers a protective immu- 
 nization against the disease, by the fact of the leprosy of the parents. 
 The evidence v/hich exists is hardly sufficient to establish an inherited 
 specific predisposition to the germs of leprosy in particular. Besnier 
 says that the predisposition of children of leprous parents to leprosy, 
 if it exist, is certainly less accentuated, less particularized, and espe- 
 cially^ less characteristic than the predisposition of children of tuber- 
 culous parents to tuberculosis. 
 
 The question whether there is a direct transmission of leprosy 
 from parents to offspring is still subjndice. From a scientific stand- 
 point the acceiDtance of leprosy as a parasitic disease is hardly recon- 
 cilable with the theory that it is susceptible of transmission by the 
 ovum or sperm cell. Hansen declares that a parasite cannot be 
 transmitted by inheritance. "It maybe handed on to the xihild by 
 the parent, but in a different sense from the transmission of qualities 
 primarily embraced in the sperm cell or germ cell. To speak of in- 
 herited infection is a contradiction in terms." 
 
 It is evident that the transmission of the germs of a disease by 
 direct inheritance must take place by the sperm, the ovum, or through 
 the uteroplacental circulation. There is no evidence that the bacilli 
 find lodgment in the seminal cells, and from the comparative rarity 
 of the bacilli in the ovary and in the female organs of generation, it 
 is doubtful whether they are found in the ovum. 
 
 Besnier believes that in the rare cases in which direct inheritance 
 is effected it is by the uteroplacental contamination of the foetus. 
 The lepra bacilli, he believes, may penetrate the placenta by way 
 of the blood current. This mode of contagion he terms heredo-con- 
 tagion. It must be remembered that the presence of the bacilli in 
 the placenta or in the foetus has never been demonstrated. The only 
 recorded instance of an attempt to find bacilli in these structures was 
 made by the writer, who secured the placenta, cord, and portions of 
 the body of a child still-born at full term of leprous parents. Care- 
 
426 MORROW — LEPROSY. 
 
 t'ul repeated examinations of the specimen bv Dr. Fordvce showed 
 the entire absence of bacilli. 
 
 As regards the doctrine maintained by Zambaco Pacha and other 
 leprologists, that the germs of leprosy may be inherited, bnt remain 
 latent and appear only in later life (fifty-five to fift}' -eight years) or 
 reappear in succeeding generations, it may be said that it is entirely 
 opposed to our knowledge of the laws of heredity and the pathogenic 
 action of parasites. It involves the assumption that the pathogenic 
 bacilli may remain inert in the organism for one or more generations 
 and be transmitted conceptionallj^ by the progenitors who are them- 
 selves uucontaminated. Hansen declares that the atavic transmission 
 of physiological characters is not reproduced in the history of infec- 
 tive diseases. In discussing this question the Indian Leprosy Investi- 
 gation Committee says : " In the study of embryological deformities, 
 atavism may be of great importance, but if the term is employed to 
 denote the sudden appearance of constitutional diseases after having 
 skipped one or several generations it is inapplicable. Atavism has 
 no place in the etiology of leprosy." It is to be noted that all alleged 
 cases of atavic inheritance have been reported from countries where 
 leprosy is endemic, with more or less numerous centres of infection, 
 and where there were infinite chances of contagion from contact with 
 lepers. 
 
 But independent of theoretical considerations the facts of observa- 
 tion show that heredity cannot be regarded as a prominent factor in 
 the propagation of leprosy. A vast number of statistics have been 
 collected from various sources in favor of the doctrine of heredity. 
 Nothing shows more conclusively the misleading nature of statistics 
 than the wrong interpretation which has been given to those bearing 
 upon the question of heredity. The conclusions whicli are derived 
 from a superficial or insufficient observation of certain facts are 
 entirely traversed hj the more careful study and a more intelligent 
 interpretation of the same facts. 
 
 One or two sources of error to which statistics of this character 
 are liable may bo here i:)ointed out. The defendants of the doctrine 
 have been accustomed to class in the category of hereditary transmis- 
 sion all cases in which leprosy occurs in the descendants irrespective 
 of the age at which the disease develops, while ignoring the multi- 
 tudinous chances of infection from the leprous entourage. 
 
 It is well known that the early writers on syphilis grouped in the 
 category of hereditary syphilis all cases occurring in infants. That 
 they made no distinction between congenital and acquired infantile 
 syphilis is evident from the fact that they speak of many children in 
 whom the first infection occurs in the mouth or on the face, which 
 
HEKEDITY AND CONTAGION. 427 
 
 cases we no-w recognize as examples of tlie acquired form of tlie dis- 
 ease from nursing or otherwise. In the same way the advocates of 
 heredity speak of all leprosy in children as inherited without elimi- 
 nating the possibilities of post-natal contagion. Statistics show that 
 the average age at which leprosy develops is from the twenty-fifth to 
 the thirtieth year, and unless we concede an habitual latency of the 
 germs during this i)rolonged period, it is evident that the disease in 
 the average case is not transmitted by inheritance. 
 
 It may be admitted that leprosy is more common among the chil- 
 dren of leprous parents than among those of healthy parentage, but 
 this fact alone does not necessarily prove that the disease is inherited. 
 Leprosy is essentially a family disease, not because it is hereditary, 
 but because it is contagious and because in family life contagion more 
 readily takes place. It may be restricted to one or several definite 
 groups of families in a community for a long period, but the oppor- 
 tunities for postnatal infection in the thousand and one intimacies of 
 family life cannot be ignored, and a closer study of these cases shows 
 that the occurrence of leprosy among them is more reconcilable with 
 the chances of accidental contamination than the theory of heredity. 
 
 The facts which may be invoked in favor of the non-hereditary 
 character of the disease may be considered under the following heads : 
 
 (1) Rarity of Congenital Leprosy. — The exceeding rarity or com- 
 plete default of cases of children born with leprous manifestations 
 has been remarked by most observers. The testimony of careful and 
 painstaking observers living in leprous countries, who have person- 
 ally studied the disease in all its phases for years, is almost without 
 exception to this effect. 
 
 Daniellsen and Boeck have never seen leprosy appear before the 
 third or fifth year. They state that lepers have come to them saying 
 .that their children were born with spots or with bullae of the extrem- 
 ities, appearing in the first months of life, but personally they have 
 never seen a new-born child bearing leprous stigmata. 
 
 Leloir, in his extensive personal investigations of leprosy, never 
 found a fostus or new-born child affected. Out of 149 cases only 3 
 developed leprosy under ten years— at four, six, and eight years of 
 age respectively. W. M. Jelly, in his investigations of leprosy in the 
 Spanish provinces of Alicante and Valence, searched in vain for a 
 leprous infant. He declares : " I have never seen or been able to find 
 an exanthematous leprous baby or child." Falcao found in 709 cases 
 only 3 as early as four years. The Leprosy Commission of India 
 found in 2,371 cases only 49 as early as six years. Among the 6,000 
 or more cases observed in Hawaii, the youngest patient was three and 
 one-half years old. In Cape Town, Africa, Impey states that of 1,( 
 
428 MORROW — LEPROSY. 
 
 cases in only 2 was the disease developed in children under five years 
 of age, the youngest person contracting the disease being three years 
 old. It would be easy to adduce testimony to the same effect from 
 numerous other sources. 
 
 In the article to which reference has alreadj^ been made I wrote : 
 "There is no well-authenticated case of congenital leprosy on rec- 
 ord. Navarro has reported a case of congenital leprosy which is ap- 
 parently one of inherited syphilis. Two months subsequent to the 
 child's birth the mother showed decisive signs of leprosy, as did also 
 her daughter eight months later, and a daughter of three years died 
 two years later; but as syphilis is bj^ no means excluded, we are not 
 bound even to accept this as a decided case of the hereditary trans- 
 mission of lei^ros}'." 
 
 In contravention of this statement the only observations which 
 may be regarded as of a positive character are those of Zambaco 
 Pacha, reported in his " Yoj'^ages chez les Lepreux." He admits that 
 congenital leprosj^ appearing a short time after birth, some months 
 or some days, is exceedingly rare. Sometimes one child in a family 
 will be a leper, the others remaining unaffected, Avhile in other cases 
 one child may remain healthy while all the other children become 
 lepers. He reports a number of cases in which children were born 
 with undoubted manifestations of the disease. It is to be noted, how- 
 ever, that Zambaco Pacha denies the contagiousness of leprosy and 
 accords the first place to heredity in the spread of the disease. He 
 also denies the pathogenic role of Hansen's bacillus and asserts that 
 to be born of leprous parents or to belong to an ethnical group in 
 which leprosy is endemic would be sufficient evidence of heredity. 
 
 It will be seen that according to the testimony of the most com- 
 petent observers leprosy is not manifested in the offspring until 
 years after birth ; very exceptionally as early as the third year, rarely 
 before the fifth or sixth year, which would correspond to the classical 
 period of incubation of the acquired disease. Even conceding the 
 authenticity of Zambaco Pacha's cases of congenital leprosy, the pro- 
 portion of such cases is infinitesimally small. 
 
 Aye at ivh'wli Leprofiy DeveJoj^s. — In quite a proportion of cases 
 leprosy may be first evident at the age of puberty, from the twelfth to 
 the fifteenth year, but in the immense majority of cases it does not 
 develop before the thirtieth year of age. The clinical history of 
 leprosy is more in accordance with the doctrine of contagion than 
 with that of inherited transmission. The incidence of the disease in 
 the children of leprous parents is in direct ratio to their exposure to 
 the ordinary sources of contagion. 
 
 The evidence presented in favor of heredity has never been exclu- 
 
HEREDITY A^T) COXTAGIOX. 429 
 
 sire of all possibilities of i:iostnatal contagion. There is uo case 
 recorded of a new-born cliild promptlv removed from all chances of 
 contact -with lepers, wliich later showed signs of the disease. In all 
 cases of so-called heredity there is everr reason to believe. that if the 
 children had been iiromptly removed from their leprous entourage, 
 they would have escaped the infection. It was largely because of the 
 commonly observed exemption of the offspring of lei^ers from the 
 parental disease that the Kapiolani Home was established at Hono- 
 lulu. The results of this practical scheme of separation show that if 
 children are removed from exposure to contaminating contact at an 
 early age, before postnatal infection takes place, they remain free 
 from the disease. 
 
 The Comparative Rariiy of a History of Leprous Antecedents. — An- 
 other argument which goes to show that the inffuence of heredity, if it 
 exist, must be exceedingly restricted is the small proportion of cases 
 in which there is a history of leprosy in the iDarents. According 
 to Impey, there are at present (1896) in the Eobben Island Asylum 
 520 lepers, of whom 475 were born of healthy parents ; of the remain- 
 ing 45 cases, the father alone was affected in 25, the mother in 16, and 
 the father and mother both were diseased in only 4. Again there 
 are 2Q% leper parents at the asylum who have had 951 children. Of 
 these children 23 became leprous, which is less than 3 per cent, of the 
 whole. 
 
 The comparatively small proiDortion of children (less than three 
 per cent.) who became leprous would seem to indicate that the exist- 
 ence of leprosy in parents exercises upon the offspring a protective 
 rather than a predisposing influence to the disease. We can scarcely 
 conceive that, of an equal number of children born of healthy parents 
 placed in this leprous environment and subjected to the numerous 
 chances of contamination incident to the intimate contact of family 
 life, only three per cent, would escape. A^Tiether there has been in 
 these children a " vaccinatory immunization, " as it has been termed, 
 or whether there is a greater resisting power in the tissues of chil- 
 dren against the lepra germs cannot be determined. The assertion 
 that the lepra bacilli may lie latent for a long time in children and 
 not develop until individual resistance is lowered is purely hypo- 
 thetical. Certainly these facts do not tend to favor the theory of a 
 specific predisposition to the disease. 
 
 The statistics of the Almora Asylum in India may be referred 
 to. Of 14 children who had been admitted, 1 had died; a girl 
 of twenty-two had married and had children to all appearances 
 healthy. Of the remaining 12, 7 were born in the asylum, of two 
 leper parents, and 5 were the offspring of parents, both lepers. 
 
430 MORKOW — LEPROSY. 
 
 They were iu excellent health aud showed no signs of leprosy. At 
 Crete, Carter found that among 88 grown-up children of lepers, sev- 
 eral thirty years of age, only 6 per cent, were leprous. Bracken re- 
 jiorts that of 34 Norwegian lejiers who had emigrated to this country, 
 21 are known to have been married — 15 men and 6 women. These 
 marriages have resulted in 78 children, not one of whom show signs 
 of the parental disease. Hansen, who in 1891 made a tour of investi- 
 gation iu the Scandinavian colonies of North America, found that of the 
 descendants of 108 lepers who had emigrated from Norway to this 
 country, not oue had become a leper. Dr, Brockman estimates that 
 there must be in Minnesota alone 100,000 persons with leprous an- 
 cestors of Norwegian descent, direct and collateral, yet leprosy has 
 never appeared among them. My examination of numerous lei)ers iu 
 Mexico failed to reveal the history of hereditary taint in a single in- 
 dividual. 
 
 Spread of Epidemics. — The history of leprosy in the Sandwich 
 Islands and other endemic centres shows conclusively that the rapid 
 increase in the number of lepers is vastly disproportionate to the 
 number of births among lepers. Sterility is a common result of mar- 
 riages among Hawaiian lepers. Only five children were born in the 
 leper settlement of Molokai within ten years, although no restriction 
 was placed upon the intermarriage of lepers. In 1886 Mouritz col- 
 lected statistics of twenty -six children born in the leper settlement, 
 whose ages ranged from three to fourteen years. Seventeen of these 
 showed no sign of the disease. All of these children lived under the 
 most favorable conditions that could be conceived for contracting the 
 disease, and it is altogether i)robable that if the nine who became 
 infected had been removed from contact with their leprous parents at 
 an early age they would have escaped the disease. 
 
 In tracing the develoj^ment and spread of leprosy in the Sandwich 
 Islands, a careful study of the facts shows that heredity cannot be 
 considered an important factor. According to the most authentic 
 accounts the first case of leprosy was observed about 1846. Twenty 
 years later several hundred lepers were sent to the leper settlement, 
 a large proportion of whom must have been born years before lep- 
 rosy was introduced into the islands. 
 
 When we consider that over six thousand lepers have been con- 
 signed to this leper settlement since its establishment, it is evident 
 that onl}' a very small contingent could have been the offspring of 
 leper parents. 
 
 Finally may be noted the numerous cases in which heredity is 
 impossible, shown by the fact that Europeans who have lived in 
 countries which have been free from leprosy for centuries, and iu 
 
HEREDITY AND CONTAGION. 431 
 
 whom by no possibility could a hereditary taint be alleged, acquire 
 the disease when sojourning in countries in which leprosy prevails. 
 
 Another argument may be drawn from the historical fact that the 
 Chinese have spread leprosy through the greater part of the Indian 
 Archipelago, Oceanica, and the islands of the Pacific. The many 
 natives and foreigners who have contracted the disease are not of 
 Mongolian descent. 
 
 Is Leprosy Contagious ? 
 
 As before intimated in reviewing the change which medical opin- 
 ion has undergone in reference to the etiology of leprosy, the doc- 
 trine of its contagiousness has within recent years regained the 
 ascendency and this is now generally regarded as the principal factor 
 in the propagation of the disease. 
 
 The discovery of a specific bacterium which is invariably and ex- 
 clusively found in the bodies of lepers, and which can be brought into 
 causal relation with every manifestation of the disease, gave a new 
 aspect to the question of contagiousness. Even before the demon- 
 stration of the constant presence of the bacillus leprs3 in the anatomi- 
 cal elements and secretions of the lejDrous subject there was abundant 
 clinical evidence of the communicability of the disease. The facts of 
 observation, as well as analogies with other diseases admittedly con- 
 tagious, rendered it difficult to conceive how a disease so specific in 
 its characteristics could develop without a specific cause. Bacterio- 
 logical research simph^ confirmed what clinical evidence had already 
 demonstrated. 
 
 The contagiousness of leprosy would seem to be a necessary 
 corollarj^ of the demonstration of its parasitic nature. The existence 
 of a specific bacillus is not, however, accepted by all as convincing 
 proof that it is the pathogenic agent and that it is transferred 
 directly by contact of a leper with a healthy person. The only link 
 wanting in the chain of direct evidence is that the modus operajidi of 
 contagion, the actual transference of the bacillus from one person to 
 another, does not admit of positive demonstration. The circumstan- 
 tial evidence is sufficiently comjjlete. An individual affected with 
 leprosy in whose lesions the bacilli are found comes into more or less 
 intimate and prolonged contact with a healthy person free from these 
 germs. By and by the latter shows symptoms which indicate that 
 he has been the recipient of the germs of the former — he becomes 
 leprous. It is evident that in some way or manner the germs from 
 the diseased person have passed into the healthy organism and 
 infected it. This infection takes place under certain well-fixed laws 
 and conditions which are doubtless peculiar to the leprous process. 
 
432 MORBOW— LEPROSY. 
 
 It is probable that the mode of contagiou of every bacillary disease has 
 au iudividuality of its own, depending partly upon the germinative 
 qualities of the bacilli causing the disease and partly upon the soil 
 that these organisms re(iuire for their development and the comple- 
 tion of their cycles of life. 
 
 Whether, as has been suggested, the lepra bacillus undergoes an 
 evolutionary change outside the, human bod}' in some intermediary 
 host before it becomes endowed with a germinative capacity when 
 brought in contact with human tissues is immaterial to the present 
 inquiry. The hyi^othesis of an intermediary host does not alter the 
 fact that the bacillus which comes from the leper's body is the essen- 
 tial agent of contagion. 
 
 Lhstaiices of Co)itagio)i. — The literature of lejorosy abounds with 
 well-authenticated cases of individual contagious, showiDg in the 
 clearest and most positive manner that the disease spreads from 
 leprous to healthy persons by contact. Thin, in his work on 
 "Lepros}'" (page 141 ctscq.), has quoted more than sixty well-authen- 
 ticated observations tracing directly the communication of the disease 
 from lepers to previously healthy persons by individual contact or in 
 family life. A few of these cases may be here given : 
 
 At Grenada, a girl, aged about twelve to fourteen, slei:)t in the 
 same bed with a young woman who had symptoms of leprosy. 
 Within twelve months the girl had a. leprous rash, and was a con- 
 jfirmed leper seven or eight years afterwards. The mother of this girl 
 contracted the disease ; the father escaped. 
 
 A healthy girl, aged seven, slept in the same bed with a bo.y, aged 
 nine, who was leprous, and she became affected with leprosy. 
 
 Dr. Davy cites the case, on the authority of the medical officer of 
 Trinidad Hosj^ital, of a man who became a leper after two children 
 had been born to him. Afterwards these children became leprous. 
 
 A European officer in India became leprous when he was forty- 
 five, and within two years had developed the full stage of tubercular 
 leprosy. His large family and many relations, as well as parents, 
 were perfectly healthy. 
 
 A boy lived with an apothecary who was a leper, and became 
 leprous. A convict, acting as orderly to the same apothecary, became 
 affected with the disease and died within a year of the first appear- 
 ance of the affection. 
 
 A European, who was a leper, stated that he had contracted 
 the disease from a favorite servant who was constantly about his 
 person. 
 
 A child wh(;se ])arents, grandparents, and four brothers and sis- 
 ters were healthy was the favorite of a leper, the brother of his grand- 
 
HEEEDITT AND CONTAGION. 433 
 
 father, and frequentlj slept in tlie same bed witli liim. He became 
 affected witli leprosy. 
 
 A woman in whose family it was known that for three generations 
 there was no leprosy was sent when a child to Eze, County of Nice, 
 to be wet-nursed by a woman who appeared to be healthy, but in 
 whose family there had been cases of leprosy. On the woman her- 
 self, immediately after the child was weaned, leprous manifestations 
 were observed. The child grew up and became leprous in mature 
 years. She married and had four children. Her husband and two 
 daughters, who died young, had no lepros}". The other two children 
 (sons) have since died lepers. Of these sons there is the following 
 history : One developed symptoms of leprosy when doing his mili- 
 tary service, after having left Eze. He died, aged twenty-eight, of 
 lepros3^ His brother died of leprosy at fifty. His wife still lives 
 and is well. He had been long in intimate relations with a woman 
 who came from the north of France, and who belonged to a family in 
 which there was no leprosy. This woman and one of her sons, who 
 had been much associated with the man, became leprous three years 
 after he showed symptoms of the disease. 
 
 A family named Quin, consisting of a father, mother, and five 
 children, all in good health and free from leprous taint, left Nice for 
 St. Laurent d'Eze. There they associated daily with a family of 
 lepers. They had meals in common and slept on straio in the same 
 granary. After six years of this intimacy leprosy appeared in the 
 family of Quin. The mother and five children successively died of 
 leprosy, and the father has just died of leprosy in the hospital at 
 Nice. 
 
 The village of Turette, situated on the right bank of the Paillon 
 river of Nice, was free from leprosy until 1815. At that time a fam- 
 ily Mas took a servant who was a leper. From this patient 
 
 leprosy was conveyed gradually to nine persons. The household 
 
 Mas , husband and wife, were attacked first; then a family 
 
 Gar , who had frequent relations with the Mas . A cousin of 
 
 the Gar family, who lived with them, was also affected, as well 
 
 as his wife. His three children still live at Tourette, and are lepers. 
 One- of the latter, having long lived in a shepherd's hut, made a pres- 
 ent of the cabin in which he had slept to a shepherd belonging to a 
 healthy family. This shepherd lived in the cabin for a long time. 
 He is now a leper. 
 
 According to Simond, quoted by Forne, fourteen convicts, trans- 
 ported to Guiana, thirteen of whom were born in France and one in 
 Algiers, became leprous after they were set free. 
 
 A Sister of Mercy, born in France of healthy parents, and who 
 Vol. XVIII.— 28 
 
434 MORROW — LEPROSY. 
 
 had excellent health until she was forty-six years of age, came to 
 French Guiana in 1862. Five years after her arrival there she be- 
 came attached to the service of the lazaretto of Acarouany, where she 
 was occupied in attending to lepers in various ways. In 1878, at the 
 age of forty -six, after having been eleven years in the lazaretto, she 
 experienced the first symptoms of leprosy, and in 1883 was in the last 
 stage of the disease. She believed she had been infected by washing 
 linen beloDging to leper women ; but Dr. Hulin do Godon stated that 
 the Sister became leprous after having pricked her fingers with a 
 needle, which she had used in sewing le^iers' clothes. 
 
 A European Sister of Mercy, free from heredi^ry taint, who was 
 occupied in the linen room of the hospital at Tahiti, inoculated her- 
 self with a sewiug-needle under the same condition as the Sister at 
 Guiana. Se was sent home to France, in 1885, a leper. 
 
 A European child, nine years old, free from taint, associated with a 
 leprous colored child. During their play the leprous child took a 
 pin or penknife and thrust it into the aneesthetic skin of his leg with- 
 out experiencing pain. The astonished white child repeated the 
 experiment on himself, causing severe pain. He was afterwards sent 
 to Holland to be educated, and returned, when nineteen years old, to 
 Java, a confirmed leper, the disease having appeared two j-ears before 
 his return. The gentleman was well known in Batavia, and the case 
 was clearly either one of contagion or inoculation. 
 
 Sir William Moore relates that when he was stationed in India he 
 had the patients (some of whom suffered from leprosy) who were 
 affected with itch rubbed with sulphur ointment at the dispensar3^ 
 One of the persons employed to do this injured her hand and after- 
 wards developed leprosy, her family being quite free from the mal- 
 ady, and no history of other association with le^iers being obtainable. 
 
 Prof. Cayley relates that, in 1886, the leper ward at Burdwan 
 jail contained about thirt}"^ lepers. During the twelve months that he 
 was in charge of the jail two persons who had been there four or five 
 years, and who were selected as healthy men, were put in charge of 
 the leper ward and were attacked with lepros3\ 
 
 A white girl, aged fifteen, of good family, without leprosj^ taint, 
 accepted an invitation from a young friend, members of whose family 
 were lepers, the fact being concealed. The girls slept in the same 
 bed, and lived intimately together. After three months the girl be- 
 longing to the leprous family left her friends, and some time after- 
 wards the disease made its appearance. The girl who was invited 
 grew up to womanhood, married, and had children; but after a few 
 years the disease attacked her, and she died a leper. 
 
 A boy belonging to a clean family used to play and sleep with a 
 
HEEEDITY AND CONTAGION. 435 
 
 boy who belonged to a family in whicli there was leprosy. The 
 tainted boy soon became a leper, and three years afterwards his play- 
 fellow, in whose family there was taint, became leprous. 
 
 A white man, aged twenty-five, was on intimate terms and slept 
 with a young man who had leprous spots. In the course of about a 
 year the previously clean man found spots on his person, and died 
 in a short time of leprosy. His family was and remained free from 
 all taint. 
 
 A young colored boy, of clean family, while suffering from an 
 eruption, played with a boy who was a leper and had a suppurating 
 ulcer in the foot. The previously healthy boy became a leper about 
 a year afterwards, his family remaining untainted. 
 
 A young Scotchman, whose parents had never left Europe, was 
 contaminated by a leper woman. Within ten months he developed 
 leprous spots and died a leper. 
 
 A colored man, a leper of Kaoo Island, stated that he attributed 
 his disease to the fact that his mother washed the clothes of several 
 lepers and used to wash his along with them. He stated that his 
 parents and relations, so far as he knew, were free from leprosy. 
 
 Dr. Liveing relates that a soldier who had served in India died in 
 Guernsey, and that in his last illness he had sores on his fingers and 
 toes, an enlargement of the nose, and discoloration on the skin of the 
 face. One of this man's sons, when fifteen years old, developed 
 leprosy. 
 
 The only case except that of Dr. Hawtrey Benson that we have 
 found recorded, in which the disease must have been communicated 
 in England, is that published in Guy's Hospital Eeports for 1868, 
 and referred to by Munro. Johanna Crawley, an Irishwoman, aged 
 thirty-four, had lived thirty years at Stepney. In 1866 she had lost 
 part of the first finger of the right hand. On her body and limbs 
 were large brown patches, and there was decided anaesthesia as far up 
 as the elbows. The face was puffy, the lips and ears were swollen. 
 Munro saw her daughter at Stepney, a woman aged twenty-five, and 
 was informed by her that Johanna died in 1874, after losing part of 
 all her fingers and toes, the blisters and destruction of bone causing 
 great pain. 
 
 A widow, aged fifty-eight, with several children, went to live with 
 a daughter who was a leper, and was attacked five years afterwards 
 when she was sixty-five years of age. 
 
 In St. Kitts, Hannah Carty, when a girl, slept with and washed 
 the clothes of T. Wilson, who was covered with leprous sores. She 
 was attacked at the age of seventeen. Her family were all healthy. 
 
 Epidemic and Endemic Contagions. — When leprosy invades a new 
 
436 MORROW — LEPROSY. 
 
 counh'T or a commimitr, which is biit an aggregation of individuals, 
 the same mode of contagion is manifestc It spreads from individual 
 to individual b}- proximity or contact. The primarj^ essential condi- 
 tion of the development of leprosy in a country or race pre%-iously ex- 
 empt is the importation of leprous germs in the body of a leper who 
 becomes a centre of contagion, and creates new foci of the disease 
 around him. The disease spreads more or less rapidly, assuming 
 epidemic proportions or becoming circumscribed in small endemic 
 foci according as the conditions are more or less favorable. When 
 introduced into a virgin soil, as in the Sandwich Islands for example, 
 where the racial susceptibility to disease is marked and the conditions 
 for its multiplication are favored by promiscuity in the habits of eat- 
 ing, drinking, and sleeping, and where free and intimate contact with 
 the leper is restrained by no wholesome fear of the disease, it spreads 
 with exti'aordinary rapidity and shows all the characteristics of a 
 virulent epidemic. 
 
 WTien imported into countries of advanced civilization, in the 
 United States or Central Europe for example, whsre the physical 
 stamina is of a higher order, where the rules of personal hygiene and 
 sanitary living are observed, and where public sentiment or popular 
 prejudice looks upon the leper as the bearer of a deadly contagion to 
 be shunned and avoided, lej^rosy rarely spreads, and contagion can 
 scarcely be said to exist. 
 
 In countries where leprosy has been endemic or maintained in 
 permanence for generations or centuries it will be found that its lim- 
 itation or spread is largely influenced by the more or less free con- 
 tact of the leprous with the healthy. Where public opinion has 
 inculcated a wholesome dread of the disease or where governmental 
 authority has taken measures of isolation and protection the disease 
 is circumscribed and limited ; in countries where neither law nor pub- 
 lic opinion prevents the free intermingling of lepers with the healthy 
 of the community the disease siDreads. 
 
 In India, Mr. McNamara says: "Although lepers move about 
 among their countrymen, they are to a great extent isolated from 
 them. )iMio ever saw a healthy native touch, much less eat with, one 
 afflicted with leprosy? In many parts of India the fact of admit- 
 ting a leper to a general hospital is sufficient to drive every other 
 person out of it. The wealthy leper may purchase immunity from 
 some of the social evils to which his poorer brethren are exposed; 
 but even he is frequently obliged to leave house and home and wan- 
 der as an outcast over the face of the earth, visiting shrines and holy 
 places in expiation of his sins which he believes have been punished 
 by the infliction of leprosy. Rich and poor lepers, however, though 
 
HEEEDITY AND CONTAGION. 437 
 
 living and moving among their fellow-men, are as isolated from tliem 
 as vi^ere those condemned to the lazar houses in the Middle Ages. 
 
 Of interest in this connection are Vandyke Carter's observations of 
 the method of dissemination of leprosy in India. " Taking the more 
 infected districts, we find that while much of the surface is covered 
 by disease, yet the leper villages are not indiscriminately scattered. 
 Thus the chief town always represents a chief ' focus ' ; nest the vil- 
 lages immediately around are affected, and beyond these pass off, as 
 it were, lines of leper localities in various directions which may meet 
 and blend or become continuous with similar lines in adjoining dis- 
 tricts. At present I find hardly a single instance in which a leper vil- 
 lage does not form either a focus or a part of lines or groups such as 
 those now mentioned. No leper village is found to be isolated ; all 
 are connected with others immediately adjoining, the rare uninfected 
 intervening villages being temporary or incidental exceptions. All 
 these data may be said to point to transmission of the leprous disease 
 by human intercourse — that is, by contagion." 
 
 The opponents of contagion base their belief largely upon the fail- 
 ure of all attempts to inoculate the disease, the observations of numer- 
 ous persons who have lived in prolonged contact with lepers without 
 having contracted the disease, as for example physicians, Sisters of 
 Charity, nurses, and attendants who have come in contact with lepers 
 in hospitals, the comparative infrequency of conjugal contamination, 
 the failure of leprosy to spread when imported into certain countries, 
 and finally the fact that leprosy does not comport itself as a contagi- 
 ous disease. These objections may be considered in detail. 
 
 Failure of Inoculation Experiments in Animals. — The result of ex- 
 perimental attempts in inoculating animals is a record of failures 
 simply because leprosy is an exclusively human disease. The tissues 
 of the human species furnish a culture soil favorable to the reception 
 and development of the pathogenic agent, while the tissues of ani- 
 mals are immune. 
 
 The proposition, that because a disease cannot be inoculated in 
 animals, it therefore cannot be transmitted from man to man, would 
 be equivalent to a denial of the contagious nature of many diseases 
 admittedly contagious. There is no well-authenticated proof of the 
 inoculation in animals of syphilis, which may be considered the type 
 of an inoculable disease. Besides, all experience shows that nothing 
 is more difficult than inoculating animals with human diseases. The 
 failure may in many instances be due to our ignorance of the precise 
 conditions which determine the vegetability of disease germs. As is 
 well known, the earlier attempts to inoculate the products of tubercu- , 
 losis were failures. 
 
438 MORROW — LEPROSY. 
 
 Failure of Atfempfs to Iiiocniafe Blan. — While the results of these 
 experiments, which are elsewhere referred to in detail, were simply 
 negative, they cannot be considered absolutely demonstrative of the 
 impossibility of inoculating leprosy in man. It must be remembered 
 that they Avere undertaken at a period when the bacteriology of the 
 disease was unknown, and with no attention to technical details which 
 are now deemed essential in experimental imjuiry, or it is possible 
 that the systems of the healthy, well-fed individuals who were subjected 
 to experiment were not in a condition to conceive and develop the 
 ]iathogenic action of the bacilli. As Besnier suggests, " one should 
 not forget that the iusuccess of an inoculation often depends upon the 
 ignorance of the experimental conditions attached to the special mode 
 of contagiosity peculiar to the affection" ; further, " if experiments 
 upon man were lawful at the present day, absolute demonstration 
 would not be long in forthcoming. " The only case in which inocula- 
 tion from man to man was claimed to be successful was that of Keanu, 
 elsewhere referred to. 
 
 Unless we single out leprosy as an exception to other infectious 
 diseases, the negative facts of inoculation experiments cannot be con- 
 sidered proofs of its non-contagiousness. It is well known that the 
 germs of diphtheria, scarlatina, cholera, typhoid fever, etc., have 
 never been inoculated in man, but this negative evidence cannot be 
 considered as proof of their non-infectious character. 
 
 Keference might be made to the repeated attempts to inoculate 
 favus in man and the uniform failure of all the earlier attempts to 
 transfer the disease from one host to another. The question of vac- 
 cination leprosy has an important bearing upon the determination 
 of the possibility* of inoculating the disease and will be considered 
 later in connection with the modes of infection. 
 
 My own belief is that leprosy is inoculable in man, and that w^e 
 have abundant clinical proof that accidental inoculations play an im- 
 portant role in the introduction of the germs. 
 
 Rarity of Conjugal Contamination. — The concurrent testimony of 
 many observers in various parts of the world where leprosy is endemic 
 shows that when one partner of a marriage is a leper the incidence of 
 the disease in the other partner is surprisingly small, on the assump- 
 tion that contagion takes place from intimate contact. Besnier dis- 
 poses of the whole question, especially of the cases in which a healthy 
 woman has borne children to a leprous man wdiile she herself shows 
 no signs of the disease, on the ground that the immunity of the wom- 
 an is not a fact of non-contamination, l)ut a fact of conceptional im- 
 munization comparable to Avhat is realized in conceptional syphilis, 
 as formulated in the law of Colles. It may be urged against this in- 
 
HEEEDITT AND COXTAGIOX. 439 
 
 terpretation that it takes no account of the e4iially large and perhaps 
 larger number of eases in which a healthy man is married to a leprous 
 woman, or has relations -u-ith numerous leper "n-omen, without being 
 contaminated. 
 
 I have reported the case of a Hawaiian who had been the husband 
 of a leprous woman for twenty-nine years, two daughters of this 
 union both being leprous, while he remained absolutely fi'ee from all 
 signs of the disease. This was probably a case illustrating absolute 
 immunity, as the entire family lived in the leper settlement, and the 
 opportunities for extra-conjugal contagion were numerous. Many 
 instances of similar character came under my observation, as my at- 
 tention was particularly directed to this class of cases, since they 
 were in opposition to the opinion which generally prevailed among 
 the i)hysicians, as well as the laity, of Hawaii, that the disease was 
 commonly propagated by sexual intercourse. 
 
 An explanation, though in my opinion an insufficient one, of this 
 frequent immunity from marital contagion has been sought in the 
 fact that the age at which lepers marry corresponds to a period in 
 which the susceptibility to the disease is markedly diminished. An 
 analysis of a large number of cases shows that the susceptibility to 
 the disease is particularly marked from the twentieth to the thirtieth 
 year. After the thirtieth year the tendency progressively decreases, 
 so that leprosy is apt to attack the man before the age of marriage, 
 and as it often saps the virility, especially in tubercular cases, the 
 wife incurs no additional risk to that of any other person in contact 
 with a leper. It is claimed that " when.leprosy occurs after marriage, 
 by the time the man is able to communicate the disease his wife has 
 from her age become in most cases insusceptible." 
 
 Too much importance should not be attached to explanations of 
 this nature, as observations prove most conclusively that lejjrous con- 
 tamination in maiTiage is by no means uncommon. It must be re- 
 membered that in its mode of contagion leprosy resembles tubercu- 
 losis rather than syphilis. It is a matter of general observation that 
 consumption, an admittedly contagious disease, is rarely inarital, 
 while syphilis is almost always shared with the partner in maniage. 
 
 A few of the numerous cases recorded in literature which show in 
 the most positive manner that the wife or husband has contracted the 
 disease from the other during marriage may be here quoted. 
 
 The following cases are taken from the reports to the Government 
 of India and other well-authenticated sources ("Leprosy," Thin, pp. 
 139 et seq.) : 
 
 A girl, in whose family there was no trace of leprosy, married a 
 leper, and after some years became leprous. 
 
440 MORROW — LEPROSY. 
 
 A sweeper, who belonged to a family iu which there was no lep- 
 ros}', married a leper woman, and himself became a leper. 
 
 A weaver, whose father and elder sister were lepers, became lep- 
 rous at thirty. His wife continued to live with him and eventually 
 became a leper. 
 
 A weaver became a leper at forty -five. His wife continued to live 
 with him and became leprous. 
 
 A cultivator became leprous at forty-eight. His wife became 
 affected with leprosy a year later. 
 
 A man became a leper at thirty-two, his brother being a leper. 
 His wife lived with him for two jears afterwards and became leprous. 
 
 A woman, whose grandfather and father were lepers, became a 
 leper at twenty-eight. Her husband, who lived with her a year after- 
 wards, became affected. 
 
 A sweeper became a leper at eighteen, and his wife was afterwards 
 affected. 
 
 A woman, whose father died of leprosy, became affected, and her 
 husband developed leprosy the following year. 
 
 Deputy Surgeon-General Cockburn states that he had seen a wife 
 with her two children contract the disease by remaining with her hus- 
 band, who was affected by it, while three other children who left him 
 remained free. 
 
 Greene states that he has seen several instances at Sehampore 
 Hospital in which the disease was acquired by sexual intercourse. 
 
 Ghose relates a case of a woman who became leprous after her 
 , husband. When he died, she went to live with her brother, and 
 within a year the brother acquired leprosy. In the course of six 
 years three other individuals in neighboring houses got the disease. 
 Ghose was assured that before this woman returned home after her 
 husband's death there had not been a leper in that village. 
 
 Van Hoist relates the case of an officer in Dutch Guiana who con- 
 tracted leprosy from cohabiting with a woman whose family were 
 affected with the disease. 
 
 Two instances at Corfu are related iu which the wives became lep- 
 rous some years after the husbands. 
 
 At Mauritius, a case is related in which a wife became affected 
 after her husband, and another in which, after a man became a leper, 
 the child of his wife by a former husband became affected. 
 
 An Englishman in British Guiana cohabited with a colored woman 
 and became leprous. The woman had not been suspected of leprosy, 
 although afterwards it was found that she had had the spots on her 
 body previously. One of her sisters was leprous, and the woman's 
 child, when five years old, exhibited signs of the disease. 
 
HEREDITY AND CONTAGION. 441 
 
 A wliite man, aged twenty -five, became a leper after sleeping in 
 the same bed and using the same pipe with a leper. 
 
 A man, soon after the birth of his first child, discovered that his 
 wife was a leper, and shortly afterwards became one himself. His 
 children remained free. 
 
 A girl belonging to a leprous family of Laghet left her home when 
 twelve years of age and became a servant at Nice. When she was 
 twentj'-two, and in perfect health, she married a healthy, strong young 
 man from the north of France. She was nineteen years old when her 
 father first showed signs of leprosy. When she was twenty-seven 
 years old she had leprous tubercles below the left breast, and died at 
 the age of thirty at the hospital at Nice. Two years after the death 
 of his wife the husband showed leprous development in the face, and 
 died of the disease three years later. 
 
 An Englishman, whose parents never left Europe, lived with a 
 woman who some time afterwards showed symptoms of leprosy. The 
 man became a leper and was seen by the commission. 
 
 A white man, aged thirty -five, born in England, cohabited with a 
 colored woman who was leprous without the fact being known. He 
 became a leper and died of the disease in Europe. 
 
 Munro also quotes Schilling to the effect that he could point out 
 many examples of husbands and wives contracting the disease during 
 marriage "did shame j)ermit." 
 
 Rm^ity of Contamination of Physicians, Nurses, and Others loho Care 
 for Lepers.- — The argument of the Koyal College of Physicians against 
 the contagiousness of leprosy was chiefly based upon data of this na- 
 ture, viz. , " the evidence derived from the experience of attendants in 
 leper asylums is especially conclusive upon this point." 
 
 The same argument might be employed against the contagiousness 
 of syphilis, tuberculosis, etc. During his long service at the Bromp- 
 ton Hospital for Consumptives Williams declares that he has observed 
 only three or four cases of contagion among the personnel of the hos- 
 pital. 
 
 In the great establishments for consumptives at Gorbersdorf, in 
 German}^ which have received twenty-five thousand jjatients within 
 forty years, the mortality among the attendants, who are taken from 
 an outdoor to an indoor life, is very low in spite of most exhausting 
 work. 
 
 The immunity against leprosy is no more remarkable than that ex- 
 hibited by the attendants upon consumptive patients. In general hos- 
 pitals where tuberculous i)atients are received without being isolated, 
 as well as in special sanatoria for this class of patients, the rarity or ab- 
 sence of transmission of the disease is a matter of common observation. 
 
442 MORROW— LEPROSY. 
 
 lu my observatiou of more tliau fifteen jears in the venereal 
 wards of the Charity Hospital of this city I have known of but two 
 jihysiciaus who have contracted syi)hilis from contact with patients 
 in this service. Within the same period I have been consulted by 
 twenty times that number of medical men w^ho have contracted syph- 
 ilis in family practice, surgical and obstetrical. It is a noteworthy 
 fact that specialists in venereal disease who are most exi:iosed to con- 
 tact with syphilis are rarely contaminated, because they recognize 
 the possible dangers and take greater jjrecautions against infection, 
 while those engaged in family practice are not impressed with a recog- 
 nition of the risks incurred and the necessity of great circumspection 
 in the examination of patients of whose possible syphilitic historj- 
 and antecedents they know nothing. 
 
 Neve has suggested the possibility of immunity to the infection of 
 leprosy being acquired by habituation. " We know that a pathologist 
 engaged in constant post-mortem work enjoys a freedom from acci- 
 dental blood poisoning not shared by those fresh to the work. The 
 surgeon who frequently attends cases of infectious disease appears to 
 become similarly protected. Does living in contact with leprosy ever 
 produce a like immunity?" 
 
 Physicians who care for lepers in hospitals and asylums are quite 
 as liable to contract leprosy as others who are equalh' exposed. The 
 reason why they commonly escape contamination is because simple 
 measures of precaution and disinfection and the intelligent avoidance 
 of intimate contact reduce the chances of contagion to a minimum. 
 But even with all the precautions which may be taken the exemption 
 of physicians is not nearly so complete as has been pretended. We 
 are obliged to admit professional leprosy as well as professional 
 syphilis. 
 
 Vidal has reported the case of a Braziliau" doctor who attended 
 
 lepers and became himself a leper. Some years ago Dr. X from 
 
 South America, who had attended lepers in his country, came under 
 my observation for leprosy. Miss C , of Ohio, a medical mis- 
 sionary, who attended on lepers in India, consulted me on her return 
 to this country and was found to be suffering from leprosy. I have 
 information of three physicians wdio contracted leprosy in Hawaii. 
 "Schilling, McNamara, Lander, Hillebrand, Kobertson, Livingston, 
 Carter, Pas(iuier, and many others have published cases of attend- 
 ants on lepers and even doctors themselves who have been after a 
 time attacked by the disease" (Leloir). 
 
 Numerous cases are recorded of Sisters of Charity and nui^es who 
 have contracted leprosy in caring for the sick in asylums and hospi- 
 tals. The proportion of the Kohuas or helpers in the leper settle- 
 
HEEEDITY AND CONTAGION. 443 
 
 ment of Molokai who become contaminated is from nine to ten per 
 cent. 
 
 As conspicuous examples of priests who have, in attending upon 
 lepers, contracted the disease, may be mentioned Father Baglioli, who 
 attended lepers in the Charity Hospital of New Orleans, and remem- 
 bers giving extreme unction to two of them, rubbing their hands with 
 oil during the administration of the rites. In his case the first symp- 
 tom was swelling of the mucous membrane of the nostrils. The case 
 of Father Damien, which was long cited as an example of the non-con- 
 tagiousness of leprosy, although he finally succumbed to the disease, 
 is too well known to require more than mention. Undoubtedly the 
 proportion of attendants upon lepers who contract the disease is much 
 larger than is generally supposed. Prolonged exemption does not 
 guarantee a continued immunity. 
 
 A case which has been frequently cited as a proof of the non-conta- 
 giousness of the disease was that of the washerwoman of the Leper 
 Hospital of Molokai who had washed the soiled clothing of the worst 
 patients for seventeen years. In addition she had lived with two 
 leper husbands in succession, and yet she had remained hale, hearty, 
 and apparently healthy during all this period. Upon the occasion of 
 my first visit to the leper settlement in 1889 I found that this woman 
 was suffering from undoubted manifestations of the disease. 
 
 Several years ago I instanced the case of Mr. D , who had lived 
 
 for nine years in the leper settlement of Molokai in daily and inti- 
 mate contact with lepers — his principal work being the dressing of 
 leprous sores and ulcers, sometimes attending to one hundred and 
 fifty a day — as a notable example of immunity against contagion. 
 Quite recently it has transpired that he, too, has become a leper. 
 
 Leprosy Imported into Certain Countries does not Spread. — Con- 
 clusions as to the interpretation of this fact and its bearing upon the 
 contagiousness of leprosy will depend largelj- upon the point of view 
 from which the question is envisaged. If the observer limits his field 
 of examination and judgment to certain parts of Europe and the 
 United States, he may find little clinical evidence of the active spread 
 of lepros}^ by contagion. Observation shows that leprous germs in- 
 troduced into these favored regions do not take root and spread ; they 
 rarely survive the death of the leper. 
 
 In New York, for example, large numbers of lepers coming from 
 countries where leprosy is endemic have lived for years, many of 
 them have been sent to general hospitals where they have died, and 
 yet so far as is known no case of indigenous leprosy can be traced to 
 association or contact with these patients. The same experience has 
 been noted in London, Paris, and Berlin, where lepers from other 
 
444 MORROW— LEPROSY, 
 
 countries have flocked for treatment and have been received in the 
 general hospitals without special measures of isolation, and yet 
 no case of leprous contamination has been traced to contact with 
 them. 
 
 If, however, the field of observation be somewhat enlarged, em- 
 bracing the whole of Europe and the United States, it will be found 
 that wliile in certain regions the disease when introduced does not 
 spread, but rather tends to die out from natural causes, yet in other 
 regions leprosy exhibits the unmistakable characters of a contagious 
 disease. 
 
 For more than fiftj^ years there has existed in Northern Europe 
 an active and important centre of leprosj^ which spread more or less 
 rapidly during a certain period until it assumed epidemic propor- 
 tions, but which is now fortunately in process of extinction. Equally 
 conclusive evidence may be found in the development of endemic foci 
 in Parcente, Alicante, and other provinces in Spain, and of small is- 
 olated epidemics in other parts of Europe. 
 
 In the United States we find the same apparent anomalies or para- 
 doxes of leprous contagion. Thus one hundred and sixty Norwe- 
 gian leper immigrants have settled in the Scandinavian colonies of 
 our Northwestern States, and their histories have been followed np, 
 yet there has not been a single case of contamination (with the pos- 
 sible exception of one case reported by Dr. Hoegh) traced to contact 
 with these imported lepers. Almost all of them have died and the 
 seeds of the disease have perished with them. 
 
 If now we turn our attention to the more tropical region of our 
 Southern seaboard, we shall find that there has been in Louisiana a 
 notable and alarming increase in leprosj^, and that within the past 
 twentj'-five jears it has spread so rapidly as to i^rove a serious men- 
 ace to the public health. A remarkable feature of the Louisiana epi- 
 demic is that the disease had formerly existed there during colonial 
 times, had become jiractically extinct, and after nearly a century of 
 silence and repose has reawakened into activity. 
 
 On the other hand, if one takes a broad and general survey of lep- 
 rosy in all ages and in all countries, there is found the most abundant 
 and conclusive evidence that the disease, when introduced into a com- 
 munity or country previously exempt, always spreads when the con- 
 ditions are favorable. The history of leprosy is one continuous 
 illustration of local and general epidemics originating from the 
 incoming of foreign lepers into non-infected countries. 
 
 The study of the disease in small circumscribed leprosy areas with 
 a fixed population, where the state of health of the different families 
 has been known for a long period, shows that its development may al- 
 
HEREDITY AND CONTAGION. 445 
 
 ways be traced to the introduction of a leper, and its spread is deter- 
 mined altogether by conditions of promiscuity and intimate contact. 
 
 The outbreak of leprosy in a new country or a non-infected race 
 can always be traced to the immigration of lepers. The facts of the 
 development and spread of leprosy in the Sandwich Islands furnish 
 the most conclusive proof of its contagiousness. Upon no other pos- 
 sible ground can be explained the remarkablj^ rapid dissemination of 
 the disease which in the space of a single generation decimated the 
 native population of these islands. It is estimated that at the pres- 
 ent day from five to ten per cent, of the entire native population is 
 affected with the disease, while many foreigners coming from coun- 
 tries w^here leprosy is not endemic and free from leprous antecedents 
 have become infected. The number of such cases is already over one 
 hundred, exclusive of the Chinese, Japanese, Portuguese, and South 
 Sea Islanders. 
 
 Practically we find that in leprous countries, where the observer 
 has the opportunity of studying the disease at close range and in all 
 its phases, there is little scepticism as to its contagiousness, while 
 in non-leprous countries, especially where the observer bases his 
 judgment upon a superficial and limited observation, doubt begins to 
 enter. 
 
 Leprosy does not Comport Itself as a Contagious Disease.- — Finally 
 there remains to be considered the objection to the doctrine of con- 
 tagion which is based upon the exceeding variability of the contagious 
 power of leprosy, and the observation that under certain conditions 
 this characteristic is doubtful or fails altogether, or, at any rate, is 
 not exhibited with that uniformity and coristancy which one would 
 naturally expect in a communicable disease. 
 
 It is claimed if leprosy is contracted always and only from the 
 leper that, whenever the necessary conditions — the presence of a leper 
 and proximity or contact with healthy persons — coexist, infection 
 should take place. This objection, however, loses its importance 
 when it is considered that each infectious disease has a contagious 
 mode peculiar to itself, dependent partly upon the life conditions of 
 the individual germ and partly upon the favorable or counteracting 
 qualities of the soil in which it is implanted. 
 
 It would be illogical to assume that the contagious mode of a 
 chronic infectious disease, like leprosy, of long incubation and slug- 
 gish evolution should conform in every particular to that of an acute 
 infectious disease with a short incubation in which the phenomena 
 succeed each other with great rapidity, like smallpox, for example. 
 And yet many physicians deny the contagiousness of leprosy because 
 it cannot be demonstrated that it is contagious in the same manner 
 
446 MORROW — LEPROSY. 
 
 or in tlie same degree of intensity as smallpox or even sj'pliilis. It 
 may be admitted that the evidence of contagion in these diseases is 
 more positive and direct than in the case of leprosy. The intensity 
 of the contagious activity of the two diseases mentioned and the re- 
 ceptivity of the human organism are so i^ronounced that contagion is 
 efifected almost invariably when the conditions of infectious or inocu- 
 lative contact exist. 
 
 If, however, we compare lepros}^ with tuberculosis, we can trace 
 numerous analogies in their contagious modes. AVe find the same 
 apparent anomalies and paradoxes of contagion, due to the variable 
 virulence of their respective germs under different conditions. The 
 contagion of tuberculosis is not constant or invariable, but contingent 
 upon the constitutional state and individual resistance of the recipient. 
 The most intimate and prolonged contact with a consumptive is not 
 necessarily followed by infection. Marital contamination is rare in tu- 
 berculosis. Climate and other conditions exert an inhibitory influ- 
 ence not only upon the development of the disease, but also upon its 
 contagious activity. Tuberculosis is contagious in certain regions, 
 feebly or not at all so in others. 
 
 The contagiousness of tuberculosis has been established not only 
 by clinical facts, but by successful cultures and inoculations of the 
 tubercle bacillus. The bacillus leprae has not been successfull}^ cul- 
 tivated, and experimental inquiry has thrown no light upon its modes 
 of growth and manner of reproduction. But while we are ignorant of 
 the exact conditions under which the pathogenic agent of lei^rosy is 
 best able to maintain and perpetuate its existence, observation shows 
 conclusively that the surroundings which man acquires in certain 
 localities are destructive of the microbes, while in other localities the 
 conditions which surround man favor their preservation and propa- 
 gation. 
 
 Van Dyke Carter remarks, apropos of this aspect of the question, 
 that " the direct communication of disease is hedged around also by 
 modifying influences belonging to both giver and taker, and these in- 
 fluences are so i)owerful and complex that the event in question — con- 
 tagion — becomes to be regarded by many as a matter of doubt." 
 
 Further, it may be said that the "variable virulence," as it has 
 been termed, of leprous contagion at different epochs and in different 
 countries is no more remarkable than that exhibited by other diseases. 
 Its development and decline, its exacerbations and subsidences, and 
 its resurrection in certain countries after long i^eriods of silence and 
 apparent extinction are paralleled in the history of other diseases. 
 The epidemic of lepros}^ which devastated Europe during the Middle 
 Ages has its analogue in the invasion of Europe by syphilis at the 
 
MODES OF INFECTION. 447 
 
 end of the fifteentli century, which broke out in the form of a wide- 
 spread and malignant epidemic and overran a large part of Europe, 
 and which, after maintaining an excessive virulence for several 
 decades, gradually lost its epidemic character and assumed the 
 milder type which it exhibits at the present day. The phenomenal 
 outbreaks of syphilis in the character of an epidemic or endemic in 
 Scotland during the seventeenth century, in Norway and Sweden, 
 and in various parts of Europe during the eighteenth century, may 
 also be mentioned as illustrating the variable virulence of this dis- 
 ease. 
 
 The epidemic violence of leprosy when introduced in a new coun- 
 try where the racial susceptibility and habits of living favor its 
 sjjread, and which has been so strikingly seen in the Sandwich 
 Islands, New Caledonia, and other modern centres of leprosy, is only 
 an illustration of the special virulence and malignancy which any 
 infectious disease assumes when transplanted into a favorable soil. 
 Other illustrations of this are seen in the ravages of syphilis intro- 
 duced into Hawaii by Captain Cook's men in 1779, of measles in 
 1849, and of smallpox in 1853, and the pestilential violence of smallpox 
 in Iceland in 1707, which killed eighteen thousand persons. The epi- 
 demic of measles in 1846 destroyed not only a large proportion of the 
 inhabitants of Iceland, but killed almost all the lepers. Numerous 
 other examples might be cited to show that the inequalities and ir- 
 regularities of contagion by no means particularize leprosy, but are 
 exhibited by all infectious diseases. 
 
 Modes of Infection. 
 
 Although the pathogenic agent of leprosy has been identified, and 
 its constant presence in the lesions it causes demonstrated beyond all 
 possibility of doubt, there are many points connected with the modes 
 of its entrance into the system and the conditions which favor its 
 growth and i^ropagation which are yet undetermined. It is very 
 probable that the modes of leprous contagion are many. While we 
 must recognize that the knowledge of the possible numerous and 
 varied processes by which leprous contaminations take place pos- 
 sesses the highest interest and importance from a prophylactic point 
 of view, yet it must be confessed that the precise manner in which 
 the leprous virus is transferred from one individual to another is 
 unknown. 
 
 The bacillus leprae must be transmitted either directly or medi- 
 ately from individual to individual. It has been suggested that it 
 may run through a stage of intermediate life (spore condition) which 
 
448 MORROW — LEPROSY. 
 
 we are at present unable to detect, either on account of the minuteness 
 of the spores or on account of the imperfection of our staining meth- 
 ods ; which may be present in the soil, water, or food, but can get 
 into them only from diseased tissues of the leper (Arning) . 
 
 It is possible that the contagious activity of leprosy, like that of 
 syphilis and other infectious diseases, may undergo certain modifi- 
 cations during the evolution of the disease and be inoculable only at 
 certain periods. 
 
 Whether leprosj' may be propagated by inoculative contact, 
 through sexual intercourse, through the skin by accidental wounds 
 and lesions of continuity ; whether it lasbj be conveyed by the process 
 of vaccination, by bites or stings of flies, mosquitoes, and other 
 insects ; whether its virulent principle may attach to the soil, water, 
 and food and be introduced as are the germs of cholera by imbibition, 
 or by inhalation of the virus contained in the sputum, disseminated 
 in the form of dust through the air, as in tuberculosis ; or whether 
 objects surrounding the leper upon which the virus has been acci- 
 dently deposited may serve as a medium of transference from one per- 
 son to another, are points concerning which there is great diversity 
 of opinion. The absence of any definite primary lesion upon the 
 outer surface of the body which marks the point of entrance of the 
 virus into the system tends to still further complicate the difficulties 
 in solving the pathogenic problem. 
 
 Sexual Intercourse. — Although I formerly attached considerable 
 significance to this possible mode of contagion, I now believe it plays 
 a very inappreciable role in conveying the germs of lepros}'. The 
 thousand and one intimacies which attach to the married relation 
 afford abundant facilities for infection quite independent of sexual 
 contact. It is quite conceivable, however, that if the sexual organs 
 are the seat of leprous lesions, as is not infrequently the case in the 
 tubercular form, the abrasions or solutions of continuity of the mu- 
 cous membranes which often occur in coitus constitute favorable fora- 
 mina contagiosa. 
 
 In some leprous countries this mode of contagion is generally ac- 
 cepted 1)3' the lait}"- and also by many of the i^rofession as the almost 
 exclusive mode of propagating the disease, the belief being based upon 
 the observation that if the husband or wife is leprous the healthy 
 partner often becomes contaminated, and that healthy persons having 
 illicit relations with lepers frequently contract the disease. This 
 opinion is so universal and deeplj^ rooted in the Sandwich Islands 
 that accusations of immorality M-ere brought against Father Damien, 
 based solely on the ground that his disease could have been contracted 
 only through illicit intercourse. Two of my patients from Honolulu 
 
MODES OF INFECTION. 449 
 
 have assured me that their principal dread of having the real nature 
 of their disease known was that it would carry to the minds of their 
 friends a conviction of their immorality. 
 
 Kissing. — It is well known that kissing represents one of the most 
 common modes of syphilitic contagion; it is very probable that 
 leprous infection may take place in the same way. In tubercular 
 cases, as is well known, the buccal cavity swarms with bacilli which 
 are present not only in the leprous lesions, but also in the saliva, 
 which is mixed with the secretions of these lesions. Any break in 
 the continuity of the delicate epithelial covering of the lips would 
 render inoculation possible. 
 
 It has been suggested that the custom which exists in Iceland of 
 kissing all persons present when entering a room may be a fruitful 
 source of contagion. Dr. Ehlers has seen lepers thus kissed by well 
 persons. On account of this custom he is opposed to the isolation of 
 lepers in their own homes, as practised in Norway. 
 
 The custom of salutation, which is common among the Hawaiians, 
 of kissing and rubbing their noses together when they meet has been 
 suggested as one of the means of spreading leprosy^ in the Sandwich 
 Islands. 
 
 Wounds and Ah^asions of the Integument. — It is a question whether 
 the virulent principle of leprosy may find entrance to the organism 
 through cracks, fissures, or abrasions in the integument. The fact 
 that the first appearance of the leprous manifestations is commonly 
 on the exposed parts, the face and extremities, and that in countries 
 where the natives go barefoot the plantar ulcer is often the earliest 
 lesion, lends support to this view. It is worthy of note that in coun- 
 tries where leprosy is endemic, the opinion generally prevails that the 
 disease is often spread by accidental inoculation through contact of 
 broken surfaces. Since the demonstration by Babes of the passage 
 of lepra bacilli along the hair follicles and through the intact skin 
 and that the skin of lepers in tubercular cases may be coated with 
 bacilli coming through the hair follicles, the theory of inoculation by 
 contact with a leper's body is quite plausible. 
 
 Nursing. — Since the milk in women suffering from tubercular 
 leprosy contains the parasite, Babes has expressed his belief that 
 leprosy may be conveyed in the process of suckling. He reports a 
 case in which a lesion on the cheek was observed as the first evi- 
 dence of the disease in a child nursed by a leprous woman. In 
 certain leprous countries, especially in India, the opinion prevails 
 that the germs of leprosy may be conveyed in the act of nursing. 
 Sir Konald Martin states that the dangers to Europeans of contract- 
 ing leprosy in India arise chiefly through nursing and vaccination. 
 Vol. XVIII.— 29 
 
450 MORROW — LEPROSY. 
 
 Other observers also speak of the probability of the infection having 
 been conveyed in this way. 
 
 Leprosy Communicated by the Bite of a Leper. — If leprosy may be 
 inoculated through the skin, the possibility of this mode of infection 
 is evident. I find in my notes taken in Molokai the following : 
 
 John G , on July 4th, 1877, was bitten by a leper in an ad- 
 vanced stage, who died of the disease in 1883. The bite was on the 
 middle finger of the right hand and cut through nearh' to the bone. 
 The hand and forearm at once became swollen, and were lame and 
 })ainf ul, with shooting pains, for about a week. The wound gradually 
 healed and the arm l3ecame as usual. Some years later he noticed 
 that the right hand assumed a bluish appearance occasionally. Later 
 on the other hand became similarly affected. Soon afterwards a 
 bluish spot appeared on the right hand, which still persists, although 
 it has now become yellow. Earl}- in 1885 he was declared to be a 
 leper and sent to the leper settlement. He firmly believes from all 
 the circumstances that the disease has its origin in him from the bite 
 of a native leper. 
 
 Vaccination. — The question whether leprosy may be conveyed to a 
 healthy person in the process of vaccination possesses at the present 
 time rather a retrospective than an actual interest. In many leprous 
 countries the methods and appliances of modern medicine are em- 
 ployed, and the use of humanized has been supplanted by that of 
 bovine virus. In some countries, however, even at the present day, 
 where bo\dne virus cannot readily be procured, and especiall}- when 
 a smallpox epidemic threatens, arm-to-arni vaccination is still prac- 
 tised. It must be admitted that if leprosy be inoculable, arm-to-arm 
 vaccination in leprous countries constitutes a direct and most effec- 
 tive method of conveying the germs. 
 
 Even when bovine virus is used, if a number of individuals, one 
 of whom ma}' be leprous, are inoculated in succession, the possibility 
 of conveying the germs from one person to another, b}' not thoroughly 
 disinfecting the lancet after each vaccination, must be borne in mind. 
 
 The clinical evidence that vaccination may be the means of propa- 
 gating leprosy rests upon the observation of individual cases in which, 
 for example, a single member of a family has been vaccinated and 
 afterwards develops leprosy while the other unvaccinated members 
 escape, and upon the rapid spread of leprosy in certain countries after 
 a general vaccination. Of course, it is to be remembered that in 
 leprous countries there must exist many opportunities for infection 
 in other ways that may escape observation, and the proof is rather 
 presumptive than positive. It is also claimed that as children, who 
 are commonly exempt from leprous manifestations, are usually 
 emijloyed as vaccinifers, the danger is reduced to a minimum. It 
 
MODES OF INFECTION. 451 
 
 should not be forgotten, however, that children may have the disease 
 in a latent or undeveloped form, and the question then arises whether 
 the disease is inoculable in its latent stage or only in a subsequent 
 period in the evolution of the disease. 
 
 The most noteworthy individual examples of presumed inocula- 
 tion by vaccination are two cases reported by Professor Gardiner, of 
 Glasgow, and two cases of Dr. Daubler, of Eobben Island. 
 
 Professor Gardiner reports that Dr. J. C , a resident of a Brit- 
 ish colony, vaccinated his own son with the virus taken from a child 
 X^resumably healthy, but who afterwards developed leprosy ; and from 
 his own child he vaccinated the son of a Scotch ship captain trading 
 between Scotland and the colony. By an extraordinary coincidence 
 Professor Gardiner had occasion afterwards to see both children, the 
 son of the medical man and the son of the ship captain, in Scotland, 
 both being affected with tubercular leprosy. In both - of these cases 
 the proof of leprosy having been conveyed by vaccination is pre- 
 sumptive, as the child of the doctor may have acquired the disease 
 independent!}^ of the vaccination. In the case of the other child, who 
 visited the colony only temporarily, the chances of accidental con- 
 tamination in other ways were much less, and the evidence in favor of 
 vaccination was stronger. 
 
 The first of Dr. Daubler' s cases was that of a woman who was 
 quite healthy until vaccinated in 1885. She had never in her knowl- 
 edge come in contact with leprosy. About a j^ear after vaccination a 
 large livid patch began to apxjear around the vaccination mark. A 
 few months later a creeping sensation on both sides of the face was 
 noticed, and soon afterwards the face began to swell, and she de- 
 veloped a tubercular condition of both sides of the face and ears, 
 with loss of the eyebrows and other evictences of tubercular leprosy. 
 
 The other case was that of a girl fifteen years old, who was quite 
 healthy until she was revaccinated in 1885. She had never seen any 
 one with leprosy to her knowledge. The same local ai^pearances fol- 
 lowed on the arms as those described in the previous case, and they 
 were followed later by maculae of the cheeks and leprous tubercles 
 on the forehead. Investigation showed that the person from whom the 
 lymph was taken died of tubercular leprosy. 
 
 Dr. Hillis reports a case of a Portuguese, born in Demerara, aged 
 twenty, the son of healthy parents, and his sister, aged eighteen, who 
 were the subjects of tubercular leprosy. They had both been vacci- 
 nated with lymph obtained from a Portuguese family known to be 
 affected with tubercular leprosy. They were the only members of 
 the family vaccinated with this lymph. Three sisters and one brother 
 were perfectly healthy. 
 
452 MORROW — LEPROSY. 
 
 Mr. B , an intelligent resident of Maui, narrated to me the fol- 
 lowing case coming under his personal observation : A family on the 
 island consisted of the father, mother, and five children. The older 
 members of the family having been vaccinated previous to coming 
 there, only the youngest child was vaccinated with humanized lymph. 
 This child alone of the entire family became a leper. 
 
 In the Sandwich Islands the opinion generally prevails that leprosy 
 may be inoculated in the process of vaccination. This opinion was 
 based upon the observed fact that there was a notable increase in the 
 number of cases of leprosy after a general vaccination immediately 
 succeeding the smallpox epidemics of 1852, 1868, and 1872, and that 
 numerous leprous centres developed in various parts of the islands 
 where the disease had previously been unknown. In many places 
 vaccination was performed by careless and unskilful persons. Hu- 
 manized virus was used, and it is presumed that careful discrimination 
 was not always made between lepers and healthy persons as vacci- 
 nifers. 
 
 Dr. Arning says : " There can be no doubt as regards the ajm- 
 chronousness of the diffusion of leprosy and the introduction of vac- 
 cination into the Hawaiian Islands. I am able to state, having excel- 
 lent authority for so doing, though unfortunately no statistics, that a 
 very remarkable accumulation of fresh leprosy cases took place in 
 1871 and 1872, at a place called Lahaina on the island of Maui. This 
 happened about a year after a universal arm-to-arm vaccination which 
 had been most carelessly performed. From fifty to sixty cases oc- 
 curred suddenly in this locality, which up to this time had been com- 
 paratively free from the disease." Impey, medical superintendent of 
 the leper settlement at Eobben Island, said : " I wish to draw atten- 
 tion to one very serious matter in respect to the spread of leprosy. 
 It is contagious and can be communicated from one person to another 
 by inoculation. In South Africa the reprehensible practice of arm-to- 
 arm vaccination is carried on to an enormous degree. Some means 
 should be employed to stop the dangerous practice of vaccinating 
 with humanized lymph, " etc. 
 
 Arning has demonstrated the presence of bacilli in the crusts of 
 vaccine pustules in tubercular lepers. Dr. A. Mitra, chief medical 
 officer of Cashmir, says : " I have on three occasions searched for 
 bacilli, and in one instance I found them in lymph from a vaccinated 
 leper." 
 
 Dr. A. Brown, in a pamphlet on " Leprosy in its Contagio-syphi- 
 litic and Vaccinal Aspects," says: " The unanimity and persistency 
 with which vaccination, in markedly' leprous countries, is charged 
 with propagating and disseminating the malady, the well-confirmed 
 
MODES OF ESTFECTION. 453 
 
 coincidence of leprous centres with vaccination centi'es, and the dis- 
 covery of the specific bacilli in those leprously vaccinated ought to 
 satisfy all who are capable of reading evidence or of rational reflection 
 that controversy on the questions must and will ere long be silenced." 
 
 Tebbs, in a recent work, endeavors to demonstrate that the remark- 
 able recrudescence of leprosy- in various countries at the present day 
 is chiefly due to inoculation through the process of vaccination. 
 Wliile such a sweeping statement cannot be unqualifiedly accepted, it 
 must be admitted that the author has collected a vast number of ob- 
 servations which give plausibility to his views. It is, of course, only 
 in countries where humanized virus is employed that this possi- 
 ble danger exists, which emphasizes the necessity of controlling the 
 source of the vaccine matter. 
 
 Inoculation hy Insects.— The theory that certain diseases are con- 
 veyed by insects rests on a fu-m foundation. The investigations of 
 Manson and Eoss on the intimate relations existing between mos- 
 quitos and the dissemination of malaria have given a new interest to 
 this question. Again, in many countries where leprosy is endemic 
 there is a more or less general impression that the germs of the dis- 
 ease may be transported from the leper by flies and mosquitos and 
 inoculated into healthy i:>ersons. Although the communicabilitj^ of 
 leprosy in this way has not been demonstrated, it is quite credible 
 and worthy of scientific investigation. 
 
 It is interesting to note that the plague of mosquitos and the 
 plague of leprosy appeared simultaneously in the Hawaiian Islands. 
 Mosquitos which had previously been quite unknown there were im- 
 ported, probably from China, towards the end of 1840 (Arning). 
 
 The same observer states that he has frequently examined bacteri- 
 ospically mosquitos engorged with blood, found inside the mosquito 
 netting of beds conttiining cases of severe cutaneous leprosy, without 
 discovering traces of bacilli either in or upon them. Others have 
 examined flies and mosquitos which came in contact with leprous 
 patients and pustules on the bodies of lepers, but the results have 
 always been negative until recently Alvarez claims to have discovered 
 the presence of bacilli in mosquitos engorged with the blood of 
 lepers. 
 
 That mosquitos and flies are common carriers of leprous contagion 
 would seem improbable, since if this were the case, the transference 
 of the disease from lepers to healthy persons, in countries where 
 these pests abound, would be much more common. 
 
 Ashmead, in speaking of the agency of mosquitos in conveying 
 the bacilli of leprosy, does not limit his theory to the idea that the 
 virus is conveyed by the insect's haustellum. He thinks that eating 
 
454 MORROW — LEPROSY. 
 
 fish, sucli as carp, which are fed on the eggs of mosquitos, maj' be 
 tlie cause. 
 
 Dr. Hutchinson, in reviewing this theorj^ of the etiology of the 
 disease, states " that leprosy prevails on the seaboard where neither 
 nioscjuitos nor mosquito-eating fish are found." It is probable that 
 there are manj^ places where leprosy prevails and where nios(iuitos 
 are unknown. If the poison were conveyed by insects, we should 
 l)robabl3^ have some localities where every person, residents and vis- 
 itors all alike, would suffer, just as there are i^laces where no one 
 escapes malaria. 
 
 Inhalation. — While this mode of infection rests upon presumptive 
 rather than positive evidence, recent advances in our knowledge of 
 leprosy would seem to indicate that it plays an active, if not the most 
 prominent, part in the propagation of the disease. It is i)ossible that 
 the germs are contained in the expired air, when the aerial passages 
 are the seat of leprous deposits, and are projected in the process of 
 sneezing and coughing. Just as in the case of tuberculosis, the spu- 
 tum of leprous patients, which has been shown to be loaded with 
 bacilli, may, I believe, when scattered through the air with particles 
 of dust, serve as a means of transporting the contagion. 
 
 It is to be observed that the theory' of contagion through the re- 
 spiratory passages was held by the ancients. It was forbidden to 
 lepers in walking to go between the wind and those passing by, lest 
 they should be contaminated by the leprous emanations. In the Mid- 
 dle Ages the leper " was especially prohibited from walking in narrow 
 paths or from answering those who spoke to him in the roads and 
 streets, unless in a whisper, lest they be annoyed hy his pestilent 
 breath and with the infectious odor which exhaled from his body." 
 
 Imhibifio)/. — Liveing believes that leprosy ma}^ be propagated by 
 the imbibition of the secretions of those affected, much in the same 
 way, though not in the same degree, as typhoid fever and cholera are 
 propagated ; but as leprosy is developed slowly there is far greater 
 difficulty in tracing it home to its true source. 
 
 Fish Theory. — The fact that leprosy occurs more frequently along 
 maritime coasts, where the inhabitants employ fish as their main 
 article of diet, led doubtless to the popular tradition that leprosy 
 was caused by salted or rotten fish. 
 
 Mr. Jonathan Hutchinson, who is the strongest supporter of the 
 fish hypothesis at the present day, thinks fish may cause leprosy in 
 one of two ways — either there is direct introduction of bacilli into the 
 stomach or some element of fish food rouses into activit}' the bacilli 
 which exist in the tissues. The hypothesis that fish serves an in- 
 termediary host function for the bacilli is improbable from the fact 
 
MODES OF INFECTION. 455 
 
 that the bacillus has never been found in fish caught in epidemic 
 areas, although frequent examinations have been made. The fallacy 
 of the fish theory is proved by the fact that leprosy occurs among 
 people who have never tasted fish, either because it was not obtain- 
 able or because its use was forbidden by their caste or religion. 
 
 Dr. Tholozan, of Persia, states that while there is a great deal of 
 leprosy in Kurdistan, there are no large rivers there, and he is sure 
 that the inhabitants never eat any fish. In Teheran, where leprosy 
 does not prevail to any extent, salt fish is the staple article of food. 
 
 A view of the fish hypothesis, differing radically from that of 
 Hutchinson, is taken by Neve, who believes that the lepra bacillus 
 may find conditions favorable to its germination among the consider- 
 able number of organisms generated by putrefying fish, hence serv- 
 ing as a culture medium as well as a means of transport. Almost 
 every article of food has been in turn incriminated as the etiologi- 
 cal factor, as salted meat, especially pork, vegetables, milk, etc. 
 Forster has shown that various bacilli may retain their vitality in 
 salt meat. Milk also is especially liable to different forms of infection. 
 
 The herdsmen of Cashmere never eat fish, but consume large quan- 
 tities of milk (twelve pounds of curds in twenty-four hours). This 
 milk, it is claimed, could easily serve as a transporting medium for 
 the bacilli as well as salted meat or any kind of impure food or water. 
 
 Hicks and Blanc believe that the influence of diet is limited to 
 preparing a defective and inflammatory condition of the intestine for 
 the reception of the bacilli, and in the study of the transmission of 
 lejjrosy it cannot be a question of the particular kind of food, but only 
 if the characteristic bacillus is present. If food contains the bacilli, 
 they must have been derived from the diseased tissues of the leper. 
 I believe that the bacilli may be deposited on vegetables, fruits, and 
 other articles of food handled by lepers and in this way carry the con- 
 tagion. We can also understand that certain foods may so modify 
 the constitution of the tissues that they afford a more suitable soil 
 for the growth of the bacillus which has been introduced into them. 
 
 31ediate Infection. — It is probable that infection may take place 
 by means of clothing or objects used by the leper or through the 
 intermediary of food, drink, pipes, cups, or other objects upon which 
 the virus may be deposited. 
 
 Many authorities believe in the probability of this mode of trans- 
 ferring the virus, and instances are cited which would seem to prove 
 the probability of infection occurring in this way. The popular 
 superstition of the danger of handling tools or other articles which 
 have been used by lepers doubtless has some basis in fact. 
 
 The case reported by Hawtrey, of an Irishman who had never 
 
456 MORROW — LEPROSY. 
 
 beeu out of his native country except for a short voyage to England, 
 and who contracted the disease by wearing the clothes or sleeping 
 in the bed of his deceased leper brother, who had become a leper 
 in India ; the case of a patient who came into the Leper Hospital in 
 Norway with a history of no leprosy in his family comprising twelve 
 brothers and sisters, but who seven years previously had bought a 
 coat which had belonged to a deceased leper and which he wore daily ; 
 and numerous others of like tenor scattered through literature would 
 indicate that the disease ma,y be conveyed in this manner. 
 
 The wearing of the boots or shoes of a leper, it is said, may be 
 the means of conveying the contagion. In India leprosy is believed 
 to be propagated by bathing in the reservoirs which have become 
 polluted by lepers. Numerous cases are reported of infection of 
 laundresses who washed the soiled linen or bedding of lepers and 
 who were never brought into close personal contact with lepers, which 
 is a fact worthy of note. 
 
 The recent unsuccessful attempts of the health authorities of Hon- 
 olulu to stamp out the disease by the absolute segregation of every 
 person found to be affected with leprosy is said to be largely due to 
 the fact that the clothing and belongings of lepers who are transported 
 to Molokai are utilized by the famil^^ and friends of the leper. Many 
 of the government physicians have called attention to this possible 
 source of danger in perpetuating the disease. 
 
 Le Blond says : " There should be rigid laws in reference to the 
 distribution of the effects of lepers. A native has no scruple in wear- 
 ing the cast-off coat of his exiled brother or sleeping in his unclean 
 bed." 
 
 Lindley says: "There are many things which could be done 
 that would go far to lessening the dangers of contagion. In almost 
 all cases where lepers are sent away their effects, such as mats, 
 clothing, etc., are given to grieving friends and relatives left behind. 
 These, of course, are great sources of contagion." 
 
 Besnier believes that the leper can soil with his pathological ex- 
 cretions the ground, his garments, bedding, linen, dressings, and the 
 walls, and that the dust of his room may be a source of leprous con- 
 tamination. 
 
 In this connection it will be of great interest and value to give the 
 most recent views of the leprologists of all countries, which were pre- 
 sented to the Berlin Leprosy Congress, upon the modes of the trans- 
 mission of the bacillus leprre. 
 
 Sticker makes the sweeping statement that in about ninety-six per 
 cent, of all cases the primary focus of the disease is in the nasal cham- 
 bers and that leprous contamination is from nose to nose. 
 
MODES OF ESTFECTION. 457 
 
 Lassar suggests tiiat since lupus is primarily developed on the lips 
 and nose of children by picking or scratching these parts, leprosy 
 may be communicated in the same way, and recommends that chil- 
 dren in leprous countries should be taught to avoid this habit. 
 
 Ai"ning does not believe that the primary manifestation is in all 
 instances intranasal. In many cases he had carefully examined the 
 nose and found nothing. He had seen in one case at least the pri- 
 mary lesion on the skin. In countries where people go barefoot there 
 are more cases in which leprosy begins on the foot. 
 
 Geill believes that the leper contaminates the soil and that it 
 is through the soil that healthy individuals are most often infected. 
 He thinks that in order to transmit the virulent bacilli certain quali- 
 ties of soil, not found everywhere, are essential. 
 
 In India and Tonquin, where the natives go barefoot, the dis- 
 ease appears first on the feet in more than fifty per cent, of the 
 cases. 
 
 Hellat (Kiga), while accepting the theory that the bacilli may be 
 inhaled, thinks that there is no proof that the vital power of the nasal 
 mucous membranes, which is efficacious enough to expel and destroy 
 numerous other bacilli, is powerless against the lepra bacilli. He 
 thinks that the skin may be the seat of entrance and refers to numer- 
 ous cases in which leprosy has been transmitted by boots. 
 
 Ehlers believes that the initial lesion of leprosy varies according 
 to the geographical latitude and conditions of life. In Iceland the 
 first manifestations appear upon the face and hands. As is well 
 known to be the case in syphilis, there is no place that may not be 
 the point of entry for leprosy. In this country the respiratory 
 passages are the first affected. 
 
 Babes says the most important question is, whether we can con- 
 sider the first visible manifestation as the place of entrance of the 
 infection. He indicates the possibility of infection through milk in 
 which he has found bacilli, and cites a case of Kalindero in which a 
 child nursed by a mother with mixed leprosy developed an isolated 
 leproma on the cheek, 
 
 Petrini thinks it possible that the bacilli may be introduced into 
 the organism by means of certain aliments, as we see many cases of 
 leprosy in families where the food is in common. 
 
 Abrahams believes that the lepra bacilli may enter into the human 
 system in as many ways as may those of tuberculosis. 
 
 Alvarez says that in Hawaii one may incriminate as a means of 
 transmitting leprosy the common use of the pipe, which is passed 
 from mouth to mouth in families. 
 
 Jeanselme refers to his investigations which would indicate the 
 
458 MORROW— LEPROSY. 
 
 nose as the principal point of entry, as well as the most virulent 
 source of contagion, 
 
 Hallopeau oj^poses the view of infection through the nasal mucous 
 membrane and also by sexual transmission. If invasion through the 
 pituitary membrane was habitual or even possible by atmospheric 
 dust, we cannot comprehend why our patients living for years in a 
 medium charged with infected dust should remain unaffected. He is 
 inclined to accept the hypothesis of infection through linen, clothing, 
 stings of mosquitoes, etc. 
 
 Neisser thinks that the contagion may be received by respired air, 
 and the infection of the skin, mucous membrane, and nerves follows 
 extending from within outwards. The intestinal canal is also a pos- 
 sible way. There is no heredit}-, and what we looked upon as hered- 
 ity is infection favored by famih' life. 
 
 Hansen entertains the same view as Neisser, though he refers to 
 mediate transmission through clothing, linen, shoes, and the furnish- 
 ings of the habitations of lepers. 
 
 Petersen relates a case in which the primary localization was in the 
 nose. He detected the presence of a large ulcer on the left side of 
 the septum the secretions from which were rich in bacilli. 
 
 In the official examination of twelve hundred cases reported to the 
 Russian Government, the disease was first seen in the extremities in 
 ninety-two jjer cent, of the cases of nerve leprosy. In one-half the 
 cases of the tubercular form it was first seen on the face. 
 
 Petersen states also that Professor Munsch, some time ago, gave 
 it as his opinion that in a certain number of cases leprosy commenced 
 in the nose. 
 
 Doutrelepont is inclined to accept the view of the nasal origin of 
 leprosy. 
 
 Kaposi denies that the frequent nasal ulcerations seen in lepers 
 signify that the nose is the port of entry. In his opinion the skin 
 is the most common place of entrance for the bacilli, but in the pres- 
 ent state of our knowledge it is impossible to say where the initial 
 lesion may be. 
 
 Besnier says the principal ways of projection and reception of the 
 bacilli are the mucous surfaces — chiefly the nasal cavities, oculocon- 
 junctival and buccal ca^-ities, pharyngeal cavity, cutaneous surfaces, 
 and perhaps the digestive tract. 
 
 It is evident from the very comprehensiveness of these views, 
 . including almost every possible mode or channel of entrance, that 
 our knowledge on this matter is only conjectural. Accurate knowl- 
 edge is expressed in precise rather than in vague, loose terms. 
 
 It will be perceived, however, from the above-quoted views that 
 
CONDITIONS INIXtJENcma INFECTION. 459 
 
 most leprologists incline to the belief that infection in leprosy takes 
 place through the mucous membranes of the upper air passages. 
 This theory presupposes the aerial transmission of the bacilli, as it 
 is difficult to conceive how inoculation of these surfaces could be 
 effected by mediate contact with objects upon which the bacilli were 
 accidentally deposited. 
 
 Several years ago, before the investigations of Jeanselme and 
 Sticker, upon the results of which this belief is based, were under- 
 taken, the writer expressed his personal views as follows : 
 
 " In the writer's opinion, most observers err in assuming that there 
 is one exclusive mode of infection in leprosy. It is probable that, like 
 the bacilli of anthrax, glanders, and tuberculosis, the mode of en- 
 trance of the parasite into the system is not unique, but multiple. 
 We know that the bacillus of tuberculosis, which presents so many 
 analogies with leprosy, may enter through the respiratory tract, the 
 intestinal mucous membrane, or be inoculated through the skin. I 
 believe that, similarly, the bacillus leprae may be introduced through 
 more than one channel of entrance. Direct inoculation through the 
 skin, in any of the manifold ways which have been considered, plays 
 in my opinion, a very unimportant role in the propagation of lep- 
 rosy. In the vast majority of cases, I believe that the vehicles of 
 the virus through which contagion is effected are the secretions of 
 the nose and mouth, and that the port of entrance is the mucous 
 membrane of the respiratory and intestinal tract, with secondary in- 
 fection through the blood or lymi)hatic system." 
 
 My observation and study since the above was written have more 
 than ever impressed me with the conviction of the widespread preva- 
 lence of infection through the upper air passages. If it be estab- 
 lished by further investigations that the bacilli leprae most frequently 
 follow the aerial route in penetrating the organism, it may be as- 
 sumed that they find in this locality the tissue soil most suitable for 
 their reception and growth. 
 
 Conditions Influencing Infection. 
 
 Individual Predisposition. 
 
 From the fact that in countries where leprosy is endemic and the 
 bacilli are abundant many are exposed but few are infected, it is 
 evident that predisposition does not depend upon causes which, act- 
 ing upon all alike, would reduce the entire population to the same 
 degree of susceptibility, but upon conditions pertaining to the indi- 
 vidual. The whole matter of individual susceptibility resolves itself 
 
460 MORROW— LEPROSY. 
 
 into a question of the capabilities of the body to restrict and limit 
 the growth of the bacilli. That predisposition must exist as a condi- 
 tion of leprous infection is evident from the observed fact that certain 
 individuals are absolutely immune. They escape the disease despite 
 the most prolonged and intimate contact with lepers and constant 
 exposure to every condition favorable to the communication of the 
 germs. Their immunity evidently depends upon a lack of receptiv- 
 ity, or a greater capacity of resistance to the action of the patho- 
 genic agent. 
 
 In such individuals, even though infection takes place, the resist- 
 ance of the tissues to the inroads of the bacilli may be manifest in 
 the further evolution of the malady, which is exceedingly slow and 
 protracted. In certain cases the capacity of resistance is sufficient 
 to dominate and destroy the pathogenic microbes. Abortive cases 
 are occasionally seen in which there may have been indubitable signs 
 of leprosy which after a time disappear definitively, and the persons 
 remain ever afterwards free from any manifestation. 
 
 Individual predisi)osition, whether inherent or acquired, must be 
 recognized as one of the moat powerful factors in influencing infec- 
 tion. This predisposition may be constituted by a native weakness 
 or debility, due to a certain type of conformation or peculiarity of tis- 
 sue organization which renders the tissues of the individual more vul- 
 nerable and less capable of resisting infection. Those physiological 
 peculiarities doubtless determine the type of the morbid process 
 according as the cutaneous or nerve structures are more or less pre- 
 disposed to the action of the bacilli. The preferential infection of 
 the integument in the tubercular form and of the nerves in the anaes- 
 thetic form can. be explained only on the ground of an existing pro- 
 clivity in the tissues of the individual which for lack of a better term 
 has been denominated idiosyncrasy. 
 
 But quite independent of this inherent organic predisposition 
 there are certain accidental conditions of a general or local nature 
 which create a pathological predisposition by lowering the resistance. 
 All causes or conditions which impair the health or lower the vital- 
 ity of the individual predispose to contagion. Excessive work, poor 
 food, privation, misery, bad hygiene, nervous exhaustion, etc., must 
 be placed in the category of conditions favoring infection. It is only 
 upon the assumption that the capacity of resistance may be lowered 
 by various causes that we can explain those cases in which immunity, 
 though manifest for a long period, may finally be lost and the indi- 
 vidual fall a victim — just as in tuberculosis an exemption prolonged 
 for years does not guarantee an absolute permanent immunity. 
 
 In addition to the causes acting upon the general economy, certain 
 
CONDITIONS INFLUENCING INFECTION. 461 
 
 local conditions may influence infection by creating in certain tissues 
 a locus mtvoris resistentice and thus permitting the entrance of the 
 bacilli through this weakened part. Even after the bacilli come in 
 contact with the tissues they probably lie latent, without patho- 
 genic action, until excited into activity by some special cause. 
 
 The more our bacteriological knowledge advances the more we 
 recognize the importance of pathological modifications in the organ- 
 ism as a necessary condition of the growth and multiplication of bac- 
 teria. There are manj' morbid germs which are susceptible of be- 
 coming pathogenic but manifest their virulence only under special 
 circumstances. It is well known that many microbes of a common 
 order, the streptococcus, the pneumococcus, the colon bacillus, etc., 
 though capable of causing serious infections, may remain upon the 
 cutaneous or mucous surfaces or in the air passages absolutely inert 
 and innocuous, until they are provoked or excited into activity by 
 some pathological change which creates for these microbes a " morbid 
 opportunity." 
 
 The specific microbes, especially those of tuberculosis and lep- 
 rosy, would seem to form no exception to this rule. It is probable 
 that they lie latent upon the mucous surfaces of the air passages and 
 await their opportunity until some localizing influence creates a spe- 
 cial aptitude on the part of these tissues to conceive and develop their 
 pathogenic action. 
 
 Prominent among the local conditions which influence this mode 
 of infection I would place the inflammation of the upper air passages, 
 known as a "cold" or a "catarrh," which so often precedes the de- 
 velopment of other diseases. 
 
 In all countries where leprosy is endemic "a cold" followed or 
 not by fever is among the first signs of ill health. In South Africa, 
 according to Impey, "if you ask a leper how he contracted the 
 disease, he will almost invariably reply that it was due to a cold. 
 I am of opinion that cold is the exciting cause of leprosy. The 
 bacillus lies inactive in the system until it is excited into action 
 by the body being subjected to a severe cold." Again, in speaking 
 of the symptoms of the tubercular form: "The first symptoms of 
 this form of leprosy usually manifest themselves after a cold. The 
 patient when heated has a cold bath, or he has been out in a snow 
 storm, or subjected to some severe cold and becomes feverish. He 
 thinks he is suffering from an ordinary catarrh or from an attack of 
 simple fever." 
 
 In his personal observations of leprosy in Colombia, Garces says : 
 "Most people attribute the origin of the malady to cold after ex- 
 posure, allowing the sudden cooling of the body after profuse perspi- 
 
402 MORROW — LEPROSY, 
 
 ration, living iu damp rooms, going from a lower to a higher alti- 
 tude," etc. 
 
 The testimon}' of many observers in leprous countries in differ- 
 ent quarters of the globe is to the effect that " a cold" is most fre- 
 quently blamed by the patient as the starting-point of the disease. 
 The catarrhal condition thus engendered may not only favor lej^rous 
 infection by heightening the vulnerability of the mucous surfaces, thus 
 l)ermitting a ready penetration of the pathogenic agent, but the 
 changes iu the tissues caused by the inflammatory fluxion maj- create 
 the biochemical conditions favorable to the germination of the bacilli. 
 
 Since writing the above, I have received a letter from Mr. J. Dut- 
 ton, who has charge of the Home for Leper Boys in the Molokai 
 settlement, in which he refers to the modes of communication of 
 leprosy. For thirteen years he has been in intimate daily contact 
 with lepers, and his opjiortunities for studying the disease iu all its 
 phases give his observations a special value. He says: "I cannot 
 point to any initial lesion, many of the cases are advanced when I 
 first see them." ... "I shall say here, however, that if there is an 
 initial lesion in any case, something in the skin seems to have that 
 appearance. I have always thought, however, that inhalation has 
 more to do with acquiring the disease than is generally supposed. 
 The mucous surfaces are usually much affected in advanced cases, and 
 also in — I should say — a decided majority of cases not yet old or 
 far advanced. I have wondered if leprosy and catarrh do not find 
 congenial conditions when they meet — a sort of afiinity. The results 
 in man}^ cases — so much like catarrh — emanate from leprosy, but the 
 ulcerations are extensive and rapid. I have also wondered if the 
 bacilli are really the first invaders, if their busy duties do not con- 
 sist at first in merely occupying tissues, previously made ready, in 
 some way to us as yet mysterious and unexplainable." 
 
 Unhygienic Habits and Surroundhujs. — While the seed and the soil 
 are the essential elements in the production of leprosy, it is obvious 
 that they are both neutral until brought into conjunction. For the 
 successful cultivation of leprosy, it is necessary that the seed be im- 
 planted in the soil. The intimate and s'ordid contact which comes 
 from the unhygienic habits and surroundings of certain races or peo- 
 ples would seem to constitute the most effective means of carrying 
 out this condition. This view is supported hy the observation that 
 in all countries where leprosy has rapidly spread, dirty habits and 
 promiscuity or communism in the matters of eating, drinking, and 
 sleeping prevail. To take, for example, four important epidemic cen- 
 tres of leprosy within the past century : 
 
CONDITIONS INFLUENCING INFECTION. 463 
 
 The propagation of leprosy in Norway lias been ascribed as 
 largely due to tlie unhygienic habits of the people. According to 
 Leloir : " The Norwegian peasant is very dirty. The greater number 
 of the peasants have never taken a bath. They may sometimes wash 
 (once a week) the face and hands, and the feet once a 3'ear, but the 
 other parts of the body are not washed from the day of their birth to 
 that of their death. Their clbthing is never taken off even for the 
 purposes of sleeping. It is generally made of wool. Their gar- 
 ments are never washed. Dirt is allowed to accumulate upon them, 
 and when not too rotten, they are often transmitted from generation 
 to generation. They live promiscuously gathered together in a small 
 house. The cabin of the peasant is a hut made of firs with a wooden 
 roof covered with earth, upon which a little turf is placed. The 
 chimney is often nothing but a hole made in the roof, and the rain 
 falls through it to the beaten earth which forms the flooring. Dung 
 and filth are accumulated around the house amidst pools of dirty 
 water. Often pigs, poultry, and other domestic animals live with the 
 family. Almost always several persons sleep in the same bed, which 
 is nothing but a kind of wooden chest upon which are thrown some 
 sheep skins or goat skins which are scarcely ever washed. If a 
 stranger comes he shares the bed. Everybody eats at the same 
 table, from the same dish, often with a common spoon and drinks 
 from the same vessel." 
 
 In addition the Norwegian peasants are weakened by poor food, 
 damp, piercing cold, and the i^hysical exertion necessary to gain a 
 meagre subsistence, while skin disorders, due to the general prev- 
 alence of scabies among them, furnish an open entrance for the 
 lepra bacilli and the agents of putrefaction as well. It cannot be 
 considered surprising that leprosy rapidly spreads under such con- 
 ditions, while these same lepers, transported to the United States and 
 adopting the more civilized customs of living, with greater cleanliness, 
 in separate newly built houses, which are not filthy nests of conta- 
 gion, have not spread the disease. 
 
 Hansen attributes much importance to the habit of sleeping in 
 the same bed with lepers in connection with the communication of 
 the disease. 
 
 Turning now to another important centre, we find that while the 
 natives of the Hawaiian Islands are more cleanly in their persons, 
 the same promiscuity prevails in their habits of li^^ing. The habits 
 of the natives of the Sandwich Islands have been thus described to 
 me by Mr. Meyer, the superintendent of the leper settlement of Molo- 
 kai : " Their modes of eating are so extremely careless that inocula- 
 tion can readily take place through the mouth by means of the saliva 
 
464 MORROW — LEPROSY. 
 
 or otherwise. They pass their pipes from mouth to mouth, whether 
 any of their number is a leper or not; they kiss and rub their noses 
 together; they eat out of the same calabash with their fingers, and 
 drink out of the same cup; in eating fish or meat it is not cut up, 
 but one takes the meat in his hand, and, after taking a bite, passes 
 it on. They drink ova, which is prejiared by others chewing the 
 root, and whether the chewer is a feper or not is not considered. 
 Foreigners also become addicted to this habit of ava drinking, and 
 it is remarkable that most of the foreigners who have become lepers 
 were ava drinkers. Most of them have been mechanics, and the only 
 cause to which they ascribe their disease is having worked with 
 lepers and handled the same tools. The disease ma}^ have been 
 communicated in some instances from food handled by lepers in an 
 advanced stage." 
 
 In Madagascar, Dr. Davison, quoted by Hillis, says : " Probably 
 the dirty habits so prevalent in half-civilized nations must tend to 
 aggravate the disease ; eating from a common dish with the fingers ; 
 the custom, very common in Madagascar, of interchanging garments, 
 and of all lying huddled promiscuously together at night cannot fail 
 to render it more inveterate, even in the way of originating it. It 
 certainly deserves notice that, while the laws of Madagascar excluded 
 leprous persons from society, the disease was kept within bounds : 
 but after they were permitted to fall into disuse, it has si:)read to au 
 almost incredible extent." 
 
 In New Caledonia, anoth'er hotbed of leprosy, the conditions of 
 life among the aborigines are thus described by Dr. Le Grand: 
 "Naked or almost naked, covered with mosquito stings and scratches, 
 they lie sleeping in their smoky huts upon dirt}^ mats. The rags 
 which serve them as garments, their turbans, their handkerchiefs, 
 their pipes — all is in common, and the scanty garde robe makes often- 
 times the tour of the tribe. Place among them a leper, the secretions 
 from whose ulcerations are diffused over the garments, the mats, and 
 the soil, the result is that the first parts attacked are the parts most 
 intimately brought into contact with objects or neighboring bodies in 
 the different acts of common life. In addition, the leper in New Cale- 
 donia has the detestable habit of making deep ulcerations in his spots 
 and tubercles with the aid of pieces of glass, treating them with caustic 
 applications, etc. In addition their bodies are covered with a thousand 
 insignificant hurts from insect bites and scratches, which serve as ports 
 of sortie in diseased persons, and ports of entry in healthy persons." 
 
 Dr. Le Grand believes that leprous contagion is effected by in- 
 oculation, but that the leper is contagious only at an advanced stage, 
 when he becomes a sort of "ambulant ulcer." 
 
CONDITIONS INFLUENCING INFECTION, 465 
 
 Climate. — From the extensive geographical distribution of leprosy 
 it is evident that its development is independent of conditions of cli- 
 mate and soil. It extends from the tropics to the Arctic regions. It is 
 found in damp malarial subtropical regions and in those of temperate 
 non-malarial zones. It is disti'ibuted through the length and breadth 
 of India. On this continent, it prevails in both marshy and mountain- 
 ous regions, in the lowlands of Louisiana as well as on the elevated 
 tablelands of Mexico. 
 
 While the widespread and diversified distribution of leprosy pre- 
 cludes the possibility of climate per se being invoked as a causal fac- 
 tor, it must be admitted that it may materially influence infection. 
 As a rule a hot, moist climate favors the development of leprosy just 
 as a cold, damp climate does. Leprous patients do better in equable 
 temperate climates. It is probable that a propitious climate aids in 
 the extinction of the disease by its favorable influence upon the gen- 
 eral health as well as by its tendency to diminish bacillary virulence. 
 
 Reference has already been made to the observations that leprosy 
 transplanted to this climate or to that of Central Europe does not take 
 root and flourish, and each centre of infection, instead of spreading, 
 dies out from the lack of conditions favorable to its development. 
 So far as we can apprehend the nature of these inhibitory conditions, 
 a major importance must be assigned to climate. 
 
 In the dry, cool climate of our Northwestern States, leprosy does 
 not spread, but rather tends to die out from natural causes ; on the 
 other hand, the warm moist, semiti'opical climate of our Southern 
 seaboard seems favorable to its development. Just as in the case 
 of tuberculosis, with which leprosy presents so many analogies, cli- 
 matic conditions seem to lessen or reduce its infective capacity to the 
 point of extinction. In certain parts of this country, as, for example, 
 in the elevated regions of the Colorado plateau, tuberculosis is but 
 feebly contagious. In Colorado Springs, which is essentialh' a city 
 of homes for consumptives, where the population of 25,000 is not 
 transient, as in many health resorts, but permanent, carefully com- 
 piled statistics show that during twenty years there had been only 
 ten deaths from non-imported consumption. Now the multitude of 
 consumptives living there must have furnished tubercle bacilli in 
 plentiful abundance for infection. It is evident that in certain cli- 
 mates it is more difiicult for the germs of both tuberculosis and lep- 
 rosy to maintain their virulence and to find a suitable soil in the body 
 for their growth. 
 
 Bace. — No race is immune to leprosy. We must recognize, how- 
 ever, that racial peculiarities may infliience susceptibility to the disease 
 and modify its mode of evolution. 
 Vol. XVIII.— 30 
 
466 MORROW — LEPROSY. 
 
 Leprosy is decidedly more common among the dark than the 
 white races. In the far East, the Mougolic races seem to exhibit a 
 si^ecial susceptibility to the disease ; it is much less common among 
 the Malays. The negroid races of the Philippines, the Malay penin- 
 sula, aud the tribal representatives of this race in Java are not af- 
 fected to any great extent, while the Chinese (wherever they have 
 emigrated) form the bulk of the lepers. The pure Indian races of 
 South America show a marked immunity as compared with the 
 African aud mixed races. The same observation applies to the 
 inhabitants of the Antilles. In the West Indies there is marked 
 prop(m(leranc6 of leprosy in the negroes over all other races. 
 
 Hillis comments iipon the remarkable immunity from leprosy 
 enjoyed by the aboriginal tribes of British Guiana, whereas it is com- 
 mon among the Bovianders or the offspring of the Indians with the 
 Wack or colored natives of the colony. This immunity' may be due 
 to their open-air life, their habits of cleanliness, and their isolation. 
 He instances as a remarkable fact that the Warroo tribe, which was 
 the only native tribe that constantly associated with the negro lepers, 
 alone became contaminated, and that leprosy prevails among their 
 descendants to the present day, while no other Indian tribe has be- 
 come affected. 
 
 The extraordinarily rapid increase and terrible mortality' of leprosy 
 among the natives of the Sandwich Islands must be ascribed partly 
 to the habits, but largely to the racial qualities, of this people. They 
 have a feeble vital tenacity ; their capacity of resistance is small, and 
 they succumb readilj^ to diseases from which the average Anglo- 
 Saxon easily recovers. 
 
 Age. — While leprosy attacks persons of all ages, from infancy up 
 to fourscore, or even fourscore and ten, the greatest incidence of the 
 disease seems to fall in the third decade, from twenty to thirty 
 years. It would ai)pear that tubercular leprosy attacks the patient 
 at an earlier age than the anaesthetic form, or at least the first mani- 
 festations are several years earlier; Hillis says ten years. 
 
 Sex. — There is an undoubted predisposition to leprosy conferred 
 by sex. In all leprous countries the number of males who suffer 
 from leprosy is always in excess of that of females. This proportion 
 varies somewhat in different countries. In Norwaj^ among 7,302 
 cases there were 4,164 men, 3,183 women. In Iceland, about the 
 same proportion — 4 men to 3 women. In Bosnia and Herzegovina 
 Neuman's statistics gives 116 men to 16 women. In Cape Colony 
 Impey's statistics show 1,296 males to 475 females. In British 
 Guiana the proportion is about 3 males to 1 female. In Hawaii the 
 number of male lepers is about double that of the females. 
 
SYMPTOMS AND COUBSE. 467 
 
 This disproportion in the incidence of the disease in the two sexes 
 may be due partly to occupation, the males being more exposed to 
 vicissitudes of weatheij and from their manual labor more liable to in- 
 juries resulting in broken surfaces and wounds. In Eastern countries 
 the rooted aversion of the women to see foreign doctors and the 
 strict seclusion in which women are habitually kept by the rule 
 of Mohammedan tradition doubtless make the discrepancy appear 
 greater than it really is. In Hong-Kong, for example, statistics 
 show that of 125 lepers there were only 1.3 females, or 10.4 per cent. 
 
 SYMPTOMS AND COURSE. 
 
 "While tubercular leprosy is not sufficiently regular in its evolution 
 to admit of its division into distinct stages or periods, we may, for the 
 convenience of clinical description, speak of (1) a period of invasion, 
 (2) a period of erythematous eruption, (3) a period of tubercular 
 eruijtion, and (4) a period of ulceration, succeeded by a final period 
 in which the clinical symptoms constantly increase in intensity and 
 severity owing to the continued degeneration of the tissues and the 
 diminished vitality of the organism damaged by the multiplication of 
 the bacilli and their toxins, as well as by the absorption of the prod- 
 ucts of suppuration. 
 
 It must be borne in mind, however, that in the ordinary evolution 
 of tubercular leprosy the cutaneous manifestations do not develop in 
 an order sufficiently regular or uniform to enable us to draw distinct 
 lines of demarcation between these stages. There is no sharp chron- 
 ological limitation of the erythematous eruption. This form of qx- 
 anthem may and commonly does recur coincidently with the eruption 
 of tubercles and may continue its outbreaks during the entire course 
 of the disease. During the active neoplastic period many of the 
 tubercles may become ulcerated or disappear by a process of resorp- 
 tion long before the ulcerative phase of the disease becomes definitely 
 established. 
 
 Likewise in describing the course of anaesthetic leprosy we recog- 
 nize (1) a period of invasion, (2) an eruptive stage, (3) an atrophic 
 stage attended with tendinous retractions, deformities, and anaesthe- 
 sia, and (4) an ulcerative stage with consecutive mutilations. 
 
 Strictly speaking, the macular lesions of this form are practically 
 permanent and persistent during the entire course of the disease. 
 Anaesthesia is also a more or less fixed feature and may coexist with 
 hyperaesthesia. Ulcerations and deformities, while common and 
 characteristic, are by no means invariable features. 
 
468 MORROW— LEPROSY. 
 
 It will thus be seen that any schematic arrangement is one of con- 
 venience rather than of scientific accuracy. It is intended only to 
 outline the general course of the disease and indicate the more 
 prominent phases which it successively exhibits in its ordinary evo- 
 lution. 
 
 The manifestations of leprosy present the widest variations in 
 character, morbid activity, and the intervals which separate their 
 outbreaks. The explanation of the apparently capricious character 
 of the leprous process which is especially marked in the earlier stages 
 must be sought for in the tendency of the bacilli to multiply at irreg- 
 ular intervals, periods of activity alternating with periods of quies- 
 cence and repose. 
 
 It will be convenient to study the invasive period of tubercular 
 and anaesthetic leprosy together, since the i)henomena of this period 
 present nothing absolutelj^ characteristic of either form. 
 
 Period or Invasion or Incubation. 
 
 The term " invasion" is employed in this connection with a clear 
 comprehension of the fact that there is not in leprosy, as in certain 
 other infectious diseases, a rapid and general intoxication of the sys- 
 tem, but that during the entire life term of the malady there may be 
 repeated and progressive invasions by the bacilli and their toxins of 
 structures previously exempt. The phenomena of this period present 
 nothing absolutely characteristic; they are essentially transitory and 
 uncertain, and in many cases they may be so slight as to pass unper- 
 ceived by the patient. 
 
 Leloir has suggested that the invasion period of leprosy i)resents 
 certain analogies with the period of the secondary incubation of syphi- 
 lis or with the prodromal period of certain forms of tuberculosis. 
 
 The claim of recent investigators, that leprosy has an initial lesion, 
 would, if demonstrated to be constantly present, indicate a closer 
 analogy between the primarj^ phases of leprosy and syphilis than has 
 hitherto been suspected. This leads to the inquiry : 
 
 Has Leprosy an Initial Lesion ? The fact that the first cutaneous 
 manifestations of leprosy commonly occur upon exposed parts — the 
 face, hands, or feet — in the form of erythematous spots has led to the 
 opinion, still held by many observers, that these spots represent the 
 initial lesion, from which, as infective centres, the germs are distrib- 
 uted. 
 
 Arning has reported an instance of what he regards as a primary 
 localization of the virus in the skin. The patient came from a non- 
 leprous part of the United States to Honolulu. Three months after 
 
SYMPTOMS AND COUESE. 469 
 
 her arrival slie noticed a small, red, slightly raised spot ou the left 
 forearm, which slowly enlarged and in a year became anaesthetic. 
 Two years later a group of papules developed around it. Lepra 
 bacilli were found abundantly in the tissues. 
 
 Kaposi reports a case of what he regarded as the initial lesion 
 upon the finger of a patient in the form of a bulla, which the bearer 
 thought was caused by the sting of an insect. Later the face became 
 infiltrated with anaesthetic lepromes. Hillis says that " if leprosy 
 may be introduced through the integument, the initial lesion must be 
 an ill-defined erythematous spot, soon followed by other macules in 
 the vicinity or any other part of the body." Blanc asserts that this 
 sort of history was received from a number of his patients, and that 
 in one case such a lesion came under his observation. 
 
 In the vast majority of cases, however, in which the date of infec- 
 tion can be fixed with approximative certainty within narrow limits, 
 the erythematous spots do not appear for months or j'ears later and 
 during this time the presence of certain prodromal sj'mptoms indi- 
 cates clearly that systemic derangement is already in progress. Be- 
 sides, the presence of these spots is not an absolutelj^ constant feature 
 which invariably precedes the development of tubercles or degenera- 
 tive changes in the nerves. The leprous spots must be regarded 
 not as a primary lesion from which autoinfection takes place, but 
 rather as the evidence of an already accomplished infection of the 
 system. 
 
 The writer's views upon this point were expressed several years 
 ago as follows (Morrow's "System of Genito-Urinary Diseases, 
 Syphilology, and Dermatology") : "There is, so far as we can deter- 
 mine, no initial lesion of the integument. It is probable that in the 
 mucous surfaces of the upper air passages, the pituitary or pharyn- 
 geal membrane, or other ports of entrance of the virus there may be 
 an initial patch which serves as an incubating medium for the bacilli 
 before they become more generallj- diffused through the system. 
 This view is quite in accordance with our knowledge of the modes of 
 infection in glanders, tuberculosis, and other bacillary diseases. But 
 there is no evidence whatever to show that leprosy has a primary 
 lesion of the external parts which corresponds in any way to the in- 
 itial lesion of syphilis." 
 
 These conclusions, at which I arrived several years ago and which 
 were based upon my clinical studies of the disease, would seem to be 
 confirmed by bacteriological proof. The recent bacteriological inves- 
 tigations of Sticker and of Jeanselme and Laurens, the results of which 
 were submitted to the Berlin Leprosy Congress (1897), and to which 
 reference is elsewhere made, would seem to substantiate my state- 
 
470 MORROW — LEPROSY. 
 
 ment that the lepra bacilli, in many cases at least, are first depos- 
 ited upon the nasal mucous membrane, which constitutes a favorable 
 culture ground for their multiplication and subse^iueut dissemination 
 through the system. 
 
 Of the one hundred and fifty -three cases studied bacteriologically 
 by Sticker, evidences of lej^rous changes in the nasal mucous mem- 
 brane were found in all but thirteen. He maintains that these 
 changes caused by the bacilli constitute the initial lesion of leprosy, 
 which he thus describes : " It is an ulcer, rarely a tubercle, situated 
 upon the nasal mucous membrane, usually the cartilaginous portion. 
 It is usually simply erosive; it may be more or less penetrating and 
 ultimately leads to necrosis of the osseous framework of the nose." 
 The best evidence that this is the primary focus he finds in the 
 peculiar distribution of tlie early lepromata of the face, which indi- 
 cates dissemination of the parasite by the lymph channels. These 
 nasal changes, he asserts, often precede by several years the fir.st 
 cutaneous nodules or the first nervous symptoms and may persist dur- 
 ing the entire course of the disease as an active centre of autoinfection 
 as well as of contagion. 
 
 Jeanselme and Laurens found lei:)rous lesions of the nasal fossae, 
 the mouth, throat, and larj'nx in sixty per cent, of the twenty-six 
 cases examined by them. They conclude that the bacilli first pene- 
 trate into the organism through an insignificant erosion of the pitui- 
 tary membrane, and that the alterations of the nasal mucosa constitute 
 the first exterior manifestation of leprosy. Thus is explained how 
 the leprous chancre hidden in the anfractuosities of the nasal fossae 
 always passes unperceived. 
 
 These observers make the important reservation that this hy- 
 pothesis, however plausible in certain cases, should not be generalized 
 in all, since in certain subjects leprous coryza does not appear until 
 the disease is fully developed. This view coincides with that ex- 
 pressed hj myself (/. c.) that the nasal mucous membrane is not the 
 sole port of entrance, as the mode of infection in leprosy is not unique 
 but multiple. 
 
 Incubation. — Even admitting the existence of a leprous initial 
 lesion in the nasal fossae as more or less constant, we have no data, 
 since the moment of contagious contact is always indeterminable, 
 which would enable us to establish the period of its incubation or 
 what, from its assumed analogies with syy)hilis, might be termed the 
 period of primary incubation. For the recognition of leprosy the so- 
 called leprous chancre is practically non-existent, since we are unable 
 to identify the disease before the advent of certain symptoms which 
 point to a systemic infection. 
 
SYMPTOMS AND COUKSE. 471 
 
 The incubation of leprosy is understood to embrace that period 
 which elapses between the introduction of the bacilli into the system 
 and the appearance of visible signs of the disease upon the cutaneous 
 surface or the evidences of characteristic changes in the peripheral 
 nerves. This period varies within wide limits and is often very pro- 
 tracted. 
 
 It is probable that, for a time at least, the bacilli remain dormant 
 and inactive. No sign, local or constitutional, indicates that infecr 
 tion has taken place. We do not know what process of preparatioE 
 may be taking place during this period of apparent quiescence. 
 Whether there is a real sleep or hibernation of the germ, as is main- 
 tained by Besnier — a latent phase analogous to that of a seed whici 
 conserves for a time more or less prolonged its torpid life until the 
 moment when its germinative conditions are realized — can only be con- 
 jectured. Certainly the subsequent reactions which show that the 
 seed has germinated and become endowed with virulence and infec- 
 tive capacity may not be in evidence until months or years later, li 
 would appear probable that if the tissue upon which they are first 
 deposited is inapt for their propagation, they are carried to and fro 
 in the lymphatic circulation until they find somewhere a favorable 
 soil for their germination and growth. From this source of genera- 
 tion the bacilli are transplanted to other culture grounds, which ia. 
 turn constitute fresh foci of infection until a more or less general in- 
 fection takes place. 
 
 During this process of invasion of the system by the multiplica- 
 tion of bacilli and the creation of new centres of autoinfection theia 
 are usually certain constitutional reactions, to be described in connec- 
 tion with the prodromes, which mark a phase in the evolution of the 
 disease and furnish clinical evidences that the implanted germs are 
 active. 
 
 The duration of the 'period of incubation varies within wide limits 
 and may be quite protracted. It has been variously estimated at from 
 a few weeks or months to several years — three, five, twenty years or 
 longer. In countries where leprosy is endemic and where there i& 
 more or less constant exposure to the chances of contagion it is im- 
 possible to determine this point. 
 
 Observations have been made in cases in which a leper has removed 
 from an infected to a healthy district and has communicated the dis- 
 ease to persons previously exempt from any possible exposure. Ln 
 these cases the period which elapses between the coming of the leper 
 and the date of the first leprous manifestations in others has been 
 taken as the basis of calculation. Obviously, however, conclusions 
 founded upon such a basis are loose and unsatisfactory, since weeks 
 
472 MORROW— LEPROSY. 
 
 or months may elapse before there is a concurrence of conditions 
 favorable to infection. 
 
 An estimate based ui)on the observation of persons without lep- 
 rous antecedents who have been exposed for the first time in travel- 
 ling or passing a limited time in a leprous country, and who have 
 developed the disease after their return, may be accepted as approxi- 
 mately correct. But even here, unless they can fix definitel}^ upon 
 the time and circumstances of a known exposure, or tho duration of 
 their stay has been brief, it is evident that such calculation is open to 
 error. Thus I have been consulted by a patient who lived eight years 
 in South America without any known exposure and who showed no 
 signs of the disease until shortl}^ after his return to this country. Now 
 in this case it is not possible to determine at what period of his stay 
 he received the infection. It may have been soon after going there or 
 immediatel}^ preceding his return. In another case under my obser- 
 vation a patient who had spent two weeks in the Sandwich Islands 
 presented undoubted symptoms of leprosy within ten months after 
 his return. Arning's case, in which leprosy developed within three 
 months after the arrival of the j)atient in Hawaii from a non-leprous 
 part of the United States, has alreadj' been referred to. 
 
 Bidenkap reports a ease in which the incubation was of only a few 
 weeks' duration. Impey (South Africa) says : " While bacilli may 
 be in the system for years before producing signs, I know of a case in 
 which symptoms of leprosy were produced within three months after 
 their introduction. In the majority of cases it does not exceed two 
 years." 
 
 As examples of prolonged incubation, Daniellsen and Boeck, 
 Leloir, and others report cases in which the duration of this period 
 varied from ten to twenty or even thirty years. In almost all these 
 cases the patient had removed from a leprous district to a country 
 where the disease was not endemic. 
 
 According to Besnier, one cannot accept the idea that persons who 
 have emigrated from leprous countries and who have developed the 
 first signs of the disease dozens of years later in non-leprous countries 
 present a real incubation of such length. "This delay," he says, 
 " can be due only to the conservation of the bacillus in an inert state 
 in some neutral part of the organism. This period of silence corre- 
 sponds not to a gradual germination of the pathogenic agent, but to 
 a real sleep, a hibernation of the germ." "True incubation compre- 
 hends the time which elapses between the moment when the lepra 
 bacillus reaches an opportune place, finds the exclusively human 
 biochemical elements necessary to its multiplication, and setting it in 
 action, and the moment when the first leprous manifestations occur. 
 
SYMPTOMS AND COUESE. 473 
 
 This duration varies according to the anatomical place of its _ocali- 
 zatiou and the vital conditions of the invaded tissues, but it does not 
 necessarily exceed an average of several months." 
 
 I am convinced from my observation of a number of patients who 
 have consulted me that the period usually accorded by most text-book 
 writers to the incubation of leprosy is much longer than it actually is. 
 By careful questioning of many lepers who have contracted the dis- 
 ease abroad I have found that their initial symptoms, many of which 
 they had paid no attention to or had almost forgotten, antedated by 
 several months or even years the appearance of symptoms recognized 
 as leprous. 
 
 It is probable that many cases recorded in literature as examples 
 of prolonged incubation may have had for years symptoms undoubt- 
 edly leprous, but of so mild and equivocal a character that their true 
 nature was misinterpreted and referred to rheumatism, malaria, or 
 some other malady. Besides, it must be remembered that the initial 
 symptoms of leprosy are so variable, uncharacteristic, and absolutely 
 indefinite that they never would be ascribed to leprosy in any country 
 where the disease was not endemic or there were not decided reasons 
 for suspecting its presence. 
 
 Among the conditions which contribute to advance or materially 
 retard the date of development of leprous symptoms are the state of 
 the patient's health, climate, food, habits of living, etc., and, as in the 
 case of other infectious diseases, the slower the action of the patho- 
 genic agent the more likely is it to be affected by extraneous influ- 
 ences. 
 
 The duration of the period of incubation is not determined solely 
 by the specific germ, but depends ui)on conditions of individual 
 receptivity. The germination of the seed is especially subordinate 
 to conditions of the soil. The resistance of the patient's tissues to 
 the bacillarj' invasion is one of the principal factors in lengthening 
 this period. Poverty, dirt, poor alimentation, and unhealthy sur- 
 roundings have been the appurtenances of leprosy in all countries 
 and in all ages. Where persons live in low, damp habitations with 
 malarial surroundings and frequently exposed to cold and wet the 
 bacillus is excited into activity and the incubation is shorter. All 
 observation goes to show that the removal of a person from a leprous 
 to a non-leprous country tends to retard the development of the disease. 
 
474 MORROW — LEPROSY. 
 
 Prodromes. 
 
 Ill the majority of cases tliere are certain prodromal symptoms 
 more or less pronounced, but exceedingly variable in their character 
 and order of development, which precede the outbreak of the eruptive 
 phenomena. While they are not sufficiently characteristic to indicate 
 with certainty the nature of the disease, they give evidence that some 
 sort of systemic deraugeiiieut is already in progress long before any 
 outward signs furnish the necessary confirmation of the diagnosis. 
 In the present state of our knowledge it is impossible to determine 
 the pathological basis of these prodromal phenomena. We do not 
 know whether they are due to the topical effects of the bacteria or to 
 a more or less general intoxication by the chemical products or toxins 
 of the microorganisms. 
 
 It is probable that the mode of onset of leprosy is analogous to 
 that of tuberculosis, in which local or constitutional symptoms, such 
 as haemoptysis, laryngitis, or bronchitis, may be evident long before 
 there is a general invasion of the pulmonary tissues by the bacilli. 
 
 The constitutional reaction does not necessarily imply that there 
 is a general infection, but only that there is a disturbing cause at 
 work in some part of the organism. In the case of anaesthetic leprosy, 
 it would simplify our conception of the morbid process and at the 
 same time be reconcilable with the clinical evidence to assume that 
 the phenomena of this stage are the expression of a peripheral neuritis, 
 due to the impression of the bacteria and their toxins upon these 
 structures, and entirely independent of any central nervous trouble. 
 
 Febrile Symptoms. — Fever is a more or less constant feature of the 
 tubercular form of leprosy and may be considered as the most impor- 
 tant initial symjitom. The types of leprous fever vary. In malarial 
 regions it is commonly of the intermittent type. Many lepers date 
 the beginning of their disease to an exposure to cold, followed by an 
 attack of what they considered at the time malarial fever. It has 
 been observed that this mode of origin is more apt to occur among 
 jiersons who live in damp, swampy localities, and it is possible that 
 their malarial environment exercises a predominant role in determin- 
 ing the febrile access. The febrile concomitants of the outbreaks of 
 leprosy at a later stage are probably due to the invasion of new parts 
 of the body by the bacilli and the toxic effect produced by their 
 emanations. 
 
 In perhaps the majority of cases the fever is of the remittent type. 
 The febrile access is more apt to come on during the afternoon or 
 evening, attain its maximum, and be followed by a remission in the 
 
SYMPTOMS AND COUKSE. 475 
 
 morning and forenoon. Wliile tlie fall of the fever may be attended 
 with moderate sweating, it contrasts in this respect with the drench- 
 ing perspiration so common and distressing a feature of tuberculosis. 
 Weakness and Prostration. — Coincident with the febrile paroxysms 
 there oftentimes exists a very marked degree of prostration, which 
 may continue after the febrile symptoms have passed. Patients com- 
 plain of weakness, of an indisposition for exertion, and of an inclina- 
 tion to sleep. 
 
 Digestive Troubles. — Loss of appetite, nausea, difficult digestion, 
 and other morbid stomachal conditions are among the earlier mani- 
 festations. 
 
 While anaemia is common as a result of the digestive disorders, the 
 progressive emaciation which is so pronounced a feature of tubercu- 
 losis is not common in leprosy. 
 
 Upistaxis. — Among the local symptoms rhinitis, often attended 
 with a sense of tickling, sneezing, coryza, and not infrequently with 
 epistaxis, more fitly belongs to the prodromal period than to the later 
 one to which it is usually assigned. 
 
 Leloir regarded the epistaxis of leprosy as similar in nature to 
 the prodromal epistaxis of typhoid fever, incipient tuberculosis, and 
 other infectious diseases. Later investigations would indicate that it 
 is a specific rather than a symptomatic manifestation, the pathologi- 
 cal basis of which is the existence of primary leprous foci in the 
 nasal mucous membrane. Their presence would explain the precocity 
 as well as the comparative constancy of the irritative symptoms. 
 This mild epistaxis, which proceeds from congestion of the nasal mu- 
 cosa, is not to be confounded with the epistaxis which results from 
 ulceration of the pituitary membrane and other destructive changes 
 manifest at a later period. L-ritative symptoms of the nose are much 
 more common in the tubercular form. 
 
 jTJie prodromes of the ancesthetic foron are much more variable in 
 kind and degree and are distinguished by their more marked neurotic 
 character, pointing to the active participation of the nervous system 
 in their production. 
 
 From the relatively small number of bacilli in this form general 
 systemic disturbance is not so pronounced as in the tubercular form. 
 Disorders of sensation constitute the most constant and characteristic 
 feature of the prodromal period of anaesthetic leprosy. 
 
 Formication and pruritus, tingling and pricking, burning pains of 
 the surface, which vary in degree of intensity, oftentimes of a severe 
 character, are common in the invasive period. Some patients can- 
 not keep still from the imperious desire to rub and scratch the 
 limbs. At night the sensation is not entirely dulled by sleep, evi- 
 
476 MORROW — LEPROSY. 
 
 dences of which may be manifest iu the morning in the shape of 
 scratch marks unconsciously inflicted. 
 
 One of m\' patients described the sensation as that which attends 
 the contact of air or water with a freshly abraded surface. On more 
 than one occasion, as he informed me, he removed his shoe, feeling 
 assured that he would find an abrasion of the surface. These sensa- 
 tions are not invariably present, but are more or less intermittent in 
 character. They are exceedingly capricious in their seat, first in one 
 locality, then in another. 
 
 These hypersesthetic symptoms, which are doubtless due to irrita- 
 tion of the peripheral nerves, are not confined to the skin. Tender- 
 ness and pain of a lancinating, boring character may be felt in the 
 deeper structures, usually in the extremities, in the toes or heel, about 
 the ankle, often associated with a sense of stiffness and weight of the 
 members. 
 
 Cephalalgia sometimes accompanied with vertigo has been noted 
 among the precursory signs of ansesthetic leprosy. The cephalalgia 
 varies in intensity and severity, and is usuallj^ more pronounced in 
 the evening. The i)ain is more apt to be localized at the back and 
 base of the brain, and may be quite persistent. 
 
 Various ahjias and rht'iiniatoid 2^ciiiis, especially in the lower limbs, 
 may be present in the prodromal period. 
 
 Disorders of the suchrvparous and sebaceous glauds, although much 
 more pronounced later in the evolution of the disease, may neverthe- 
 less be manifest in the prodromal stage. The first evidence of irregu- 
 larity is usually observed in the abnormal excitability of the sweat 
 glands, which i)our out their secretion spontaneously or under the 
 influence of light exercise, which normally would not provoke this 
 secretion. This hy peridrosis does not depend upon anaemia or general 
 weakness as in tuberculosis, but is due to vasomotor disturbance from 
 peripheral nerve lesion and possibly, according to Leloir, to central 
 complications. 
 
 All of the above-described symptoms vary in character and inten- 
 sity. They may fail altogether or be so slight as to escape attention. 
 As in syphilis, the prodromes are by no means constant and invariable. 
 In many cases the patient does not feel any indication of disorder 
 until after the appearance of the eruption. Their significance is rarely 
 recognized or rightly interpreted until after unmistakable evidences 
 of the disease have declared themselves. Even in countries where 
 leprosy is endemic their occurrence, taken in connection with known 
 exposure, would afford presumptive rather than positive jiroof of their 
 true nature. 
 
 It will be more convenient to study separately the clinical features 
 
SYMPTOMS OF TUBERCULAR LEPROSY. 477 
 
 of the two principal forms of leprosy, since the determination of the 
 morbid process to the tegumentary system in the one form and to the 
 nervous system in the other gives rise to such a diversity of manifesta- 
 tions that the clinical pictures presented by each are entirely distinct. 
 
 Tubercular Leprosyo 
 
 While- the leprous process may affect various tissues and organs 
 of the body, its most constant and characteristic manifestations are 
 determined towards the skin and mucous membranes of the upper air 
 passages. The clinical picture of this form is made up almost exclu- 
 sively of the changes in these structures caused by the bacilli. 
 
 The eruptive elements consist of macular lesions, which may be 
 simply erythematous or pigmented, infiltrations, diffuse, or circum- 
 scribed in the form of nodules, succeeded by the secondary changes 
 of softening, ulceration, and crusting, or fibroid degeneration. The 
 cutaneous manifestations are not, as a rule, continuously present in 
 the early stage, but come out in successive crops. At first they are 
 slight and transitory, but at a more advanced stage, they are perma- 
 nent and impart to the disease a peculiar physiognomy which is 
 pathognomonic (see Figs. 4 and 5). Their first appearance is impor- 
 tant as marking definitely the debut of the disease, and they often 
 furnish the necessary confirmation of the diagnosis which was fore- 
 shadowed by the premonitory symptoms we have just been consider- 
 ing. 
 
 Period op Erythematous Eruption. 
 
 The first cutaneous manifestations occur in the form of erythema- 
 tous spots or patches, which are sometimes described as erythema 
 leprosum or leprous roseola. These spots exhibit a great variety of 
 asi^ect in their size, shajje, color, situation, and subsequent evolution. 
 They are usually round or oval, sometimes irregular in outline, from 
 the size of a lentil to that of a silver dollar or the palm of the hand. 
 
 The surface of the spots is as a rule flat and smooth, presenting a 
 greasy, shining appearance without perceptible elevation or infiltration 
 of the integument. All of the spots do not, however, correspond to 
 this definition. Later they may be perceptibly elevated aboye the 
 surrounding skin, with a slight degree of infiltration appreciable to 
 the touch or even to the eye. 
 
 The color of the spots has been variously described as pinkish, 
 reddish, vinous red, reddish-brown, coppery, mahogany, and of a 
 sepia or iodine tint. These qualificatives indicate a wide diversity 
 
478 MOBKOW — LEPROSY. 
 
 in the color characteristics of the eruption as seen by different ob- 
 servers in different countries. The coloration varies according to the 
 complexion and race of the individual, the age of the lesion, and cer- 
 tain extraneous conditions such as exposure to the sun, the wind, etc. 
 
 In the white race they are of a pinkish or crimson color, with a 
 redness like that of ordinary erythema which deepens into a dusky 
 red or a purplish hue. In brown and dark races the color is first a 
 mahogany or brownish-red, assuming later a dark or even black color- 
 ation. In both races the color is apt to be more livid in de^jendent 
 parts of the body, as on the legs and feet. 
 
 While the eruption may have a general distribution it has certain 
 j>oints of predilection. Most commonly it appears first upon the ex- 
 posed parts, the dorsum of the feet, about the ankles, the backs of 
 the hands and wrists, upon the forehead, cheeks, and ears. It may 
 appear upon the buttocks, thighs, chest, and other portions of the 
 body, but rarely upon the palms of the hands and soles of the feet. 
 There is a certain degree of symmetry observed in its distribution. 
 
 The spots may increase in size, apparently like the spread of a 
 drop of oil on a sheet of paper. The earlier spots are usually transi- 
 tory, disappearing without leaving a trace or only a slight grayish 
 pigmentation. In other cases they may require weeks or months for 
 their involution. The color is at first usually more pronounced in 
 the centre, fading towards the circumference; in other cases their 
 contours are sharply defined. After a while the redness in the centre 
 subsides, giving place to a brownish stain or only a slight pigmenta- 
 tion. Leloir has observed an ecchymotic tint similar to that seen after 
 the disappearance of certain papular erythemas. 
 
 The spots are exceedingly variable in aspect, like that of erythema 
 solare, chloasma, and various other pigmentations of the skin, and 
 they have little diagnostic significance. Occasionally spots may ap- 
 I)ear in the form of a diffuse, somewhat erythematous blush or red- 
 dish tinge, and disappear promptly or in a few days without leaving 
 a trace. 
 
 Garces, in describing the jjeculiarities of leprosy in Colombia, 
 aajB that in that country " the initial exanthem of leprosy is almost 
 always of the urticarial type. Most people attribute the origin of the 
 malady to cold after exposure, allowing the sudden cooling of the 
 body after perspiration, and living in damp rooms. These accidents 
 are followed by the wheals of urticaria which are the starting-point 
 of leprosy." 
 
 The outbreak of the erythema is frequently preceded or accom- 
 panied by evidences of constitutional disturbance, such as chills and 
 fever, a general feeling of lassitude, malaise, etc. Local sensations of 
 
SYMPTOMS OP TTJBEECULAE LEPROSY. 479 
 
 pricking or itching may precede or attend the eruption or subjective 
 sensations may be entirely absent. Some have described the sensa- 
 tion as of " ants walking over and stinging the face" (Hillis). The 
 patches may develop insidiously, without the knowledge of the pa- 
 tient and unaccompanied by any local phenomena, and are then dis- 
 covered by chance. 
 
 The spots are, as a rule, not permanent, but they may appear and 
 disappear a number of times before the establishment of the charac- 
 teristic tubercular changes without leaving any trace of their pre- 
 vious existence. The earlier eruptions are essentially erythematous, 
 the coloration is affected by temperature changes and disappears tem- 
 porarily on pressure. Later the patches are more pigmented, they 
 pale on pressure, but the coloration is not entirely effaced. 
 
 Leloir divides the lesions of this stage into two jDrincipal groups, 
 the hi/percemic si^ots and the pigmented spots ; in the latter the pigmen- 
 tation is secondary to the hypersemia. This division appears to in- 
 troduce an unnecessary refinement of distinction, as the pigmentation 
 represents an evolutionary change which, as in the case of other le- 
 sions of the erythematous type, may be absent or present according 
 to the duration and intensity of the capillary congestion. 
 
 With each congestive attack the new macules become larger in 
 extent and more prominent than those of the first eruption. Gradu- 
 ally the pigmentation deepens into a brownish-red or bluish-red color, 
 the skin becomes thickened, slightly raised, uneven, and, finally, the 
 seat of tubercular infiltration. 
 
 As a rule, the spots are not anaesthetic ; certainly there is no loss 
 of sensibility at all comparable to what characterizes the spots of 
 anaesthetic leprosy. Exceptionally there may be a very ajjpreciable 
 loss of sensation in patches which have become thickened and which 
 have existed for a long time. Disassociation of the different modes of 
 sensation is rarely observed. While the patches, as a rule, are rarely 
 universal, there is often to be observed a marked change in the colora- 
 tion and texture of the entire skin. In white races it may become dry 
 and yellowish or bronzed — a tint which has been compared by Eayer 
 to the skin of the mulatto. 
 
 During months and years the disease may remain practically 
 stationary, the clinical picture being diversified at times by the dis- 
 appearance of old spots and the appearance of new ones, and by their 
 gradual transformation into the bluish-red infiltrated patches, which 
 remain more or less permanent. 
 
480 
 
 MORROW — LEPROSY. 
 
 Period of Eruption of Tubercles. 
 
 After a time the pigmeuted patches, instead of undergoing invohi- 
 tiou, remain jiersistent, tlie skin becomes slighty thickened and swol- 
 len and the seat of tnl)ercular infil- 
 trations, which appear in the form 
 of small jiea-sized or larger nodules, 
 which may remain stationary or 
 rajjidly enlarge. The tubercles 
 may, however, develop uijon new 
 surfaces which have not been the 
 site of preceding pigment changes. 
 Exceptiouallv the}^ may develoj) 
 coincidently with the first erythem- 
 atous eruption, constituting the pre- 
 cocious tubercular stage. 
 
 The eruption of tubercles is 
 almost always preceded by febrile 
 symjitoms and other evidences of 
 constitutional disturbance, with 
 more or less hypersemia and oedema 
 of the pigmeuted patches. At a 
 more advanced stage the tubercular 
 outbreak may be attended by no 
 appreciable rise of temperature. 
 
 The tubercles exhibit great diver- 
 sity of aspect in form, volume, con- 
 sistence, coloration, situation, and 
 mode of evolution. They may be 
 dermic or hypodermic in their situa- 
 tion. They usuallj^ appear in the 
 form of small nodides, the size of a 
 shot or a pea, and they may attain 
 the size of a cherr\', hazelnut, or 
 pigeon's egg, or they may form large 
 tubercular masses from the fusion 
 of contiguous tubercles. 
 The coloration of the tubercles varies in different races. Ordinar- 
 ily they are of the same color as the pigmented skin upon which thej^ 
 develop. In dark races they are pinkish, brownish-red, some pre- 
 senting a mahogany tint or hue like that of an iodine stain. In white 
 races they are pale or yellowish upon their first appearance, or they 
 
 Fig. 2. 
 
SYMPTOMS OF TUBERCULAR LEPROSY. 481 
 
 may on growing older show a reddish-brown or bluish-red color, de- 
 pending upon the region of the skin upon which they develop. On 
 the extremities they are darker and more elevated than on the trunk. 
 
 In consistence the tubercle is at first comparatively soft and elastic, 
 later it grows firmer and harder. The lesions are softer upon the 
 trunk than ujDon the face and extremities. The surface is smooth as 
 if oiled, and sometimes the tense epidermis breaks at the summit and 
 there may be a branny or psoriasiform desquamation. They are at 
 first painful on pressure, but later they become indolent and abso- 
 lutely insensitive, probably because of pressure ui)on and degenera- 
 tion of the compressed nerves. 
 
 The seats of predilection for the tubercles are the facial mask, the 
 forehead, especially the supraorbital region, the cheeks, chin, nose, and 
 lips, the lobes of the ears, the dorsal surfaces of the hands and feet, 
 the ankles, forearms, and wrists, the outer aspect of the thighs, and the 
 buttocks. The primary eruption almost invariably appears upon the 
 forehead or cheek, the anterior aspect of the forearms or the outside 
 of the thigh ; Imj^ey says in his experience the first tubercle is com- 
 monly seen at the inner border of the supraorbital ridge. They may 
 develop upon any portion of the body except the hair}^ scalp, which 
 is almost always exempt. They are rarely seen over the elbow- or 
 knee-joints or upon the j)alms and soles, in which situation they are 
 flattened rather than prominent. As a rule they are flatter on the 
 trunk from pressure of the clothing. They may appear upon the 
 genital parts, the scrotum, prepuce, around the anus or vagina, and 
 exceptionally upon the glans penis. 
 
 Most authorities aflirm that the tubercles never appear upon the 
 glans penis. I have, however, a photograph of a Chinaman, whom 
 I examined in San Francisco, which shows characteristic tubercles 
 on the glans (Fig. 2). 
 
 In the earlier stage the tubercles are small, resembling the papules 
 of syphilis, the tubercles of lupus vulgaris, of acne indurata, or of 
 sycosis. The remarkable resemblance of the case illustrated in Fig. 
 3 to syphilis will be noted at a glance. 
 
 The boy, H— — A , a native of Key West, Florida, is 14 years 
 
 old ; he has two sisters and a brother, all healthy ; the mother and 
 father, natives of the West Indies, both enjoy good health ; one uncle 
 has been a sufferer from a chronic skin affection for a number of years, 
 said to be an eczema. Four years ago he had an attack of measles. 
 Upon regaining his health, it was observed that he had a "rash," 
 which did not fade, as was anticipated the skin trouble would. His 
 general health, however, seemed good, but during the hot weather 
 his skin would assume a peculiar hue, and in jjlaces small elevations 
 would appear, all fading when a cool day came. From what I have 
 Vol. XVIII.— 31 
 
482 
 
 MORROW — LEPKOSY. 
 
 beeu able to glean, the boy had been most thoroughly treated for 
 syphilis ; he had beeu to school, aud led his usual life uutil the fall of 
 1893, wheu he was sent to New York for advice as to the nature of 
 his ailment. At the time I first saw him his condition was about as 
 
 Fig. 3.— Tubercular Leprosy (Early Stage). 
 
 follows : Skin sallow, tongue coated ; pulse not so full and strong as 
 one would expect to find in a boy of his age— accounted for when his 
 heart was listened to, as that organ was weak, but no murmurs could 
 be found. His appetite was poor, meat being sought for and vege- 
 tables avoided by him. He could not stand any fatigue, being unable 
 to walk any distance or perform any laborious tasks. The tubercle.s, 
 more prominent on the face than elsewhere, were also present on his 
 extremities. His bodv was free from these neoplasms, but there were 
 
SYMPTOMS OF TUBERCULAR LEPROSY. 483 
 
 areas wliicli seemed to have lost the pigmentation, or the pigment 
 was increased in some places and faded in others. No anaesthetic 
 areas could be found. In his mouth, extending from midway of the 
 hard palate to well on the soft part of the jialate, was an ulceration 
 with elevated borders. It was probablv one and a half inches in 
 length by one-half to three-quarters of an inch wide. He complained 
 of no pain or inconvenience from this lesion, which improved greatly 
 after he was placed upon nus vomica. An ulcerated condition existed 
 on his right foot, just back of the great toe; also a spot on the inner 
 side of each thigh. The ulceration on the foot healed kindly, but 
 when the boy was last seen the two other ulcers were far from healing. 
 
 The boy was taken to the Hospital for Coutagious Disease, where 
 he remained until his death in January, 1898. I am indebted to Dr. 
 J. M. Winfield, of Brooklyn, for further notes of the case. 
 
 The tubercular areas (face, neck, ears, arm, hands, legs, and feet) 
 gradually became more pronounced, and the ulcerations were deep. 
 Occasionally the skin would clear up, and the boy gain strength; he 
 grew very tall, and was exceedingly sensitive to observation. His 
 throat symptoms, which were present from the start, gradually grew 
 worse, and at times great difficulty was experienced in swallowing. 
 Once or twice the swelling of the glottis seriously interfered with res- 
 piration. This condition of affairs continued, each day the patient 
 growing more and more anaemic and emaciated until he was finally 
 obliged to keep his bed. His death occurred from suffocation. 
 
 The pharynx, epiglottis, and trachea were found to be thickened 
 and ulcerated. There were never any sensory disturbances or patches 
 of anaesthesia. 
 
 As the tubercles grow older, or as they develoiD at a later stage, they 
 are larger and more voluminous and exhibit a more pronounced colora- 
 tion. Sometimes they appear as small firm nodules closely set to- 
 gether, the spaces between them being accentuated as furrows. This 
 massing of the tubercles -is especially Sfien about the supraorbital 
 ridges, and upon the extensor surfaces of the arms and legs. The 
 tubercles in this location, while they ma}' be closely aggregated, are 
 usually well defined and sharjjly distinct from each other. 
 
 Instead of being isolated, the nodules may become confluent and 
 appear in the form of large plaques of thickened skin of variable size 
 and extent {Jepromes en nappe) . These j)laques are somewhat elevated, 
 bluish, livid, or violaceous in color or even brownish or black {mor- 
 phoea nigra of the ancient writers). In consistence they are firm, and 
 Deloir compares the plaque to a piece of cardboard mortised in the 
 skin. In other cases, the infiltration may become thick and denser, 
 like a hard oedema of the skin and subcutaneous tissues ; Bazin has 
 termed this condition leprous scleroderma. 
 
 The surface of the plaque is usually mammillated, rough, and un- 
 
484 MORROW — LEPROSY. 
 
 even, and sometimes the seat of epidermic desquamation. Tlie 
 j)laques varv in size from tLat of the palm to extensive infiltrations 
 covering the entire surface of the limb. They are usually sharply 
 demarcated; at other times they blend almost insensibly with the 
 sound skin. They may exist for years without undergoing marked 
 changes. In one case, which I had under obsen'ation for several 
 years, the plaques on the extensor surfaces of the arms and thighs 
 remained unchanged. Campana has shown that there is usually an 
 elevation of temperature, from one to two degrees, to be observed over 
 these plaques, which is sometimes succeeded by a subnormal temper- 
 ature. 
 
 The disease extends by the invasion of new areas of previously 
 unaffected skin and the development of new tubercles or plaques in 
 the neighborhood of existing tubercles. In many cases there is a 
 gradual increase in the sizo or volume of the tubercles. In other 
 cases there are repeated congestive attacks which are synchronous 
 with the multiplication of the bacilli, and, since the growth of the 
 bacilli does not take place at a uniform rate, these attacks or exacer- 
 bations occur at irregular intervals, often accompanied by fever and 
 general symptoms. They commonly coincide with or may be con- 
 secutive to softening and resorption of numbers of the tubercles. 
 
 These exacerbations may simulate an attack of erysipelas or of 
 erythema nodosum, and, according to Leloir, they are due to resorption 
 of leprous virus by the lymphatics and its extension along these chan- 
 nels. Evidence of this, he claims, may be found in the fact that 
 there are often observed painful swellings of the neighboring lym- 
 phatic ganglia and ribbon-like prolongations of lymphangitis. Xot 
 infrequently there are rheumatoid pains and painful swellings in the 
 joints in connection with these exacerbations. 
 
 At this period the skin of the face becomes tumefied with a shiny, 
 glazed, discolored appearance, the backs of the hands and feet are 
 often puffy and swollen with a diffuse infiltration, especially marked 
 over the dorsal surface of the first and second phalanges, giving the 
 fingers a fusiform appearance. The dorsal surfaces of the feet may 
 be similarly affected. Frequently the skin about the ankle and leg 
 becomes thickened and indurated and the seat of a hard, oedematous 
 swelling, which may be covered with large imbricated scales with 
 papillomatous proliferations. This pachydermatous condition pre- 
 sents a striking resemblance to that of elephantiasis arabum. 
 
 It is to be remarked that the process of ulceration in old tubercles 
 occurs coincidentally with the development of new ones. 
 
 Daniellsen and Boeck have observed that congestive attacks which 
 precede or accompany the ai>pearanceof new tubercles are often syn- 
 
SYMPTOMS OF TUBEECULAR LEPROSY. 
 
 485 
 
 chronous with tlie breaking down and resorption of old ones. This 
 process is usnalh" accompanied by fever and general phenomena of 
 systemic disturbance which disappear spontaneously. 
 
 The new tubercles remain stationary or develop until, with a new 
 congestive attack, the}' undergo the same evolutionary changes. Ac- 
 cording to Leloir the 
 skin which surrounds 
 the tubercles becomes 
 red and there develop 
 localized tumefactions, 
 resembling those of 
 erythema nodosum, 
 which are gradually 
 transformed into new 
 leprous tubercles, at 
 the same time aug- 
 menting the volume of 
 the preexisting tuber- 
 cles around which they 
 are developed. 
 
 In countries where 
 leprosy is endemic, it 
 has been observed that 
 the tubercles become 
 larger and more 
 marked for three or 
 four years, when they 
 begin to break down 
 and ulcerate. 
 
 The evolution of 
 the tubercles is not 
 sufficienth' regular to 
 admit of chronological 
 
 classification. Thoir most marked and characteristic development 
 occurs upon the face, and gives that peculiar aspect to the individual 
 which has been denominated leontiasis, and which is pathognomonic 
 of the disease. (See Figs. 4 and 5.) 
 
 In the advanced stage the integument of the face becomes infil- 
 trated with tubercular nodules or masses which exaggerate the natural 
 lines or furrows of the skin. The supraorbital regions are studded 
 with the tubercles, most marked towards the internal border, and form 
 protuberant masses separated by vertical furrows, which intersect the 
 horizontal furrows, forming lobulated masses. The cheeks, especially 
 
 Fig. 4.— Typical Facies of Tubercular Leprosy. (From Mor- 
 row's " System of Geni,.o-Urinary Diseases, Syphilology, 
 and Dermatology.") 
 
486 
 
 MORROW — LEPROSY. 
 
 over the malar i)romineuces, are enormously tiimefied aud uneven with 
 tubercles. The lii)S are swollen and everted, the ahe of the nose 
 thickened aud broadened, the chin is enlarged and covered with bossy 
 l)rotuberanc'es, giving it a S([uare appearance, the lobes of the ears are 
 enlarged, hanging down in Habby pendulous masses. These, with the 
 loss of the eyebrows and lashes, the conjunctival and corneal lesions, 
 
 are elements in a pic- 
 ture of hideous deform- 
 ity which once seen can 
 always be recognized 
 as pathognomonic. 
 
 The course of the 
 tubercles and diffuse 
 infiltration may re- 
 main stationary and 
 practically no change 
 take place, except in 
 size, for months or 
 years, the surface des- 
 (luamating and the 
 color changing into a 
 CO Pinery, dark brown, 
 or livid tint. 
 
 The tubercles may 
 undergo gradual re- 
 sorption or become 
 transformed by a proc- 
 ess of fibrous indura- 
 tion into small masses, 
 which persist indefi- 
 nitely without further 
 change, or they may 
 take on a keloidal 
 character. 
 The disappearance of one group is succeeded by another in the 
 same or new regions at variable intervals. 
 
 Lymphatic Gaiu/Jia. — Implication of the lymphatic ganglia may 
 begin at an early stage of leprosy. Swelling of the glands is most 
 pronounced in the inguinal region. Usuall}' the swelling increases 
 with each congestive attack, and the glands may attain the volume of 
 a nut or even a goose egg. The cervical and axillary ganglia may 
 also attain to large a size. The swellings of the submaxillary and sub- 
 lingual glands may be so pronounced as to impede the movements of 
 
 Fig. 5.— Typical Facies of Tubercular Leprosy. (From Mor- 
 row's " System of Geuito-Urinary Diseases, Syphilology, 
 and Dermatology.") 
 
SYMPTOMS OP TUBEECULAR LEPROSY. 487 
 
 tlie jaws and even interfere with tlie process of deglutition. All of 
 the glands of the body accessible to the touch may be found enlarged, 
 the popKteal, epitrochlear, etc. It is probable that there is coinci- 
 dent enlargement of the mesenteric glands, as has been demonstrated 
 by autopsy in many cases. There is a hyperplasia of the connective 
 tissue. 
 
 The glands rarely soften and ulcerate, but in the final stage there 
 may be found fistulous tracts communicating with the ganglia from 
 which a large quantity of thick matter escapes. Leloir believes that 
 the lymphatic ganglia are veritable sources of the leprous virus, con- 
 stituting centres of autoinfection, and that their condition is always 
 in direct relation to the course of the disease. In the early stages 
 they are but slightly swollen, but later, with the multiplication and 
 accumulation of the bacilli, they become large and painful. 
 
 During this entire period there are to be observed certain changes 
 in the glandular portions and appendages of the skin, and sensory 
 disorders more or less pronounced. 
 
 The sebaceous and sweat glands are disturbed in their function at 
 an early period of the disease. The alterations of the glandular 
 apparatus are often noticeable during the erythematous sfege, but 
 become more pronounced with the progress of the disease. There is 
 generally an increase in their functional activity, expressed by hyper- 
 secretion, which is followed by diminution or arrest, which may be 
 general or localized in certain areas. 
 
 The exaggeration in the function of the sebaceous glands in the 
 early stage gives the skin a characteristic shiny appearance, as if it 
 had been rubbed with oil. Later the sweat disappears from the af- 
 fected regions and sometimes is suppressed over the entire body, and 
 the skin becomes dry and harsh from the disappearance of the glan- 
 dular secretions. 
 
 Hair Follicles. — The leprous process usually aifects the pilous 
 elements of the skin in the most destructive manner. The alopecia 
 is first manifest in the fragility, thinning, and falling of the hair, and 
 later in complete loss of the hair in certain regions. The falling out 
 of the hair is, as a rule, confined to the localities affected by the erup- 
 tion and is absent over the spots and present in the intervals between 
 them. Usually the first to suffer are the eyebrows, the loss of which 
 constitutes one of the most characteristic features of tubercular lep- 
 rosy, and is valuable from a diagnostic point of view. The alo- 
 pecia also affects the beard, the nostrils, and other pilous portions of 
 the body which are the seats of tubercular infiltrations. Upon the 
 face the conservation of the hairs in the intervals between the leprous 
 infiltrations give the beard a sort of tufted appearance (Fig. 4). 
 
488 MORROW — LEPROSY. 
 
 The liairy scalp enjoys a surjirisiuf^ immunity from the encroach- 
 ments of the bacilli. It is not uncommon to see a leper with a fine 
 growth of hair on the head, while the hair has almost disappeared 
 from the rest of the body. On the general surface of the body the 
 hairs suffer from a pronounced inanition before gradually disappear- 
 ing, becoming dried, atrophic, and easily broken. 
 
 The development of leprosy before puberty exercises an inhibitorj'^ 
 effect upon the growth of the hair over the entire surface of the body. 
 There is commonly observed an arrest of development of the hair in 
 the axillary, pubic, and facial regions ; the eyebrows and bodj' hair 
 fall out subsequently, leaving the body entirely glabrous. 
 
 Sensory Disorders. — The disorders of sensibility are not constant 
 or characteristic features of tubercular leprosy. In many cases even of 
 extensive distribution of tubercular lesions sensation may be preserved 
 in complete integritv. Certain of the lesions may be at first hyper- 
 sesthetic succeeded by anaesthesia, and in rare cases there may be dis- 
 association of the modes of sensibility, as in anaesthetic leprosy. 
 
 It is probable that the anaesthesia of the tubercles and surrounding 
 skin is caused by pressure upon the terminal filaments of the cutaneous 
 nerves, which pass into the tubercle, and the cuticle becomes anaes- 
 thetic from paralysis. It has been observed that sensibility may 
 return in parts that have been anaesthetic, which would indicate that 
 the phenomenon is caused by comj^ression rather than by degenera- 
 tion or destruction of the peripheral nerves. In general it may be 
 said that the older the lesion the more accentuated the loss of sensa- 
 tion. 
 
 Leprosy of the Mucous Membranes. 
 
 The changes in the mucous membranes caused bj^ leprosj^ have 
 always been regarded as constituting one of the most characteristic 
 features of the disease, but the chronological order in which these 
 changes take place has not until recently been recognized. The 
 general consensus of opinion has been that morbid alterations in the 
 mucosa never occur before the skin is affected ; while most writers 
 assign the date of their development to a i:)eriod long subsequent to 
 the appearance of the cutaneous manifestations. 
 
 In an article on "Leprosy," written several years ago {loc. cit.) 
 the present writer expressed his views as follows: "Contrary to 
 what is usually taught, I believe that the first manifestations of 
 leprosy are, in the majority of cases, determined toward the mucous 
 membranes of the pharynx and upper air passages. Few of our mod- 
 ern authorities seem to recognize the precocity of these manifesta- 
 tions, although Hillis remarks that in tubercular lejn-osy the first 
 
LEPEOSY OF THE MUCOUS jVIEMBKANES. 489 
 
 tliroat manifestatious occur during tlie febrile attack. According to 
 niv observation, alteration of tlie voice, betrayed by a slightly husky 
 or rough phonation, rhinitis, with an abnormally free nasal secre- 
 tion, sometimes epistaxis, and an increase in the salivary secretions 
 are among the earliest signs of leprosy. " " At a more advanced stage, 
 when there are leprous deposits in the mucous surfaces with involve- 
 ment of the cartilages and bones, the characteristic, harsh, raucous 
 voice and the difficult, sniffling respiration from obstruction of the 
 nostrils are almost invariable concomitants." 
 
 It has usually been asserted that in anaesthetic leprosy the mucous 
 membranes of the upper air passages are not implicated. In a num- 
 ber of cases collected by Gluck, he found the mucosa of the lips 
 affected four times, the tongue twice, palate and throat three times, 
 larynx four times, and nose fifteen times. Undoubtedly there are 
 many cases of anaesthetic leprosy in which symptomatic manifesta- 
 tions are present when the existence of specific lesions in this locality 
 cannot be demonstrated. 
 
 A patient in the early stage of anaesthetic leprosy, now under my ob- 
 servation, cannot go from a warm room into the cold air without liabili- 
 ty to a copious nasal secretion compelling her to use a handkerchief 
 almost continually. In this case there are no visible leprous changes 
 in the nose, and the phenomenon is probably due to the action of the 
 bacilli upon the vasomotor nerves of the pituitary meinbrane robbing 
 it of their protecting power, so thau it responds to the action of the 
 cold air by an abnormal secretion. The increased salivary secretion 
 may be caused by reflex irritation of the salivar.v glands. Jeanselme 
 and Laurens claim that leprous coryza is not necessarily- dependent 
 upon previous infiltration, and that the coryza becomes attenuated or 
 disappears spontaneously when the leprosy tends to become anaes- 
 thetic. 
 
 According to Hillis, coincidenth- with the appearance of tubercles 
 on the cutaneous surface the mucous membranes of the mouth, the 
 pillars of the fauces, the uvula, and the tongue may become studded 
 with pinhead-sized papules. It will be more convenient to study the 
 mucous-membrane manifestations of the different regions of the up- 
 per air and food passages sexjarately. 
 
 The Nasal Mucous Meriibranes. — First in point of frequency, as 
 well as in importance, are the changes in the nasal mucous membranes 
 caused by leprosy. The investigations of Sticker and of Jeanselme 
 and Laurens, to which reference has been elsewhere made, throw 
 considerable light upon the pathological alterations of the nasal mu- 
 cosa. A unique importance has been given to lepros\' of the mucous 
 membrane by the demonstration of the precocity of its manifesta- 
 
490 MORKOW — LEPROSY. 
 
 tion. These authorities state that leprous coryza, which may simu- 
 late ordinaiy corvza, constitutes the first exterior manifestation of 
 the disease in a large proportion of all cases. In lepra nervosa it 
 shows a tendency to disappear spontaneously. In the tubercular 
 form, on the contrary, it undergoes exacerbations from time to time, 
 and these coincide with the cutaneous efflorescences, the rhinitis be- 
 ing often cauesed by leprous infiltrations in the nasal mucous mem- 
 brane. 
 
 Among the most important symptoms of the initial stage is epi- 
 staxis. This may have the same importance as a revealing sign of 
 leprosy as the hcBmoj^tysis which is premonitory of pulmonary tuber- 
 culosis. The epistaxis may be quite abundant and accompanied with 
 congestive jihenomena, vertigo, etc., in the initial stage, but later 
 becomes reduced to the loss of a few drops of blood when the patient 
 makes an effort to expel the crusts which obstruct the nostrils, and 
 later ceases altogether. In all these cases there is a marked ten- 
 dency to erosion and superficial iilceration of the pituitary mem- 
 brane, which becomes covered with thick adherent crusts formed by 
 the abundant mucous or sanguinolent secretion. 
 
 As the disease advances the ulcers, which are usually situated in 
 the septum, become deeper and more extensive, and finally perforate 
 the cartilaginous septum. This perforation may be circumscribed 
 and of limited extent, circular or elliptical in form, readily permitting 
 the introduction of a j)robe from one nostril into the other. More 
 often the septum is destroyed in its totality- with, or more frequently 
 without, involvement of the bonj" framework of the nose. The nose 
 becomes deformed, sunken, flattened out, the lobules almost touching 
 the upper lij) and separated from it only by a slight gutter. The 
 destruction of the cartilaginous septum occurs very insidiously and 
 without the knowledge of the i)atieut. It would seem to take place 
 by a process of interstitial absorption, since expulsion of cartilaginous 
 sequestra has not been observed. 
 
 The rhinoscopic picture of the pathological alterations which ex- 
 plains the functional troubles and the mechanism of the production 
 of the characteristic deformities of the nose is thus given by Jean- 
 selme and Laurens : 
 
 " Immediately above the vestibule, the skin of which is almost al- 
 ways intact, the mucous membrane is red, turgid, and furrowed with 
 tortuous and distended capillaries. This congestion attains its maxi- 
 mum at the anterior and inferior x^ortion of the septum. At this 
 point the mucous membrane is often covered with small brownish 
 crusts — vestiges of recent hemorrhages or of erosions more or less 
 extensive lined with miicopus. The slightest touch of the probe 
 
LEPEOSY OF THE MUCOUS MEMBRANES. 491 
 
 over this liemorrhagic zone provokes a sanguinolent discharge. The 
 mucous covering of the entire inferior segment of the septum is ordi- 
 narily quite thickened and its consistence sensibly diminished. Some- 
 times, also, the pituitary membrane which covers the inferior turbi- 
 nated bones is infiltrated, soft, and depressible. In one of our patients 
 the middle turbinated was voluminous, of a blanched color, and was 
 covered with a multitude of small congested points, of an almost 
 ecchymotic redness." 
 
 At a more advanced period the septum is easily depressed by the 
 probe, the consistence of the cartilage is notably diminished, and per- 
 foration takes place. " When the perforation is recent the free border 
 is thick, callous, and bleeds easily. When it has existed for some 
 time, the mucous membrane is thinned, pale, and cicatricial. These 
 two aspects may be observed in the same perforation, one portion of 
 the circumference being already cicatrized, while the other is still in 
 an ulcerous condition — one never finds the cartilage denuded. When 
 the rhinitis disappears ^the membrane which covers the turbinated 
 bones may undergo a certain degree of atrophy, resulting in a consid- 
 erable gaping of the nasal cavities, and bringing into view quite a 
 large surface of the posterior pharyngeal wall." 
 
 In addition to the changes caused by leprous rhinitis there is 
 sometimes observed a deposit of leprous tubercles which may be dis- 
 tributed over the lower turbinate, the sei^tum, the floor, or vestibule 
 of the nares. Thej^ are of variable number, flattened, lenticular, firm 
 to the touch, and contrast by their grayish-white or pinkish color 
 with the deep red of the mucous membrane. Ordinarily isolated, 
 they may become confluent and form a continuous opaline and mam- 
 mellated nappe. The vibrissse fall out at an early stage. 
 
 All authorities agree that notwithstanding the destructive charac- 
 ters of the nasal lesions the sense of odor persists intact with scarcely 
 notable modifications. 
 
 Sensation is often notably diminished or entirely abolished over 
 the affected portions. Thus ic may be entirely lost in the membrane 
 covering the septum — so that one may freely cauterize the region of 
 the septum without provoking pain, while the skin of the vestibule 
 of the nares is normally sensitive. In certain cases anaesthesia may 
 be entirely independent of any eruptive manifestation. 
 
 The Mucous Membrane of the Mouth and Throat. — Three-fourths 
 of all cases of tubercular leprosy show mouth and throat lesions ; in 
 the anaesthetic form the proportion is much smaller. 
 
 The mouth and mucosa of the lips are often affected. The lep- 
 rous infiltration causes a general thickening, with a superficial pro- 
 duction of nodules. These may excoriate or ulcerate, and healing 
 
492 MORROW— LEPROSY. 
 
 witli scars results. The iufiltration is accompanied by a tendency 
 to form rbagades which are deep, painful, and bleed readil}'. Ulcers 
 are especiallj'^ prone to occur on the free border of the lips and in severe 
 cases healing is followed bj'' stenoses and entropion of the mouth. 
 
 Ginns. — The gums are affected rarelj' and late. When they do 
 not actively participate they are hard, pale, and smooth. When they 
 are activel}^ involved they are swollen and eroded on the edges ; re- 
 traction follows. 
 
 Cheeks. — The mucosa of the cheeks is involved even more rarely 
 than the gums. The appearance when not actively participating is 
 pale red. 
 
 The Tongue. — Leprous lesions of the tongue may appear in the 
 form of tubercles or opaline patches. The tubercles exhibit consider- 
 able differences in size; ordinarily they are miliary, lenticular, pea- 
 sized. Sometimes they are quite voluminous, hard or soft, reddish 
 or livid in color, and with a smooth or vegetating surface. 
 
 The most characteristic features of leprosj"" of the tongue are 
 nodules seated usually in the middle of the dorsum. They are rarely 
 found elsewhere than on the dorsal aspect. The}' are usually multi- 
 ple and may be discrete or confluent. When they are discrete the 
 tongue has an irregular lobulated surface, the nodules being separated 
 by furrows. When confluent, the nodules have a tessellated forma- 
 tion. The fusion of the tubercles may form a mammillated plaque, 
 with a grayish surface, as if cauterized with nitrate of silver. Unlike 
 intranasal nodules they do not usualh^ break down, and have been 
 known to persist for years without change. 
 
 The number of nodules and degree of infiltration tend to increase 
 until the tongue becomes enlarged, thickened, and clums^', sometimes 
 twice the normal size, and can be moved with difficulty, mastication 
 becomes difficult and painful, while the furrows between the tubercles 
 crack and fissure. When ulceration occurs the ulcers are superficial 
 with slightl}^ undermined edges and resemble ulcerated mucous 
 patches; the resulting scars also resemble syphilitic plaques. The 
 thickened grayish epithelium may come awaj'^ in rags, leaving the 
 subjacent parts a little red or pale. The lingual papillae are promi- 
 nent, and the follicles at the back of the tongue hypertrophied; the 
 two branches of the lingual V may form a considerable elevation. 
 
 Sensibility^ is usually abolished more or less completely in the 
 surfaces occupied by the leprous infiltrations. Deep cauterizations 
 with a hot iron may occasion no sensation. The thermic sensibilitj^ 
 may also be lost. The sense of taste is in the majority of cases pre- 
 served in more or less complete integrity. Only occasionally do we 
 see pinhead to lentil-sized nodules. 
 
LEPEOSY OF THE MUCOUS MEMBKANES. 493 
 
 Lesions of the moutli may be accompanied by salivation from 
 reflex irritation of the salivary glands. 
 
 Palate and Uvula. — These tissues are often affected coincideutly 
 with the cutaneous eruption which follows an attack of fever. The 
 palate is generally occupied by a sharply limited infiltration, slightly 
 raised and covered with a bluish or grayish opaline or epithelial 
 coating, which may be slightl}' eroded. At a later period the entire 
 palatine arch may become covered with an eruption of grayish and 
 flattened tubercles of the form and volume of a split pea. These 
 nodules may spread over the uvula and the anterior pillars of the 
 palate in quite a symmetrical manner. The infiltration may extend 
 forward, involving the membrane covering the hard palate, and extend 
 to the retrodental furrows situated behind the sujDerior incisors, 
 often leading to shedding of the teeth, especially the incisors. The 
 uvula is usually elongated, thickened, and of a peculiar grayish-blue 
 color. A tubercle may form at the tip of the uvula, giving a bulbous 
 appearance, or one may form at its junction with the velum, causing 
 oedema and hypertrophy. The whole picture of the palate and uvula 
 is strikingly like moist, vegetating syphilides. 
 
 Sooner or later there is erosion or ulceration which, as a rule, 
 rapidly cicatrizes. The anterior surface of the uvula is particularly 
 prone to ulceration . The ulcers are usually as large as a lentil, and 
 as they heal new ones may appear until the whole infiltration may be 
 replaced by cicatricial tissue. As the ulcerated uvula heals it may be 
 contracted towards the palate ; or it may be fixed in one of various 
 vicious positions from adhesions with the surrounding structures. 
 The various resulting deformities may seriously interfere with nor- 
 mal deglutition — regurgitation of liquids through the nose is com- 
 mon. As cicatrization proceeds there is more and more shrinkage 
 and the pressure appears to cause rarefaction and absorption of the 
 palate bones. The results again strikingly resemble the destructive 
 lesions of tertiary syphilis, although the pathogeny is quite dif- 
 ferent. 
 
 It is to be observed that exceptionally the mucous membrane of 
 the palatine arch presents a remarkable pallor, and that this ansemic 
 condition may be manifest over the entire extent of the buccal and 
 pharyngeal mucous surfaces. 
 
 Fauces. — Both the palatine arches and the tonsils are commonly 
 affected. The ulceration of the infiltrated faucial pillars is rather su- 
 perficial, while that of the tonsils is deeper and leads almost to the 
 effacement of these structures. The leprous ulcerations of the ton- 
 sil are often covered with a grayish diphtheroid coating and simulate 
 closely syphilitic ulcers of these structures. 
 
494 MORROW — LEPROSY. 
 
 F]iarij)ix. — The posterior wall of the pharynx often escapes, yet 
 lua}' be involved when structures like the nose and mouth escape. 
 Leprous pharyngitis resembles leprous rhinitis ; the membrane is oily, 
 red, and shiny as if varnished. The nasal insufficiency which compels 
 the patients to breathe almost exclusively through the mouth is prob- 
 ably the principal cause of this dry and parched condition of the mu- 
 cous surfaces. There is an irregular deposit of small nodules which 
 become eroded or ulcerated and heal with white superficial scars. Ou 
 account of coincident anaesthesia, patients do not feel much pain un- 
 less there are deep rhagades or deep ulcers. 
 
 Tlie Ear. — Leloir and others make mention of certain auditory 
 troubles which occur in the course of leprosy. They are usually con- 
 fined to noises and rumblings in the ears with decided dulness in the 
 acuity of the sense of hearing. The condition of the alterations in the 
 tonsil, with congestion and thickening of the membrane of the Eusta- 
 chian tube with consequent obstruction, explain these auditor}^ phe- 
 nomena. There is often also some redness and congestion of the 
 membrana tympani. The hearing may also be temporarily affected 
 by the development of nodules in the external auditory canal, coinci- 
 dent with their appearance in the external parts of the ear. 
 
 The Larynx. — The epiglottis is the region of the larj^nx most fre- 
 quently involved in leprosy. There is infiltration or hypertrophj' of 
 the submucous connective tissue and the epiglottis becomes thick- 
 ened, tumefied, and stiff. The mucosa maj'' remain smooth or be 
 studded wdth small grayish nodules, and the iisual ulceration and 
 scarring may be present. Sometimes this covering becomes thick- 
 ened and is transformed into a hard spheroidal mass, which is main- 
 tained above the vestibule of the larynx by the infiltrated and inex- 
 tensible aryteno-epiglottidean folds, and the functions of the larynx 
 are gravely compromised (Jeanselme). The epiglottis may be mark- 
 edly' involved and the rest of the larynx escape. Similar changes may 
 occur in the arytenoid cartilages. A peculiarity of this locality is 
 thatfbut one side may be involved. 
 
 Next in frequency to the preceding, the glossoepiglottic and ary- 
 epiglottic folds are involved and in a similar manner. The true cords 
 frequently exhibit swelling aud thickening which maj- in time lead 
 to ulceration, and later may involve an entire cord. The tendency of 
 the ulcers to cicatrize is very marked, and not only the true but the 
 false cords may be destroyed. As a result of the ulcerative process 
 the structures of the larynx are often changed into a shapeless mass at 
 an advanced i^eriod of the disease. These changes induce hoarseness 
 up to complete aphonia and at times dyspnoea. 
 
 Attacks of dyspnoea from laryngeal stenosis are not uncommon. 
 
LEPEOSY OF THE MUCOUS MEMBRANES. 495 
 
 Tliey may result suddenly from an acute oedema conjoined with an 
 acute laryngitis from exposure to cold, attended with suffocative 
 symptoms and cyanosis, or they may develop more gradually from 
 the thickened, vegetating, and pachydermatous condition of the mu- 
 cous covering of the larynx. 
 
 Alterations of the voice are quite common during all the stages of 
 leprosy. The significance of this change was known at the time of 
 Moses; the j^riest recognized the leprous by commanding them to 
 speak before him. The voice ma}- be harsh, raucous, nasal, or other- 
 wise altered in its timbre. In other cases the voice becomes thin, 
 feeble, or there may be aphonia more or less complete. 
 
 According to Jeanselme the functional disorders of the voice may 
 be produced hy two mechanisms. Sometimes they result from clo- 
 sure of the glottic opening by some material obstacle (deposit of 
 tubercles on the laryngeal mucous membrane, destructive lesions of 
 the vocal cords, interarytenoid pachydermia) ; at other times they are 
 the consequence of an insufficiency of the glottis, the vocal cords 
 leaving between them an aperture during the emission of sound. This 
 paralysis of the vocal cords appears to be determined by a neuritis 
 of the recurrent laryngeal nerve. Lesions of the cartilaginous portion 
 of the larynx occur ac a later period of the disease, resulting at times 
 in necrosis of the cartilage. The laryngeal stenosis is often so pro- 
 nounced that tracheotomy is necessarj^ to prolong the life of the suf- 
 ferer. All observers note the analogy between leprosy and tuberculo- 
 sis of the larynx. 
 
 Leprous Affections of the Eye. — The frequency with which the eye 
 is affected in tubercular leprosy is variously estimated at from sixty- 
 six to seventy-five per cent. Even a larger proportion is given by 
 some authorities. As the leprous process almost always begins in 
 the oculopalpebral mucous membrane, these affections may properly 
 be considered under this head. At an early stage of the disease, 
 according to Daniellsen and Boeck, the white of the eye assumes a 
 muddy appearance and the vessels of the cornea are seen to be period- 
 ically injected. This change of color gradually increases and usually 
 produces upon the sclerotic towards the exterior border of the cornea a 
 grayish-yellow thickening, which forms around the cornea a rampart 
 of more or less elevation. The thickening progresses simultaneously 
 with an increase of vascular congestion until the whole conjunctiva 
 becomes the seat of the specific infiltration. There is an erj^the- 
 matous swelling of the eyelids, the eyelashes fall, and permanent in- 
 duration may remain along the tarsal cartilages, or the eyelids may 
 be completely invaded by leprous tubercles. The disease eventually 
 extends from the sclerotic to the cornea. The original infiltration, 
 
496 MORROW — LEPROSY. 
 
 which may now be called a tubercle on account of its increased vol- 
 ume, acquires c- brownish color, is firm to the touch, and extends 
 through the thickness of the cornea. After having penetrated through 
 the cornea the tubercle reaches the iris, which then assumes a dirty 
 gra3dsh color, the growth eventually passing into its substance. 
 The pupil becomes irregular and the anterior chamber is gradually 
 filled Avith tubercular matter. The j^atient feels lancinating pains in 
 the eye and the sight is extinguished. The disease progresses up to 
 the complete occupation of this chamber and the invasion of the 
 entire cornea by the yellowish-white matter. The eye is then a 
 shapeless mass. There is produced a sort of staphylomatous tumor 
 which increases to such an extent that the eyelids no longer cover it. 
 After a time the tubercular mass softens, the tumor contracts, and the 
 eye can again be closed. 
 
 Instead of this mode of invasion the iris maj- be, according to 
 Leloir, independently and primaril}- involved, constituting a leprous 
 iritis and resembling certain forms of syphilitic gummous iritis. 
 The tubercle penetrates into the posterior chamber, producing poste- 
 rior synechiae, and extends over the anterior surface of the crystalline 
 lens. It sends prolongations into the anterior chamber, which may 
 unite with prolongations of the tubercles which have invaded the cor- 
 nea. The almost invariable termination of this leprous iritis is loss 
 of sight. At other times there may be a diffuse lesion of the iris, 
 iridocyclitis. According to Hansen, thirtj' per cent, of tubercular 
 lepers have lesions of the iris. 
 
 These ophthalmic lesions may be acute or subacute in their evolu- 
 tion, but the almost invariable termination is partial or comjjlete loss 
 of vision. According to Hardy, the ulcerated surfaces of the eye- 
 lids may contract adhesions with those of the sclerotic, and the eye 
 is then immobilized in its socket. 
 
 The (jeiutal mucous membranes may also be the seat of leprous 
 lesions. The balanopreputial, or the vulvar, and the anal mucous 
 membranes are sometimes involved and then become the seat of tu- 
 bercles. 
 
 Period of Ulceration. 
 
 We have seen that, in their ordinary evolution, the lejn'ous tuber- 
 cles come out in successive crops, usually preceded by febrile at- 
 tacks ; that the earlier tubercles are usually resorbed or ulcerate and 
 may entirely disappear ; and that the disappearance of one group is 
 succeeded by another in the same or new regions at variable inter- 
 vals. After they have attained a certain degree of development the 
 tubercles may remain for weeks, months, or years without retrogress- 
 
ULCERATIVE STAGE OF TUBERCULAR LEPROSY. 497 
 
 ive changes, but, eventually, as in the case of other new formations 
 of the granuloma type, the leprous tubercle shows a tendency to 
 disappear by resorption or fibroid degeneration, or by softening, 
 breaking down, and discharge of its contents. The one process is 
 essentially curative and healing, the other destructive. 
 
 The stage of ulceration marks a period in the life term of the 
 neoplasm. Undoubtedly many tubercles ulcerate as a result of ex- 
 ternal injury, but in most cases the ulcerative process occurs as a 
 natural phase of the evolution of the disease. It is held by some that 
 the non-^dability or inaptitude for permanent organization of the 
 tubercles is caused by the gradual accumulation of the bacilli in 
 the perivascular spaces and the obliteration of the vessels, when the 
 neoplasms, being deprived of their blood supply, undergo necro- 
 biotic changes. Central mortification is first noted in the skin, which 
 softens in the centi-e, breaks, and gives exit to the contents of the 
 tubercles. 
 
 The capability of the lepra bacillus to induce suppuration by its 
 presence is undetermined, and it is a question what is the role, if 
 any, the pyogenic microbes play in the jjroduction of the suppurative 
 process. Impey thinks that suppuration of the inguinal glands and 
 other ganglia occurs through the action of pyogenic cocci and not 
 through that of lepra bacilli. In one form of ulcerative lesion, mal 
 perforans, the lepra bacilli are absent. 
 
 Fibroid Degeneration. — In many cases the neoplasms undergo a 
 sort of fibroid degeneration. As a result of frequently recurring con- 
 gestive processes there is a formation of connective tissue, and a 
 fibrous metamorphosis is effected in much the same manner as in cer- 
 tain tuberculides {lupus sclereux). The repeated congestive attacks 
 result in the formation of cicatricial tissue, which limits the multipli- 
 cation of the bacilli and is essentially a conservative element in the 
 disease. This fibroid degeneration is marked by a diminution in the 
 volume of the tubercle ; it becomes smaller, firmer, and more indu- 
 rated. On section of the tubercle it is seen to be composed almost 
 entirely of fibrous tissue, which renders it inapt for the germination 
 of the bacilli. These sclerosed tubercles are frequently permanent 
 and may become keloidal. When this fibrous transformation occurs 
 in all the tubercles, the disease is said to be arrested. 
 
 The same fibrous transformation may occur in the diffuse infil- 
 trations (lepromes en nappe). The surface becomes browner, with 
 increased desquamation. Gradually the infiltration in its entire ex- 
 tent becomes resorbed, leaving a superficial pigmented cicatrix. It 
 has been observed that this change may take place coincidently with, 
 or as a result of, an attack of erysipelas. 
 Vol. XVIII.— 32 
 
498 MORROW— LEPROSY. 
 
 Interstitial Resorption. — In some cases the tubercles haviDg at- 
 taiued a certain degree of development, a retrogressive process takes 
 place without open ulceration ; the tumors disappear by a process of 
 interstitial resorption. The upper portion of the nodule becomes 
 less prominent, often sinking in the centre, giving it an umbilicated 
 appearance ; and there is a progressive diminution of this central por- 
 tion of the nodule until only a narrow circular wall of infiltration is 
 left, which finally disappears, leaving a grayish or brownish pigment- 
 ed cicatrix. 
 
 Ulceration. — The ulcerative process varies accordingly as the necro- 
 biosis involves the centre or the totality of the tubercle. In the for- 
 mer case the skin over the centre of the tubercle becomes softened, and 
 one or more yellowish points are seen which soon open and discharge a 
 thick viscid or purulent yellow matter, which concretes in greenish, 
 brownish, or blackish crusts, resembling the crusts of s^-philitic ulcers. 
 The ulcer is round, irregular, the edges are often perpendicular or un- 
 dermined, the base is reddish-brown, grayish, or pseudomembranous, 
 sometimes fungous, secreting a sanious pus. These ulcers are indo- 
 lent and may persist for mouths or years practically unchanged. 
 
 In other cases in which the totalitj^ of the tubercle is involved in the 
 suppurative process the entire neoplasm disappears by purulent dis- 
 solution, and the contents are discharged en masse, as in an abscess. 
 The cavity may remain open for a long time, with a resistant infiltrated 
 wall, and the crateriform ulcer thus left as a rule cicatrizes, leaving a 
 slightly depressed, wrinkled cicatrix. Not infrequently two or more 
 ulcers may unite to form a large irregular ulcer ; or the whole body 
 may be the seat of these disfiguring ulcers and crusts. Leprous ulcers 
 seem to heal with remarkable facility under the influence of rest and 
 aseptic dressings, and the extensive cavities are filled with cicatricial 
 tissue. The resulting cicatrices are hard, irregular, often white iu 
 the centre, and surrounded by a brownish ring of pigmentation. 
 
 This cicatricial tissue may afterwards become the seat of tubercles. 
 It is to be noted that the development of new tubercles is often syn- 
 chronous with the ulceration and disappearance of old ones. While 
 certain tubercles are being eliminated by ulceration and subsequent 
 cicatrization, new tubercles appear which soften and ulcerate in their 
 turn. 
 
 The course and character of the leprous ulceration are modified ac- 
 cording to its situation and also by the intercurrent processes of ery- 
 sipelas-like inflammations and gangrene. Tubercles on the extrem- 
 ities are more apt to break down into ulcerative lesions, as, for example, 
 upon the dorsal surfaces of the feet and ankles, the legs, backs of the 
 hands and forearms, and the face. When an ulceration is about to 
 
TERMINATION OF TUBEECULAR LEPROSY. 499 
 
 occur in these localities, tlie skin becomes swollen, and in tliis infil- 
 trated skin violaceous, livid spots form, which open in a few days and 
 discharge an acrid, viscid material. 
 
 The occurrence of ulceration on the lower extremities is deter- 
 mined partly by dystrophic conditions here present in the shape of 
 marked oedematous infiltration — a hard, brawny, pachydermatous 
 condition of the integument which is sometimes so pronounced as to 
 suggest elephantiasis arabum. The contusions, injuries, and various 
 traumatisms to which lesions in these localities are subjected, as well 
 as lack of cleanliness, doubtless act as exciting causes. The ulcera- 
 tion rapidly extends and may involve the intervening tissues and sur- 
 rounding surfaces over a considerable area. It may advance around 
 the limb, like varicose or sj^philitic ulcers of the lower extremities, 
 or cover the entire dorsal surface of the feet and ankles. The ulcera- 
 tions are sometimes quite extensive both in area and depth. They 
 may take on a gangrenous action and cause profound loss of tissue, 
 sometimes ploughing up the soft tissues and laying bare the ligaments 
 and bones, with necrosis consecutive to the osseous denudations. 
 
 The destructive changes which occur at this stage of the disease 
 in the nasal fosste, palate, larynx, and trachea have been considered 
 in connection with leprosy of the mucous membranes. 
 
 It has been observed that intercurrent acute diseases may produce 
 a temporary subsidence of the tubercles. After an attack of erysipe- 
 las, smallpox, or other acute infectious disease many tubercles often 
 disappear. The beneficial effect of these intercurrent inflammations 
 has been explained on the ground that they alter the blood supply to 
 the part, while at the same time they favor absorption. Eeference 
 will be again made to these points in connection with the complica- 
 tions of leprosy. 
 
 Termination. 
 
 As leprosy advances in its evolution, all the symptoms increase in 
 intensity and severity. In connection with the ulcerative processes, 
 evidences of profound cachexia are usually manifest, due to leprous 
 deposits in the viscera or amyloid degeneration of internal organs. 
 Unless the unfortunate patient is carried off by some intercurrent 
 disease, he may live for years suffering a slow and progressive de- 
 composition of the hodj through the breaking down and ulceration 
 of the organs invaded by the leprous deposits. 
 
 The chief causes of death are usually tuberculosis, enteric compli- 
 cations with colliquative diarrhoea, exhaustion from ulceration and 
 gangrene, renal disorders resulting in dropsy, pulmonary lesions, 
 suffocation from oedema of the glottis, or stenosis of the larynx or tra- 
 
500 MORROW— LEPROSY. 
 
 chea. The visceral complications liave been generally regarded as 
 tuberculous in character, but it has been suggested by Arning that we 
 have been mistaken in attributing deaths of lepers to intercurrent 
 pneumonias, phthisis, and dysentery, which were simulated by the 
 clinical symptoms. 
 
 Although leprosy is regarded as among the most fatal of all dis- 
 eases, however paradoxical the statement may seem, the leper seldom 
 dies of leprosy. 
 
 According to the tables of Hillis, thirty-eight per cent, of lepers 
 die of internal leprous deposits, marasmus, atrophy, suffocation from 
 cedema of the glottis or laryngeal stenosis, or exhaustion from leprous 
 ulceration, Avhich may be the immediate consequences of the disease 
 itself. This proportion of deaths due directly to leprosj' is i:)robably 
 too high. Lepers commonly die of terminal infections which have 
 no necessary connection with the disease, as albuminous nephritis, 
 phthisis, bronchitis, pneumonia, diarrhoea, etc. 
 
 That tubercular leprosy progresses to a fatal termination is a rule 
 to which there are few exceptions. There have been cases, exceed- 
 ingly rare, in which the tubercles have entirely disappeared, the 
 ulcerations have healed, and there has been a definite cessation of all 
 further manifestations. The fires of the disease have apparently 
 burned out, and the patient lives for years, showing in his scarred 
 and disfigured features the traces of the destructive process which has 
 swept over them, and finally dies of some independent disease. 
 
 Daniellsen reports three cases of permanent arrest of the disease, 
 in one of which there had been complete exemption from all leprous 
 manifestations for thirty years. In another case, that of a woman, 
 the cure had been complete for twenty years. Kaurin reports a case 
 in which there was a complete disappearance of the tubercles with 
 apparent cure which persisted for many years, the patient finally 
 dying of cerebral hemorrhage at the age of ninety-five. The autopsy 
 showed no evidence of the bacilli in the integument or internal organs. 
 In another case there was a complete disappearance of all accidents 
 for twelve years or more, the patient remaining in good health. 
 Cases of real and api)areufc cure have been reported by others. 
 
 It is well, however, to distrust the authenticity of many cases 
 of reported cures, unless a considerable lapse of time has ensued after 
 the disappearance of all accidents. The disease may reawaken into 
 activity after a long period of exemption from all manifestations and 
 new tubercles form, or, as it sometimes happens, after the ulcers 
 lipve entirely healed there may be what is termed a visceral metas- 
 tasis, a determination of the morbid process to the lungs, liver, kid- 
 neys, or some other important organ, which soon leads to a fatal ter- 
 
COMPLICATIONS OF TUBERCUIAE LEPROSY. 501 
 
 mination. Tlie most hopeful prognosis justified by observation of 
 the usual course of the disease is that the tubercular leper may be- 
 come an anaesthetic leper. 
 
 Cases of metamorphosis of the tubercular into the anaesthetic form 
 are by no means rare. The pathological explanation of this transfor- 
 mation would seem to be simplj^ a migration of the bacilli from the 
 integument into the previously immune nerve tissues. In many cases 
 of advanced tubercular leprosy, this transition is shown by the super- 
 vention of anaesthesia, atrojphy, and other symj)toms peculiar to anaes- 
 thetic leprosy. 
 
 In one class of cases there seems to be a merging or rather a pass- 
 age of the one form into the other by almost insensible gradations. 
 Coincidently with the disappearance of the tubercles and the healing 
 of the ulcers there is the appearance of the characteristic.symptoms of 
 the anaesthetic form: atrophies, paralyses, enlargements of the nerves 
 and consecutive trophic troubles in the shape of deformities and mu- 
 tilations. Leloir has sometimes observed that in old tubercular 
 leprosy which had become associated with nerve leprosy, the skin, 
 subcutaneous tissue, and muscles of the face acquire a gelatinous 
 appearance and trembling due to a kind of colloid degeneration. 
 
 In other cases, instead of this gradual transition of one form into 
 another, the tubercles disappear completely and the patient seems 
 cured of his leprosy. After a period of exemption from all accidents 
 there may be a macular eruption, followed b}^ the regular evolution 
 of symptoms of anaesthetic leprosy, precisely as if there had been a 
 fresh infection. Daniellsen has observed a case of this kind in which, 
 six years later, the anaesthetic form was still maintained with all its 
 characteristic features. 
 
 Complications and Conditions Influencing the Course of 
 
 Leprosy. 
 
 Leprosy may be complicated with various parasitic and other 
 affections of the skin, as scabies, favus, ringworm, eczema, psoriasis, 
 etc. The incidence of these affections is much larger in tropical 
 countries, where a greater surface of the body is habitually exposed 
 and where parasitic affections of the skin are more common and of 
 more luxuriant development. It is sometimes difficult to discriminate 
 between the incipient manifestations of leprosy and chromophytosis 
 and other parasitic affections. 
 
 Daniellsen and Boeck say that in Norway leprosy is almost con- 
 stantly complicated with some chronic cutaneous malachj, the most 
 common being Norwegian scabies. Besides introducing an element 
 
502 MORROW — LEPROSY. 
 
 of confiisiou iu diagnosis, the breaks aud excoriations of the skin 
 which commonly attend these parasitic dermatoses are considered to 
 afford favorable spots for the entrance of the leprous virus and thus 
 constitute an important agency in the propagation of the disease. 
 Under the improved hygiene which has taken place in recent years this 
 complication is not at the present time nearly so frequent as formerly. 
 
 The foramina contagiosa effected iu prurigo, eczema, and other 
 ])arasitic dermatoses, by scratching or wounding the integument, are 
 regarded by Hebra and others as channels of entrance of the bacilli 
 into the system. 
 
 The complication with yaws or framboesia and also with elephan- 
 tiasis arahum, has been noted in countries where these diseases exist. 
 It is a matter of some scientific interest perhaps that elephantiasis 
 arabum is very common in the Samoan Islands, where leprosy is, or 
 was a few years ago, unknown, while the former disease is not met 
 with in the Sandwich Islands, where leprosy is so i)revalent. 
 
 Leloir was impressed with the remarkable coincidence of goitre 
 and leprosy in Italy. Among twelve Italian whom he observed in the 
 north of the peninsula, six were affected with goitre. 
 
 Si/philis often complicates leprosy. In a number of cases which 
 have come under my observation in the Charity Hospital of New 
 York syphilis was also present. Each disease, however, seems to 
 run an independent course, although it has been said that the tertiary 
 accidents of syphilis are rarely seen in sj'philitic lepers. The ante- 
 cedents of lepers are often syphilitic, and this is regarded by many 
 as constituting one of the most important predisposing causes of 
 leprosy. The native population of the Sandwich Islands was at one 
 time almost decimated by syphilis, and the impaired constitutions 
 resulting from these syphilitic progenitors, coupled with the feeble 
 capacity of resistance of the native Hawaiians, has always been re- 
 garded as among the chief causes of their remarkable susceptibility 
 to leprosy and its rapid spread among them. 
 
 The similarity of the two diseases in certain objective characters 
 and their frequent coincidence led to the erroneous opinion that lep- 
 rosy was a modified syphilis or, as it has been termed, "a fourth 
 stage of syphilis." The broad lines of distinction between these two 
 diseases are, however, too obvious to merit special mention. 
 
 Impey describes under the title of "Syphilitic Leprosy" a form 
 of the disease which he regards as worthy of sei)arate designation. 
 " Though produced by the combination of two distinct diseases, yet 
 each malady modifies the other in such a marked manner that the 
 distinctive characters of the primary disease are lost in the combined 
 diseases." He says that in these cases of syphilitic leprosy "the 
 
CONDITIONS INFLUENCIN'G THE COURSE OF TUBERCULAR LEPROSY. 503 
 
 mouth and tliroat become much affected, the hair is removed from 
 the scalp in large patches, bones in various parts of the body become 
 necrosed, lymphatic glands are enlarged and often suppurate. Indo- 
 lent abscesses are formed in various regions, the bones of the nose 
 are soon lost, and the nose itseK is soon removed by ulceration ; these 
 symptoms being almost entirely due to the syphilitic poison. When 
 to these disfigurements the deformities of leprosy are superadded, 
 the symptoms produced are almost too terrible to behold," etc. 
 
 Tuberculosis may also complicate leijrosy, in some cases consti- 
 tuting the primary affection upon which leprosy has been engrafted. 
 More commonly, however, tuberculosis represents a terminal infec- 
 tion and is the chief cause of death from its visceral complications. 
 In his investigations of leprosy in Norway, Leloir was struck by 
 the enormous number of persons affected hj scrofula, tuberculosis, 
 anaemia, and chlorosis in the leprous regions he visited. The coinci- 
 dence of the scrofulous diathesis with leprosy determines a marked 
 modification in the character and course of the leprous manifesta- 
 tions. Many observers agree that scrofula exercises a certain influ- 
 ence on the leprous tubercles which take on a " scorbutic appearance.'' 
 Leprosy occurs very often in persons of scrofulous and tuberculous 
 antecedents. Verteuil, quoted by Leloir, has often noted the coinci- 
 dent occurrence of pulmonary phthisis and leprosy in families. In a 
 European family of eight children, two of the boys died of leprosy, 
 and the third boy and two sisters succumbed to pulmonary phthisis. 
 
 Tlie eruptive fevers exert a marked influence upon the course of the 
 leprous process. An attack of typhoid fever, pneumonia, etc., may 
 cause the rapid involution of the lei)rous lesions, which may not re- 
 appear for a long time. Hardy speaks of the good effects of an inter- 
 current attack of smallpox. Vaccination is sometimes said to exert 
 an equally favorable influence. Beavan Rake particularly noted first 
 swelling and then disappearance of the tubercles in patients whom 
 he had vaccinated. 
 
 In the case of the acute infectious diseases, there seems to be a 
 sort of antagonism between the newly introduced parasites and those 
 of leprosy. The former, temporarily at least, dominate the patho- 
 logical field and prevent the development and multiplication of the 
 lepra bacilli. 
 
 The salutary influence of an attack of erysipelas in causing the 
 disappearance of leprous manifestations has been attested by many 
 observers. The curative action of erysipelas, as in other infectious 
 diseases, is not as a rale durable, but causes only a temporary inter- 
 ruption to the course of leprosy. 
 
 An acute attack of pulmonary phthisis may also arrest and render 
 
504 MORROW — LEPROSY. 
 
 stationary the course of leprosy. Leloir found that it caused tlie dis- 
 ajjpearance of the cutaneous tubercles. In this class of cases there is 
 8irai)ly the introduction of a new pathogenic factor which, as it is 
 more acute in its development, takes precedence for the time being. • 
 
 Malaria would seem to exercise a most unfavorable influence upon 
 leprosy. It has been noted that the course of the disease is more 
 rapid and severe in persons who live in low, damp dwellings exposed 
 to marshy and malarial emanations. It has also been observed that 
 the removal of a leper to a non-malarial region is almost invariably 
 followed by an improvement of at least temporary duration. 
 
 Cold and CJuoige of Season. — Undoubtedly the course of leprosy 
 is influenced by the change of seasons, especially in latitudec where 
 temperature changes are sudden and severe. 
 
 Cold seems to exercise a special excitatory influence upon the 
 leprous process. The relation between the so-called " congestive 
 attacks" or exacerbations and cold has been remarked b}' numerous 
 observers. There can be no doubt that cold in some way or another 
 exacerbates the disease. My observation of a number of leprous 
 patients goes to show that in this climate they are better in summer 
 than in winter. With the approach of colder weather in September 
 and October, many of the symi:)toms which had entirely disappeared 
 or were in abeyance during the summer begin to revive and become 
 aggravated, and this irrespective of the type of the disease. 
 
 This seasonal exacerbation of leprous symptoms represents another 
 of the numerous analogies of the disease with tuberculosis. The rea- 
 son why patients sufi"ering from pulmonary tuberculosis are better in 
 warm than in cold weather is not far to seek, but why aggravation of 
 the tuberculous process, irrespective of the localization of the tuber- 
 cles, should take place in cold weather is not so evident. Hutchin- 
 son's testimony is that lupous patients get better in summer and grow 
 worse in winter. 
 
 One reason why the more virulent tubercular form of leprosy pre- 
 dominates in cold climates may be due to the fact that cold more than 
 any other external factor favors the growth and multiplication of the 
 bacilli. 
 
 Anaesthetic Leprosy. 
 
 The anesthetic form presents a characteristic variety and com- 
 plexity of symptoms. It possesses a physiognomy peculiarly its 
 own, and its clinical aspect is so entirel\^ different from that of tuber- 
 cular leprosy that it is difficult to recognize it as a form of the same 
 disease due tc the action of an identical pathogenic factor. The phe- 
 nomena arc essentially those of multiple neuritis, consisting princi- 
 
SYMPTOMS OF ANiESTHETIC LEPROSY, 505 
 
 pally of disorders of sensation and nutrition. The trophic troubles 
 whicli are consecutive to the lesions of the peripheral nerves are dis- 
 tinctive of this form of leprosy. 
 
 The 2^€riod of hicahation is usually more prolonged, which may 
 be due to the small number of bacilli or the greater resisting-power 
 of the organism to their inroads. Its onset is gradual and insidious, 
 and the prodromes are distinguished by the absence of febrile symp- 
 toms, as a rule, and the more pronounced character of the subjective 
 symptoms of hyperaesthesia, pruritus, and pain. 
 
 CuTAKEOus Manifestations. 
 
 The Erythematous Eruption. — The first cutaneous manifestation of 
 nerve leprosy is usually in the form of a localized erythema. Excep- 
 tionally the initial lesion may be in the form of bullae. In two of my 
 cases the formation of bullae preceded by several months the ap- 
 pearance of any macular lesion. The appearance of the macular 
 exanthem is so constant a phenomenon that Hansen proposed substi- 
 tuting the title "macular" for anaesthetic leprosy; yet it is to be 
 observed that in certain cases the macules may be entirely absent and 
 the inital symptoms consist of motor and sensory paralj'ses. 
 
 While the cutaneous eruption in nerve leprosy is perhaps not so 
 essentially a part of the morbid process as in tubercular leprosy, which 
 is localized in the skin, the macules exhibit a greater varietj^ of aspect, 
 especially in their configuration and coloring. This is due largely to 
 the fact that instead of being transitory and evanescent, they usually 
 remain permanently and show a tendency to increase hj peripheral 
 extension while clearing in the centre, and also to the fact that more 
 pronounced pigment changes occur during their evolution. The mac- 
 ules may be simply erythematous, afterwards becoming pigmented or 
 achromatic, or they may be pigmented or achromatic from the first, 
 without preceding hyperaemia or congestion. 
 
 The first appearance of the eruption often follows exposure to cold 
 or damp. Many persons date its origin to a cold, and it is usually 
 preceded by a sense of formication, tingling, burning, or stinging. 
 The spots may develop without any subjective sensations, the i^atient 
 discovering them by accident. In persons who are not observant 
 or when the spots ajjpear upon the covered portions of the body, they 
 may exist for a long time without the knowledge of the patient. 
 In the patient, whose face is portrayed in Fig. 7, there was upon 
 the dorsal surface of the foot a large discrete red patch, which from 
 its size and other objective characteristics must have existed for a 
 long time and which the patient discovered by accident. In another 
 
506 
 
 MORROW — LEPROSY. 
 
 case I found lar^e patches upon tlie buttocks, of the existence of which 
 
 the patient was ignorant. 
 
 The efflorescence may resemble polymorphous erythema upon its 
 
 first appearance. The macules are usually circular or oval in outline, 
 
 or they may be irregu- 
 lar in shape (Fig. 6). 
 They vary in size from 
 that of a finger-nail to 
 that of a silver dollar 
 or larger. They are 
 usually- small on their 
 first appearance, but 
 slowly increase in size. 
 Their contour is grad- 
 uallj- lost in the color- 
 ing of the surrounding 
 skin, so it is impossi- 
 ble definitely to define 
 their limits. In some 
 cases they exhibit 
 sharply defined dentate 
 margins, as seen in 
 Figs. 6 and 7. 
 
 The color of the 
 erythematous spots 
 varies fi'om a delicate 
 pink or red to a yel- 
 lowish or bluish-red 
 color, which later may 
 deepen into a brown- 
 ish-yellow, slaty, or 
 black shade. The 
 gradations depend 
 largely upon the race 
 and complexion of the 
 individual and the 
 
 chronicity of the patch. As they grow older they exhibit a greater 
 
 variety of tints. 
 
 In many cases the redness may be so little pronounced that the 
 
 patieut does not perceive it; it disappears on pressure, to reappear 
 
 immediately. It may fade out temporarily, leaving a grayish or ye\- 
 
 lowish tint. Friction, heat, and cold, especially cold, accentuate it. 
 
 I have found that patches may be well defined by the application of 
 
 Fig. 6. — Macular Lesions of Anajsthetic Lepros.v. 
 
SYMPTOMS OF ANESTHETIC LEPKOSY. 507 
 
 cold water to tlie surface. In the earlier stage oue may observe the 
 dilatation of the cutaneous capillaries ; later these spots may become 
 brown or black, constituting one of the forms described by early 
 writers as morphoea nigra. 
 
 The achromatic patches may result from the involution of the 
 pigmented macules, or they appear at first as perfectly white patches 
 upon the healthy skin (morphcea alba). This latter form is rarely 
 seen in the white race ; it is more common in dark races and in trop- 
 ical countries. I have seen many examples in the Hawaiian lepers. 
 Sometimes these decolorized jDatches are surrounded by a hyperchro- 
 matic margin. 
 
 The surface of the patches in the earlier stage is perfectly smooth. 
 After their complete development there is more or less continue as 
 desquamation from the surface of the patches, which is usually of a 
 bran-like, furfuraceous character. In rare cases, when there is great 
 disturbance of the circulator}^ equilibrium, the epidermis may peel 
 off in large lamelliform flakes. 
 
 The hair of the affected surfaces often becomes white or falls out, 
 although the bleaching of the hair is not nearly so common or con- 
 stant a i)henomenon as has been described by many writers. There 
 is a more or less complete suppression of the sweat secretion, not 
 only of the anaesthetic patches, but sometimes of the skin immedi- 
 ately surrounding them, so that the injection of i)ilocarpiue does not 
 excite the glands into activity. 
 
 The patches may be the seat of a violent i)ruritus, which is accen- 
 tuated by elevation of temperature and exercise, or ihej may become 
 so hyper^esthetic as to give the sensation of a superficial burn. They 
 may persist for years, constituting the only sign of the disease until 
 the appearance of certain nervous symptoms indicates irritative or 
 degenerative changes in the nerves. 
 
 Like the exanthem of the tubercular form, the macules have a 
 predilection for certain regions of the body. Although the most fre- 
 quent sites are upon the face, hands, and feet, especially about the 
 ankles, they may appear upon the back, shoulders, chest, arms, nates, 
 thighs, and abdomen. They are rarely seen upon the palms and 
 soles, and most authorities concur in the statement that they are 
 never seen on the scalp. This statement is subject to modification. 
 In the case of the patient shown in Fig. 7, the eruption extends 
 up over the frontal portion of the hairy scalp to the vertex, as is well 
 shown in the illustration. 
 
 C. W. S , aged 47 years, born in Bermuda. Mother living, 
 
 in good health. Father died at sixty-five (twenty-two years ago), 
 the patient states, of some kind of " skin disease" of many years' dura- 
 
508 
 
 MOKROW — LEPROSY, 
 
 tiou. His face was blotched, his lips were swollen, the lobes of the ears 
 hung down, and he is reputed to have had syphilis. The mother and 
 father had lived together forty years. The mother is now living, in 
 good health, eighty-three years of age. Of the seven children, two 
 brothers and two sisters died of lung trouble. The youngest child 
 died thirteen or fourteen years ago, at the age of sixteen, from some 
 form of skin disease. He had an eruijtion of the skin and swelling 
 of the face for five }ears previous to his death. 
 
 The patient left Bermuda, at the age of seventeen years, to become 
 a sailor. He visited the West Indies, the Mediterranean, was in 
 hospital at Constantinople for a long while, and made several voyages 
 
 Fig. 7.— Leprosy AlTeclitiK the Hairy Scalp. 
 
 to Bombay and other ])arts of the East Indies. He also made voy- 
 ages to various West Indian and South American jjorts. He came to 
 New York in 1883, and has lived here since continuousl}' M'ith the 
 exception of a few trips in a sailing-vessel down East. 
 
 The patient first noticed a spot in the middle of the forehead just 
 above the root of the nose, sixteen years ago. It remained apparently 
 stationary for a long time, and then began to spread gradually down- 
 wards over the nose, cheek, and upper lip, and upwards, involviiig the 
 entii'e surface of the forehead and creeping up into the hairy scalp and 
 downw^ards again to the junction of the chin with the neck. Three or 
 four years ago it extended behind the ear and upon the left side. For 
 years he had experienced stinging sensations in the face, and about 
 six montlis ago he noticed a numb or "dead sensation," as he termed 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 509 
 
 it, over the entire region of tlie face. The eyelashes have entirely 
 disappeared, but the eyebrows are intact. The distribution of the 
 eruption over the right side of the cheek and forehead and extending 
 up into the hairy scalj) is seen in the accompanying illustration (Fig. 
 7). On the left side the patch has extended backwards behind the ear 
 to a point half-wa}^ between the ear and the occiput, and the plainly 
 defined hyperchromatic margin sweeps upwards in the hairy scalp, 
 to join the patch on the right side shown in the picture ; it extends 
 downwards to the middle of the neck. There are two circular, palm- 
 sized patches, one over the left deltoid region and one on the antero- 
 lateral surface of the left leg, which were first observed eighteen 
 months ago ; the patient thinks that they were then about the same 
 size as now. There is also a large circular patch beginning at the 
 root of the toes and embracing within its area almost the entire instep 
 of the right foot. The patient does not know when this patch first 
 appeared. He noticed twitching of the muscles of the toes and the 
 loss of feeling over the instep of the right foot twelve or eighteen 
 months ago. At the present time this patch is almost completely 
 anaesthetic. There is some enlargement of the peroneal and ulnar 
 nerves. He has noticed for a year or more that upon awakening he 
 finds the left arm asleep. This phenomenon occurred only occasion- 
 ally at first, but now it is frequently observed in both arms. Ho fre- 
 quently upon awakening notices the fingers of both hands asleep, the 
 sensation being most pronounced in the little and ring fingers. 
 
 The patient had syphilis fifteen years ago, and an attack of gon- 
 orrhoea which infected his left eye and impaired the eyesight. He 
 had epilepsy until twenty -five years ago. After an attack of yellow 
 fever in 18G3 or 1864 from infected clothing his epileptic seizures dis- 
 appeared, and his general health has since been much improved. 
 
 The changes which occur in the evolution of the lesions give them 
 a distinctive character. The macules may remain discrete or, spread- 
 ing peripherally, form by their confluence irregular patches with poly- 
 cyclic outlines, parts of circles (Fig. 8), or large gyrate patches with 
 slightly elevated and distinctly defined margins and pale, pigmentless 
 centres. The decolorization of the centres of the patches with the 
 slightly raised hyperchromatic margin give sthem oftentimes a dis- 
 tinctly annular appearance. This process of blanching may extend 
 over large surfaces of the body. Upon the limbs the patches often 
 exhibit a serpiginous tendency, gradually extending up the limbs or 
 spreading over the joints. 
 
 It will be observed that the centrifugal tendency which charac- 
 terizes the extension of the lesions is also marked in the retrogres- 
 sive process, which invariably begins in the centre. All the manifold 
 changes of form which are observed in the macules of anaesthetic 
 leprosy are effected by the gradual implication of the surrounding 
 healthy skin by the advancing hyperchromia with the constant blend- 
 ing of their contours and their subsequent partial effacement. 
 
510 
 
 MORBOW — LEPROSY. 
 
 The eruptiou is often symmetrical, but avouIcI seem to be indepen- 
 dent of the distribution of jiarticular nerves. In certain cases the 
 macnlje are dispersed along the intercostal nerves, forming a double 
 zona which is absolutely painless. 
 
 Eiiipfiiiii <if liiiU'i^. — Allusion has already been made to the fact 
 that a bullous erujition may be among the earliest cutaneous manifes- 
 tations of leprosy ; at 
 a later stage of the 
 disease it constitutes 
 a characteristic and 
 by no lueans uncom- 
 mon symptom. The 
 ai)pearance of bullBe 
 may be preceded by 
 symptoms of general 
 disorder, fever, and 
 neuralgic pains, or 
 they m a y develop 
 without any premoni- 
 tory symptoms. In 
 one patient of mine 
 bullae appeared along 
 the anterior lateral 
 aspect of the right 
 leg, one-half dozen or 
 more in number, as 
 the first cutaneous 
 expression of the dis- 
 ease. 
 
 The bulipe vary 
 in size from that of a 
 small pea to that of a 
 cherry or larger, and 
 the individual lesions 
 resemble somewhat 
 in appearance those 
 of pemphigus vulgaris. The epidermal walls are first distended 
 by the effusion of a pale yellowish serum, and the bullae may in- 
 crease in size and their contents become purulent ; they may under- 
 go spontaneous rupture after a few days, and their flaccid walls may 
 be wiped or brushed away, leaving slight reddish spots or slight 
 pigmented stains which soon clear up. 
 
 Instead of this rapid involution the bullae may increase in size, the 
 
 Fig. fc.— Macular Lesions of Aneesthetic Leprosy. 
 
SYMPTOMS OF AN.^STHETIG LEPROSY. 511 
 
 contents become purulent and concrete in tlie form of yellowish-green 
 or brownish crusts, which when removed reveal excoriations more or 
 less profound, and superficial ulcers ; the latter, on cicatrizing, leave 
 prominent scars which are at first pigmented and later become white, 
 smooth, and shining and frequently bordered by a darkly pigmented 
 ring. The blebs may succeed one another for several years or during 
 the whole course of the disease without being accompanied by any 
 notable disorder other than the neuralgic or rheumatoid pains. At a 
 later stage the ulcers not infrequently persist, increase in area and 
 depth, and constitute the starting-point of deep-seated ulcers and 
 mutilations. 
 
 The so-called lepra lazarine, which is common in certain countries, 
 as in Mexico, and which has been described by certain observers as 
 a distinct form of leprosy, represents only a variety of this bullous 
 eruption. There is in this phlyctenular eruption a slow formation 
 of blebs w^hich present the appearance of a slightly raised, parch- 
 ment-like covering, involving the epidermis and superficial layers of 
 the derma, which are distended by a serous accumulation (pem- 
 phigus escharotica). When this eschar is detached it leaves an 
 ulcerated surface, with grayish fungoid base and jjerpendicular sides, 
 which may either be persistent and extend in depth or be complicated 
 with gangrene and lead to mutilation (Leloir). 
 
 The points of predilection for the bullse are the backs of the hands 
 and feet, heels, back of the elbow, and the anterior surface of the 
 knees, although they may be found on any j^ortion of the external 
 integument. It is evident that these parts are more particularly ex- 
 posed to rubbing and irritation from contact of all kinds. Impey 
 believes that the buUse are merely accidental phenomena caused by 
 external injury and not essentially an expression of the leprous proc- 
 ess. He asserts that they do not contain bacilli. 
 
 The results of the bacteriological examinations which have been 
 made to determine the presence or absence of bacilli in the pemphi- 
 goid lesions of leprosy are contradictory. Kalindero, Petrini, Aristid 
 Bey, and others assert that they have found bacilli, though in small 
 numbers and not constantly, both in the crojos of bullae which come 
 out spontaneously, and in the liquid secretions of the blebs which 
 were produced artificially in lepers by the application of vesicatories. 
 These results have been contested by other observers who failed to 
 find bacilli in the bullae. The general impression has always been that 
 the bullae of leprosy were caused by the action of the toxins rather 
 than directly by the bacilli. Leloir has seen bullae form in the mu- 
 cous membranes. 
 
 Trophic Changes of the Glands. — Coincident with the development 
 
512 MORROW — LEPROSY. 
 
 of the patches certain changes take place in the glandular apparatus of 
 the skin. These changes are first noticed in the surfaces occupied by 
 the eruption, but later may affect the entire skin. The hairs of the 
 affected surface suffer in their nutrition. The dystrophic change may 
 be manifest in the bleaching or whitening of the hairs, which become 
 thin, wasted, and lanugo-like, but may or may not fall out. A simi- 
 lar process of bleachiug of the hairs has been observed by Weir 
 Mitchell upon the hands and fingers in cases of "glossy skin." It 
 has been noted that the hairs may reappear upon the patches from 
 which they have disappeared. This regeneration is always coinci- 
 dent with other evidences of improvement in local nutrition. 
 
 The Sudoriparous Glands. — Keference has alreadj' been made to 
 the abnormal activity of the sweat glands during the invasion period. 
 This hyperidrosis is invariably succeeded b\' a diminution and finally 
 a complete suppression of the sweat function. These anomalies are 
 due to trophic changes in the glands, caused b}^ the action of the bacilli 
 or their toxins upon the peripheral nerves. Weir Mitchell has de- 
 scribed a precisely- similar condition in the " glossy skin" resulting 
 from severe nerve injury, in which there was a marked hyperidrosis 
 affecting the parts supplied by the nerve, followed by a complete 
 anidrosis. The anidrosis is at first confined to the macular lesions 
 and may be so complete that the injection of pilocarpine fails to stim- 
 ulate their functional activity. The secretion is sometimes completely 
 suppressed over the surface of the patches, while the surrounding 
 skin sweats freely. I have observed, in a patch situated upon the 
 heel and side of the foot, that while the central portion was absolutely 
 dry, there was a hypersecretion around the peripheral border which 
 appeared in the shape of small beads of moisture, while there was 
 no sensible perspiration in the healthy surrounding skin. It would 
 seem that in the evolution of some of these patches, the trophic 
 changes are manifested in the central portion by achromia, anaes- 
 thesia, and anidrosis, while hyperchromia, hyperaesthesia, and hy- 
 peridrosis are marked at the periphery. After a certain period the 
 sweat secretion becomes more or less diminished or completely sus- 
 pended over the general surface of the body. In one of my cases 
 there was observed, during the summer, marked hyperidrosis of 
 the scalp, which was probabl}' compensatory to a certain degree for 
 the diminished secretion of the general surface.* 
 
 * On a visit to Molokai, several j'ears ago, T observed this phenomenon in a very 
 marked degree in two anaesthetic but not disabled lepers who carried my baggage to 
 the top of the pali which shut in the leper settlement. After a fatiguing climb the 
 sweat poured from the scalp and ran down their faces in little rivulets, while the per- 
 spiration from the hands, arms, and other exposed surfaces was hardly noticeable. 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 513 
 
 The sebaceous glands also become atrophied and altered in their 
 function. The secretion, which was at first exaggerated, becomes en- 
 tirely suppressed. At a more advanced stage, when the sweat and 
 sebaceous glands are destroyed and there is a complete arrest of their 
 functions, the skin of the general surface of the body becomes dry, 
 parchment-like, and harsh to the feel. The epidermis readily cracks 
 and fissures, and the breaks in its continuity not infrequently become 
 the starting-points of superficial or deep ulcerations. It may be re- 
 marked that very often the skin of lepers, especially that of the hands, 
 becomes dry, shiny, or glossy from atrophic changes, simulating the 
 "glossy skin" of Paget. 
 
 Sensory Disorders. 
 
 For many years the cutaneous eruptions may constitute the only 
 exterior manifestations' of ansesthetic leprosy. But during this period 
 and throughout the entire course of the disease there are certain modi- 
 fications of sensibility which, in order to prevent repetition in their 
 description, may be conveniently considered together under this 
 heading. 
 
 In the ordinary conception of anaesthetic leprosy the most impor- 
 tant clinical feature is expressed in the name by which this form of 
 the disease is designated. While anaesthesia is an essential and fun- 
 damental feature of nerve leprosy, and indeed constitutes the most 
 pathognomonic sign from a diagnostic point of view, there are numer- 
 ous modifications of sensibility which are scarcely less interesting 
 and important. In many cases the nature of the skin lesions is ab- 
 solutely indeterminable without the indic^itions furnished by the 
 sensory disorders. 
 
 In many cases the sensory disorders constitute the only certain 
 element of diagnosis, as is well illustrated in a case which came 
 under my observation about ten years ago. The following notes were 
 taken at that time : 
 
 In this patient the eruption began nearly five years ago as a small 
 red, somewhat itchy spot on the anterior surface of the left foot at 
 the base of the great toe. It enlarged slowly and almost impercepti- 
 bly. After a time it cleared in the centre while extending peripher- 
 all3\ At the present time it involves almost the entire upper part of 
 the under surface of the foot. The hyperchromatic margin may be 
 seen extending along the root of the toes and advancing with a circi- 
 nate sweep along the outer aspect of the foot upwards to the ankle- 
 joint, crossing the instep and continuing down under the instep and 
 the inner half of the sole, and emerging upon the integument of the 
 first phalanx of the great toe. The margin is irregularly scalloped, 
 slightly elevated, one-quarter to one-half an inch in width, and of a 
 Vol. XVIII.— 33 
 
514 MORROW — LEPROSY. 
 
 browiiisli or lilac tiut. The central portion presents a bluish-graj 
 tint, the coloration depending upon tlie atrophy of the skin, through 
 which the superficial vessels are more apparent. 
 
 Upon the anterior inner aspect of the leg, at the junction of the 
 middle and upper thirds, there is a patch two inches iu diameter which 
 began three years ago. The centre is faintly pigmented, the margin 
 made up of brownish-red puncta, and partly of diffused redness. These 
 minute points seem to represent infiltration of the follicles. This 
 patch is anfesthetic iu the centre. Above the external malleolus there 
 are two irregularly circular macules, each about the size of a silver 
 quarter, which made their appearance about two years ago. The 
 centre is beginning to clear, though still pigmented, the margin is of 
 a deeper, more brownish-red. But slight impairment of sensation 
 can be detected iu these more recent patches. 
 
 In the central portion of the older patch there is comjilete loss of 
 the pain and temperature sense. The tactile sense is but slightly im- 
 l)aired, and the muscular sense is apparently unchanged, while just 
 beyond the liyper?estlietic, hyperchromatic margin normal sensibility 
 is preserved in absolute integrity'. Were it not for the element of 
 anaesthesia, I believe it would be impossible to diagnosticate the 
 nature of this eruption. This patient has apparently entirely recov- 
 ered. 
 
 We have seen that the invasion period is characterized by hyper- 
 8Bsthesia, pruritus, neuralgic pains, and other symptoms which indi- 
 cate that the nervous system is the i:)rimary seat of the disease. The 
 pathological basis of these phenomena is now recognized to be a spe- 
 cific neuritis, i)arenchymatous and interstitial, which attacks the 
 peripheral nerves and leads to their more or less complete degenera- 
 tion. The sensory disorders of nerve leprosy are not, therefore, pure 
 neuroses, but rather trophoneuroses, since they are always consecu- 
 tive to irritation and degeneration of the terminal filaments of the 
 cutaneous nerves or some portion of the sensory conducting appara- 
 tus. Recent investigations would seem to show that the primary 
 action of the bacilli is exerted upon the nerve terminals, and as these 
 constitute an integral i^art of the skin, the sensory disturbances may 
 be regarded as due to trophic influences. The sensory disorders may 
 be associated with trophic changes, or they may occur without obvi- 
 ous structural changes in the skin. 
 
 These modifications of sensibility may be divided, according to 
 the usual order of their development, into (1) exaltations of sensibil- 
 ity, expressed in hyperaesthesia, pruritus, dermatalgia, and neuralgic 
 pains ; (2) perversions of sensation^ which consist of various dysses- 
 thesias, sensations of needles and pins, numb and dead feelings of the 
 limbs, delayed or retarded sensation, etc. ; (3) abolition of sensation, 
 more w less complete, expressed iu anaesthesia or disassociation of the 
 modes of sensation, etc. 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 515 
 
 The first group corresponds to tlie period of irritation of the 
 nerves which may be exceedingly prolonged in duration. 
 
 The second group marks the period which intervenes between the 
 cessation of the irritative neuritis and the complete disorganization of 
 the nerve fibres. The nerves are in a state of stupor in which the 
 sensation is delayed but not extinguished. Even at this period there 
 may be some evidences of disassociation of connected sensations. 
 
 The third group corresponds to the complete disorganization of 
 the nerves which serve as a medium of nutrition and sensation. It 
 may be practically indefinite in duration. 
 
 The first effect of the neuritis is irritation of the part supplied by 
 the affected nerve and may consist of tingling, of formication, of a sen- 
 sation of heat or cokl, or of r tinging or burning at the surface of the skin 
 or along the course of the nerve. The sensation is sometimes likened 
 to that caused by an abraded surface which is exposed to contact with 
 air or water. One of my patients would take off his shoe repeatedly, 
 feeling sure that the smarting sensation felt along one side of the heel 
 was due to the epidermis being rubbed off. One manifestation is in 
 the form of localized itching, which frequently affects the palms of 
 the hands or soles of the feet ; it may occur in any portion of the 
 limbs. It is apparently more deeply seated than in ordinary pru- 
 ritus or in the pruritus of eczema. It is often persistent and torment- 
 ing and is relieved by grasping, compressing, or pinching the parts 
 rather than by scratching. 
 
 The dermatalgia is sometimes described asared.-hot, burning pain. 
 Any blow or pressure or even slight contact may cause a shock like 
 that from an electric battery, which is felt to course along the affected 
 limb. In one of my cases, upon merely rubbing the skin or slightly 
 scratching over the anterior surface of the wrist, there was felt a tin- 
 gling, radiating along the entire course of the forearm. This condi- 
 tion persisted for months. 
 
 In another case painful smarting sensations were felt over the 
 anterior lateral aspect of the right leg in the immediate neighborhood 
 of a pigmented patch. This continued three or four weeks and sud- 
 denly disappeared. All of these subjective symptoms may develop 
 suddenly. They are exceedingly capricious, being manifest for a 
 variable length of time and disappearing with the same facility with 
 which they appeared. For weeks or months they may be entirely 
 absent. 
 
 The hypersesthesia is sometimes experienced in the greatest in- 
 tensity in the face. Neuralgic pains may be felt along the course of 
 the trifacial or along the ulnar, sciatic, and peroneal nerves, affecting 
 the forearms, hands, the entire leg, feet, and toes. Locomotion is 
 
516 MORROW — LEPROSY. 
 
 often difficult and painful. The patient may feel as if he were walk- 
 ing on pebbles or broken glass. One patient describes the sensatiou 
 "as if he were walking on stone bruises." 
 
 The pains instead of being superficial may be of a deep, boring, 
 lancinating character, as if deep down in the tissues. They are 
 paroxysmal in character and are particularly nocturnal. They may 
 be so accentuated as to be atrocious, almost unendurable, depriving 
 the patient of sleep, and the countenance often takes on an expression 
 of habitual suffering. 
 
 As the irritative neuritis is succeeded by degenerative changes in 
 the nerves, these exaltations of sensibility cede to a gradual dulling 
 of sensation and more or less complete insensibilit}'. 
 
 Many years may i>ass, and the patient, with the exception of out- 
 breaks of new eruptions of macules or bullie and occasional neuralgic 
 pains, may have no disorders of sufficient importance to awaken his 
 suspicions as to the exceeding gravity of the disease with which he is 
 afflicted. During this period there are usually' observed inflammation 
 and enlargement of the peripheral nerves which become more pro- 
 nounced as the disease progresses. 
 
 In the invasion of the nervous system the bacilli seem to manifest 
 a predilection for the ulnar and peroneal nerves. The nerves which 
 are most constantly' and characteristically involved are the ulnar, 
 peroneal, and median. Second in point of frequency are the facial 
 branches of the seventh pair and the first division of the fifth. It is 
 worthy of note that the nerves primarily involved are those which are 
 most superficially situated and therefore most exposed from their sit- 
 uation and sun'oundings to external influence. 
 
 Why the bacilli show a predilection for certain nerves — the ulnar, 
 for example, instead of the radial —has not been determined. The 
 ulnar nerve is not invariably the first to be affected, and the bacilli may 
 begin their depredations in any particular branch of the predilected 
 nerve. The thickening of the ulnar nerve which may often be felt 
 behind the olecranon, giving the sensation of a tense cord rolling 
 beneath the fingers, is one of the earliest and most valuable signs of 
 nerve lepros}'. In doubtful cases, when other symptoms are equivo- 
 cal, its presence furnishes the necessary confirmation of the diagnosis. 
 
 The interstitial neuritis may manifest itself in the form of a diffuse 
 uniform enlargement, and the nerve may attain the size of the little 
 finger. The thickening may be fusiform or more nodular or monili- 
 form. This, according to Leloir, is characteristic of the ulnar modi- 
 fication. It is exceedingly sensitive to the touch, and pains may be 
 felt radiating along its course to the fingers. At a later stage, when 
 degeneration is complete, it does not permanently conserve its vol- 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 517 
 
 ■nme. There is a diminution, not only in size, but in sensitiveness. 
 It may be forcibly compressed without provoking radiating pains 
 in the region of its peripheral expansion. 
 
 For a long period there is noticeable a disposition of the hands to 
 go to sleep, at first from pressure from lying upon them ; later the 
 numb sensation may occur without this pressure. This tendency- of 
 the limbs to go to sleep is especially marked at night, possibh^ from 
 greater exposure to pressure of the arms from the posture assumed in 
 lying. The i)atient wakes from a sound sleep finding, it may be, the 
 little and ring fingers closed and asleep. At another time the fingers 
 supplied by the median may be found closed and numb, and again 
 the fingers of the entire hand. Similar sensations are often felt in 
 the toes, more often in the great toe than in the small toes. It is 
 noticeable that they return to the normal condition without the sen- 
 sation of "pins and needles." In one of my patients the awakening 
 was described as waves of sensation passing along the forearms into 
 the fingers. Usually upon extending and flexing the fingers several 
 times, sensation returned more or less promptly. At a later stage the 
 patient, on awakening, found the fingers flexed and absolutely insen- 
 sitive, and it was necessary to use the other hand to overcome the 
 flexion. After working the fingers for a few minutes backward and 
 forward sensation returned. It is evident that this sensation of 
 numbness and deadness is to be differentiated from anaesthesia, as 
 the patient is conscious of it from his own feelings. A patient does 
 not know he is anaesthetic until it is revealed to him by some means 
 outside of his own consciousness. 
 
 During this period the acuity of the tactile sense is dulled, and 
 pins and small articles cannot be easih^ picked up. Articles are 
 readily dropped, from tremor or weakness or inability to hold things 
 firmly by the hand. The fingers lose their deftness for any form 
 of mechanical technique. There is marked evidence of muscular 
 atroj)hy and disturbance in the coordination of the muscles. The 
 handwriting becomes changed, jerky, tremulous, and irregular. In 
 performing any manual work which requires dexterity, the patient 
 cannot do it from force of habit, and the guiding and directing influ- 
 ence of the eye must be applied for its proper accomplishment. 
 
 Hillis, whose careful personal study of leprosy in British Guiana 
 gives his observations an especial value, says that many of the negro 
 field laborers have their attention first directed to their condition 
 owing to the difficulty they find in holding a cutlass. This, he 
 thinks, is not so much from loss of sensation in the parts as from a 
 want of coordinating power or muscular weakness, which amounts in 
 some cases to a general tremor or shaking of the limbs. " Shooting 
 
518 MORROW— LEPROSY. 
 
 paius or au uudue seusitiveuess are nearly always felt iu the fiugei-a 
 and toes before these parts are affected." In a case reported by Thin, 
 a butcher suffering from nerve leprosy stated that the first symptom 
 he observed in himself was a strange loss of power, as he expressed 
 it, when cutting meat in the market. In another case, reported by 
 Dejerine, a French soldier who had served for eighteen months in the 
 Tonquin was discharged from the service for inability to handle his 
 gun. 
 
 Another phenomenon which marks the transition into complete 
 insensibility is retardation of sensation. It has been observed that 
 in applying the electric current there may be quite an api)reciable 
 time before the sensation becomes distinct. The sensation does not 
 at once attain its maximum, but gradually gains iu intensity during 
 twenty or thirty seconds. 
 
 With this slowness iu the transmission of sensation certain perver- 
 sions of sensation may be associated. Jeanselme found that if a hot 
 body or a piece of ice is applied over a i)atch it causes at first the 
 simple impression of contact. If the exi)eriment is continued, a sen- 
 sation of heat or cold is finally felt, feebly and only after a long time. 
 If now, on the part where the ice has been, a moderately cold sub- 
 stance is applied, the patient is deceived and complains of a sensa- 
 tion of heat. 
 
 It is through this transition stage that the nerves pass into a stage 
 of complete insensibility. Anaesthesia develops gradually. It is 
 commonly noticeable at first in the patches, especially over the decol- 
 orized centres, and is often coincident with hyjjeraBsthesia of the 
 hy perchromatic borders. It may develop in regions not the seat of the 
 patches and so insensiblv that the patient is not aware of it. The 
 ])atient does not feel the objects he grasps. He may not feel the heat 
 of the pipe held in his hand or cuts made in shaving. One may stick 
 a pin or needle into the patch without the patient's knowledge. Iu 
 walking, the sensation has been comjiared to stepping on cotton, wool, 
 or a thick carpet. The patient may walk barefoot on rock, gravel, or 
 thorns without feeliug the wounds they make. The insensibility is 
 so complete that grave operations may be performed without any sen- 
 sation of pain. Instances have been known in which the patient has 
 chopped off the finger or toe which annoyed him without feeling pain. 
 
 Many of the cutaneous lesions encountered in nerve leprosy before 
 the mutilating stage sets in are due to the sus]jended sensibilitA . 
 The deadened nerves give no warning through the i)ercex)tion of pain 
 to the inroads of heat, cold, or other injuries. The patient often 
 receives a severe injury, or a knife may be thrust into the anaesthetic 
 I)atch without any sensation being caused. 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 519 
 
 Sensibilitj to puncture is variable, not only in cliflferent j^arts, but 
 in contiguous spots ; the same is true of sensitiveness to temperature. 
 Quinquaud found by means of a very delicate sesthesiometer com- 
 bined ^vitli a dynamometer that, while 5 gm. in one point would 
 elicit distinct sensation, it would require 100 gm. 2 mm. distant from 
 the first point, to call forth the same degree of feeling. With regard 
 to temperature, it was sometimes necessary to obtain 30"^ C before 
 obtaining a sensation; or 0° C and 10° C. would be contiguous find- 
 ings. There were frequent phenomena of disassociation. Some 
 patients had no perception of cold, but felt heat, and vice versa. Anal- 
 gesia and thermo-anaesthesia may be present with or without impair- 
 ment of the tactile sense. While the loss of the pain sense is often 
 so complete that the thrust of a pin into the affected part may occa- 
 sion no pain, simple contact by gently rubbing the surface may lie 
 readily appreciated. This disassociation of the modes of sensibility 
 is characteristic of leprosy. 
 
 The individual independence of the different modes of sensation 
 which are normally connected is established by studying cases in 
 which each of them appears isolated. In the anaesthetic jjatch of 
 leprosy we find that a certain part of the skin cannot discriminate 
 between heat and cold, another part is deprived of the sense of touch, 
 and that though a third part maj^ have the sense of feeling injury to it 
 does not cause pain. It is worthy of note that hyper^esthesia may be 
 manifest at an advanced stage of the disease, and it is frequently pres- 
 ent in close proximity to the region that is absolutelj' anaesthetic. I 
 have observed a number of times in applying electricity' that a cur- 
 rent representing the full strength of fifty elements and of sufficient 
 intensity to char the tissues when passed through a wire brush, occa- 
 sioned no sensation of pain in the central portion of the patch. In 
 the zone just within the hyperaemic margin, one-half this strength 
 would pass for a fraction of a minute without evoking any sensation, 
 and then the nerve conductivity would be aroused, shown by a sharp 
 sensation of pain, so that the strength of the current would have to be 
 largely reduced to make it bearable. In the hyperaemic margin of 
 the patch it required a smaller current to provoke sensation than 
 upon the healthy sound skin. 
 
 It is worthy of note that while anaesthesia is the most durable 
 symptom of nerve leprosy, sensation may return to surfaces formerly 
 occupied by anaesthesia, or indeed it may very exceptionally be 
 replaced by hyperaesthesia. The interpretation of the rationale of 
 this retrogressive phase of the disease is not determined. It may be 
 that not all of the fibres are destroyed and the power of conductivity 
 which was held in abeyance is restored, or it may be that the nerve 
 
520 MORROW — LEPROSY. 
 
 fibres are regenerated and this restoration is followed by recovery of 
 their physiological activity. 
 
 Jeanselme has made a special study of the mode of progression 
 of auitsthesia, its topographical distribution, and its qualitative al- 
 terations, the results of wliich may be formulated as follows : 
 
 1. The distribution of anaesthesia in leprosy is manifestly sym- 
 metrical. When insensibility affects one member, it will soon attack 
 the homologous member. In addition the anaesthesia is ordinarily 
 distributed in an almost equal manner over the four extremities. 
 Likewise the anaesthesia of the lower extremities is more extensive 
 and more precocious than that of the upper extremities. In syr- 
 ingomyelia, on the other hand, the anaesthesia, often symmetrical, is 
 generally predominant in the u])per extremities; it may even be situ- 
 ated exclusiveh' here. 
 
 2. Anaesthesia begins at the level of the free extremity of the mem- 
 bers and mounts gradually upward to their root. Sensation, almost 
 extinct in the hand or foot, is only dulled in the arm or thigh. 
 
 3. Anaesthesia of the deep parts of the derma is in general less 
 marked and of later development than that of the sui^erficial parts. 
 As the anaesthesia progresses it descends lower and lower in the skin. 
 At first the mantle of anaesthesia which covers the insensible region 
 is (^uite thin ; a needle pushed horizontally into the papillary body 
 provokes no pain, but the patient protests as soon as the puncture 
 involves the deeper part of the skin. Still later the skin becomes com- 
 pletely insensible and may be pierced entirely through without pain. 
 
 4. The anaesthesia, which is at first of ribbon form, tends to take 
 on later the segmentary type. In the upi^er limb it occupies at first 
 the little finger and the ulnar border of the hand, and forms along 
 the postero-internal portion of the arm and forearm a long band; 
 this ascends to a variable height, often to the elbow, sometimes to the 
 axilla,, the sensibility' of which always remains intact. 
 
 In the lower limb the anaesthesia first afi'ects the great toe and the 
 internal border of the foot, sometimes the external border. At the 
 same time a long band of anaesthesia commencing at the base of the leg 
 ascends more or less high upon the external aspect of the leg, attain- 
 ing the knee, the middle of the thigh, or even the region of the tro- 
 chanter, upon which it widens en raquetfe. Sooner or later the prim- 
 itive band of insensibility spreads out and forms a gutter, the two 
 lips of which finally close together. The limb is then encased in a 
 sheath of anaesthesia. 
 
 5. The segmentary anaesthesia of leprosy differs in its essential 
 characters from the segmentary anaesthesia of syringomyelia. From 
 an attentive observation of patients or from the indications furnished 
 
SYMPTOMS OP ANESTHETIC LEPROSY. 521 
 
 by the first phases of the anaesthesia one arrives at the conviction that 
 in its debut the insensibility has been of the ribbon form. 
 
 6. The anaisthesia does not occupy the zone of peripheral distri- 
 bution of a nerve trunk; the ribbon-like disposition seems to be 
 determined by an alteration of the posterior roots or of the cord. 
 
 7. The anaesthesia of the face and of the trunk, without being 
 rare in leprosy, is less frequent than that of the members. It does 
 not form a mask or a vest neatly limited around the body. 
 
 8. In the beginning all the modes of sensibility are not simulta- 
 neously abolished ; the thermo-analgesia far outstrips in its develop- 
 ment the tactile anaesthesia. At an advanced period the imperfect 
 disassociation of sensibility gives place to complete anaesthesia. Very 
 often in the same subject the tactile anaesthesia is still frankly ribbon 
 form while the thermo-analgesia has already reached the segmeutarj^ 
 period. 
 
 9. If one applies or maintains during a certain time a hot or cold 
 body upon a region partly deprived of sensibility, it is frequently the 
 case that the patient complains of a double sensation ; he immediately 
 recognizes the contact, then after from five to eight seconds he per- 
 ceives a feeble thermic sensation. This curious phenomenon is the 
 consequence of a law that the more a sensibility is altered, the more 
 slowly the sensation is produced. The number of seconds which 
 elapse between the perception of contact and the jjerception of tem- 
 perature expresses, so to speak, in figures, the degree of the altera- 
 tion of the thermic sensibilit3^ 
 
 10. In leprosy the sensitive perversions and the errors of localiza- 
 tion are not rare. 
 
 11. The anaesthesia is not circumscribed within invariable limits. 
 It embraces two zones : one fixed, which corresponds to the regions 
 first and the most profoundly aft'ected in their sensibility ; the other 
 mobile, at the level of which the sensibility is only in a state of stupor 
 and not extinct. 
 
 MuscuLAE Atrophy, Tendinous Eetractions, and Deformities. 
 
 Atrophy of the muscular tissues and tendinous retractions give 
 rise to various deformities, which are also pathognomonic features of 
 nerve leprosy. Leloir says that muscular atrophy marches, in gen- 
 eral, parallel with anaesthesia. 
 
 Among the induced changes is that of muscular atrophy accom- 
 panied by fibrillary contractions and marked diminution, ending in 
 abolition, of the electric excitability. 
 
 The dynamometer shows marked diminution in the muscular con- 
 
522 MOllKOVV — LEPROSY. 
 
 tractility. As the motor fibres are destroyed, proportionately to the 
 muscular atrophy we have paresis and not paralysis as a resultant. 
 Whether this is due to a lesion of the trophic fibres of the nerve or to 
 loss of function by motor lesion is not known. In any case, pure 
 motor i)aralysis is not met with in leprosy unaccompanied by lesions 
 of the sensory and trophic systems. The muscular atrophy and ten- 
 dinous retractions lead to conditions and deformations identical in 
 appearance with those resulting from idiopathic nervous <liseases. 
 
 The first si^u of muscular atrophy is usually seen in the upper 
 liml)s. Commencing with the thenar eminence the atrophy involves 
 the other muscles of the hands, particularly the interossei, and then 
 extends to the flexors and extensors of the forearm and arm, affecting 
 particularly the extensors. The hands become (daw-shaped from the 
 tendinous contractions; this deformation may correspond to the 
 Duchenne type of paralysis. The hand becomes flattened, the mus- 
 cular eminences disajiyjear, the forced extension of the first phalanges 
 giving a concave aspect to the metacarpal ])ortion ; the transverse diam- 
 eter of the hand is narrowed. A man's hand may wither t(^ the size 
 of a child's. 
 
 The little finger is usually the first to become flexed, followed by 
 the ring, middle, and index fingers, the thumb being usually the last. 
 This order may be reversed; sometimes, l)ut rarely, the thumb is the 
 first flexed. In the production of the " leper claw" the i)roximal ])ha- 
 langes always bend backwards, while the middle and distal ])halanges 
 are curved inwards by the flexors.. The first phalanges are thus in 
 forced extension, the others in forced flexion. There may be, instead 
 of the flexion of the thumb, a horizontal deviation by which it is 
 curved inwards. The degree of contraction and the angle at which the 
 fingers are flexed var^^ in dift'erent cases. In some cases only one 
 or two of the fingers are flexed; in other cases the fingers become 
 twisted on their axes and stand out at the most grotesque angles. In 
 advanced cases the fingers cannot be straightened out by force. This 
 tendency to flexion cannot be overcome b^^ artificial means. Experi- 
 ments have been made in straightening out the fingers and binding 
 them on a flat board, nevertheless the process still continued. 
 
 Tlie following case illustrates a characteristic deformation of the 
 hand from tendinous contractions: 
 
 The patient, aged 20, is a native of the Sfindwich Islands; 
 father and mother both living in good health ; when about eight years 
 old he had a fall, sustaining a fracture of the right clavicle. For a 
 long time afterwards he experienced a sense of soreness or lameness on 
 the affected side. Within one to three years (the patient's testimony 
 is not clear uj^on this point) he noticed a numbness of the hand, with 
 
SYMPTOMS OF ANAESTHETIC LEPROSY. 
 
 52.^ 
 
 a tendency to contraction of the fingers. Tins gradually increased, 
 becoming more pronounced. He was treated by the application of 
 the actual cautery to the spine on the supposition that his trouble 
 was of central origin. For the last several years the contraction of 
 the fingers has remained unchanged, but the sensation of numbness 
 has crept farther uj? the forearm. 
 
 Upon examination, he was found to be well nourished; there was 
 some atrophy of the muscles of the right arm, more especially below 
 the elbow ; the deltoid was somewhat wasted ; the circumference of 
 
 i 
 
 j 
 
 1 
 j 
 
 r 
 
 >* 
 
 41 
 
 
 J 
 
 ' ft 
 
 ^■B^ <■, 
 
 
 yi^ .4)*^^^ 
 
 _:iflr7 
 
 
 .^Kf'- 
 
 1 
 
 ■ 
 
 ^* ^--iaHMi^^'^fe. 1 
 
 Fig. 9.— Characteristic ' Leper Claw." 
 
 the right arm was one inch less than that of the left ; there was also 
 atrophy of the muscles of the right leg. The fingers were contracted, 
 as shown in Fig. 9; over the knuckle of the index finger a superficial 
 sore from slight traumatism had existed for several weeks without 
 healing; the nails were thickened and deformed. 
 
 Over the lower half of the forearm and hand was entire absence 
 of all sensation; from the middle of the forearm to the middle of the 
 arm there was impaired sensation over regularly limited areas, ex- 
 tending higher on some aspects than on others ; the temperature sense 
 on the inner side of the arm was abnormal, hot water being mistaken 
 for cold, etc. On the right lower extremity sensation was normal ex- 
 cept along the anterior and outer surfaces of the ankle and foot. The 
 anterior leg muscles were atrophied, with paresis. 
 
 Electrical excitability of the muscles of the arm and forearm was 
 obtainable, but below this point was lost. Reaction of degeneration 
 
524 MORROW — LEPROSY. 
 
 was found in the muscles of the hand. The patellar tendon reflex on 
 the right side was exaggerated. There were two or three brownish 
 spots on the forearm, of the duration of which the x>atient could give 
 no account. 
 
 Quite analogous deformities occur in the muscles of the lower 
 extremities. The structures affected are the extensors of the toes, 
 which are the flexors of the ankle-joint, and as a result the ankle can- 
 not be flexed, and, in walking, the foot is raised by bending and lift- 
 ing the knee-joint and the foot is carried forwards and droi)ped down 
 e)i masse, or the point of the foot may trail downwards, the toes first 
 coming in contact with the ground. There often results a condition 
 resembling paralytic clubfoot. The toes may be flexed en grijiite, 
 rendering locomotion uncertain and vacillating. The atrophy may 
 extend to the muscles of the thighs aud buttocks, producing a condi- 
 tion resembling i^rogressive muscular atropln-. 
 
 The muscular atrophy is characteristically displayed in the regions 
 supplied by certain cranial nerves. It involves the trifacial as well 
 as the facial, and the resulting deformities may resemble other facial 
 paralyses of peripheral origin. The i:)aralysis may aft'ect the facial 
 muscles, drawing the face to one side and constituting a character- 
 istic deformity. Paralysis of the motor muscles of the eyes often gives 
 a staring expression to the face, altering the entire physiognom}-. 
 The parah'sis of the infraorbital branch causes atrophy of the lower 
 lid and paralysis of the orbicularis. The upper lid overhangs the 
 lower lid, which is everted, and the tears flow down the face, diverted 
 by the deformity of the lid from their natural channel. The patient is 
 unable to close the eye, and in the effort to do so continually contorts 
 the face. The eyeballs roll upwards, while the lids remain stationary.* 
 
 When the fifth nerve is affected, the lacrymal glands become 
 atrophied and disappear, and the secretion of tears is stoi)ped. The 
 eyelashes also fall out. The eyeball being insufficiently protected by 
 its natural secretion becomes dry and inflamed, the cornea opaque, 
 and the eye may be lost through ulceration of the cornea. The eyes 
 are also liable to be injured by exposure to bright light, dust, and 
 other irritants from loss of protection of the eyelashes. The loss of 
 sensation may be so complete as to permit of operations for cataract 
 or other affections of the eye without the use of an anaesthetic. 
 
 The buccal branches of the trifacial mav also be affected, with 
 
 * In the pest liouse in San Francisco I observed three lepers, all brothers, in 
 whom this particular form of paralysis was so marked that it was impossible for 
 them to close the eyes voluntarily. At night the eyelids w^ere strapped together 
 with adhesive plaster. 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 525 
 
 paralysis of the buccinator muscles. The cheeks and lips are flaccid 
 and pendulous. In severe cases the lips puff out, as in facial paraly- 
 sis. In many cases one of the first signs of leprous involvement of 
 this nerve is inability on the part of the patient to whistle, and pro- 
 nunciation of labials is difficult. The paralysis of the lower lip 
 causes the lip to hang down, displaying the teeth and gums, and 
 there is a more or less continuous flow of saliva from the mouth. 
 
 The Mucous Membranes. 
 
 The trophic changes are not confined to the skin and muscles of 
 the face, but affect also the mucous membranes of this region. The 
 oculopalpebral membranes are subject to constant irritation from ex- 
 posure to various external irritants. Owing to the lack of the normal 
 lubricating secretion, the conjunctiva becomes dry and inflamed. 
 Photophobia is often present in a marked degree. What has been 
 termed a condition of " cutisation" of the conjunctival mucous mem- 
 brane takes place, similar to what is described in connection with 
 changes in the mucosa of the air passages. Phlyctenular lesions with 
 resulting ulcerations and opacities of the cornea are apt to occur. 
 These ulcerations are as a rule superficial and are not apt to perforate 
 the cornea and puncture the anterior chamber. 
 
 Similar trophic changes occur in the mucous membranes of the 
 upper air passages, being probably due to degenerative changes in the 
 branches of the trifacial. The mucous membrane of the nasal fossse, 
 which in the early stage is the seat of irritation and hypersecretion, 
 becomes dry, red, and inflamed and later the seat of ulcerative 
 changes. The ulcerations, at first superficial, become covered with 
 crusts which partially close the passages, interfere with respiration, 
 and modify the character of the voice. Upon detaching or blowing 
 out the crusts, they are found to be blood-stained upon their attached 
 surface, and epistaxis, more or less profuse, frequently follows. The 
 ulcerations upon the septum not infrequently lead to perforation and 
 sometimes complete destruction of the support of the nose, which 
 consequently becomes flattened out. 
 
 One of the characteristic mucous-membrane symptoms consists of 
 complete loss of sensibility about the soft palate, uvula, and back of 
 the pharynx, not amounting to paralysis, but seriously interfering 
 with the proper function of the muscles of the throat which are affected 
 by it. There may be regurgitation through the nostrils, causing 
 much difficulty in swallowing. The anaesthesia is so marked that 
 the patients do not wince when a sharp instrument is plunged deeply 
 into the parts mentioned. 
 
026 
 
 MORROW — LEPROSY. 
 
 Stage of Mutilations. 
 JJniilatio))^ of the Ski/i, l>(>}ns. <i/nl ^irt'irnhitiim.'i. 
 
 In many cases tlie mnscular atrophies aud coutractnres mark the 
 end or culmination of the deforming process. In other cases, when 
 
 there is a complete disorgani- 
 ication of the trophic nerves, 
 profound nutritional changes, 
 with destruction of the l)ones 
 and nnitilatious of the ex- 
 tremities, follow, 
 
 III the milder class of 
 cases the trophic disorder is 
 I expressed in superficial ul- 
 J cerations due to the dimin- 
 I ished vitality of the skin from 
 i changes in its structure and 
 = the loss of resisting-power 
 = conferred hy a normal nerve 
 £ supply. Owing to the de- 
 
 1 structiou of the sebaceous 
 i and sweat glands and the 
 ^ suppression of the sweat and 
 & oily exudations the skin loses 
 
 2 its soft, sui)ple feel and be- 
 i comes dry, harsh, and parcli- 
 I ment-like; the epidermis 
 I cracks easily and loses its 
 ^ protective jiower of shielding 
 I the underlying tissues. It 
 ^f has become more vulnerable 
 ^ to slight causes of injury. 
 ^ These nutritional changes 
 
 are at first confined to the 
 anesthetic patches, but later 
 become manifest over the 
 general surface of the extrem- 
 ities. On accouut of the 
 
 anaesthesia wounds, barns.. 
 
 and various traumatisms oc- 
 cur without the patient's knowledge, followed hx superficial ulcera- 
 tions wliicli aro long in healing. Even at an early stage of the 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 527 
 
 disease tlie Lands aud feet may be covered with wouuds aud scars 
 froiQ ■various causes. Tlie slightest injury may cause disorganiza- 
 tion of the tissues. The chafing of the shoe, for example, may cause 
 a blister with siiperficial ulceration which may re(iuire mouths for 
 its healing. Often the skin over the joints of the hands or fingers, 
 which are at first more prominent from atrophj^ of the overlying 
 tissues, becomes thinned, cracked, aud fissured, producing dry, deep 
 rhagades, which may ulcerate and show no tendency to heal. A 
 breach of continuity may occur in the skin over the osseous promi- 
 nences of the semiflexed phalanges, the thumb, wrist, elbow, knee, 
 metatarsal or phalangeal articulations. 
 
 The more profound trophic changes which occasion the character- 
 istic mutilations of this form may be consecutive to caries and ulcer- 
 ations of the bone, or they may take place hj a process of interstitial 
 absorption or what may be termed spontaneous resorption without 
 intervention of the ulcerative process. In other cases the deep ulcera- 
 tions may begin in the pemphigus blebs located on the phalangeal 
 articulations, uncovering the deeper tissues, the consecutive disease 
 of which leads to the elimination of bone and the extensive mutila- 
 tions which characterize this j)eriod of leprosy. 
 
 The indolent anaesthetic ulceration which starts in the fissures of 
 the skin, instead of remaining sui^erficial, may become more profound 
 and destructive. Not infreciuently the parts anterior to the fissure 
 become gangrenous, resulting in their spontaneous amputation. The 
 reparative process is usually prompt and complete, the stump healing 
 perfectly. At other times the ulcerative process gains in depth, de- 
 stroying the cellular tissue, denuding the extremities to the bones, 
 penetrating the articulations, and leading to loss of the bones. These 
 ulcers, with callous borders formed by the muscular wall, are often 
 atonic and may persist for months without healing. 
 
 In another class of cases the first sign of beginning necrosis of the 
 bones is manifest in the swollen, tense condition of the overlying tis- 
 sues and is often attended with fever and constitutional reaction. 
 This swelling becomes softer, suppurates, and makes its way to the 
 surface, which opens and gives exit to a collection of sanguineous pus, 
 and there will be found a sinus leading down to the necrosed bone. 
 This is gradually broken down and extruded by the suppurative 
 process, when the sinus heals. In the case illustrated in Fig. 11 
 the entire hand was necrosed and gradually detached from the body ; 
 in the same way an entire foot may be amputated. 
 
 The following cases which came under the observation of Dr. Mc- 
 Dougal, of New Lexington, Ohio, and were reported by him in 1895, 
 are of exceeding interest on account of their mysterious origin. 
 
528 
 
 MORROW — LEPROSY. 
 
 That they are examples of leprosy there can be but little doubt, al- 
 though the source of the infection cannot be definitely traced. Pos- 
 sibly the father may have contracted the disease in the South during 
 his militarv service and communicated it to his daughters. The cases 
 
 Fig. n.— Spontaneous Amputation of the Hand in Anaesthetic Leprosy. 
 
 are also of interest in connection with the differential diagnosis of 
 leprosy and syringomyelia. They were diagnosticated by a number 
 of dermatologists as syringomyelia of the Morvan type. 
 
 " Hannah M. Garey, 18 years old, first came under my observation 
 in December, 189-4, She presented the following manifestations of 
 a disease we diagnosed as anaesthetic leprosy : Tlie left hand and 
 lower forearm were swollen and rather firmly thickened, the hand 
 and wrist being about twice the normal size. The distal phalanges 
 were all lost, except from the little finger and thumb, and the stumps 
 
SYMPTOMS OF AN-SJSTHETIO LEPROSY. 529 
 
 were all healed. The thumb nail was deformed and discolored. The 
 hand was being amputated at the radiocarpal articulation by a nar- 
 row, encircling ulcerative process, and the work was so near comple- 
 tion that only the ulnar vessels and some of the tendons remained. 
 Both surfaces were covered by granulations, were bathed with ex- 
 tremely foul-smelling pus, and were yet held in close apposition, 
 except at the bordering skin, where some retraction had taken place 
 in the healing process which had begun. 
 
 " The right hand and fingers were somewhat swollen and clubbed, 
 and all the distal phalanges, except those of the little finger and 
 thumb, were lost. The wrist-joint was somewhat deformed because 
 of an unnatural prominence of the head of the ulna on the dorsal side. 
 Both feet were swollen and thickened, and this condition also in- 
 volved to some extent the legs, being more marked in the left. From 
 the left foot the first and second toes were entirely lost, the third 
 toe was off at the proximal phalangeal joint, and the fifth toe was all 
 lost. On the plantar surface of the stump of the great toe was a thick, 
 dark crust covering an unhealed ulcer. In the middle of the left sole 
 was an ulcer, the size of a silver half-dollar, which reached deep into 
 the foot and from which there came a very offensive discharge. From 
 the right foot the great toe was lost, the second and third were off at 
 middle of proximal phalanx, and the fourth was pointed upwards so 
 that it was considerably out of line with the others. The little toe 
 was not affected, except that it was involved in the general thickening 
 of the foot. All the affected members were more or less anaesthetic, 
 the thermal anaesthesia being especially marked. 
 
 " There was a blister the size of a silver quarter on the back of 
 right arm just above the olecranon. The end of the tongue had been 
 destroyed by ulcerations that had healed, the left side of the lower lip 
 and both wings of the nose had suffered loss from the same cause and 
 were consequently deformed, and the lower jaw had likewise suffered 
 loss of bone, teeth, and gum. The girl's eyes looked weak and blink- 
 ing, and her vision was poor. 
 
 " This malady began to manifest itself, so the mother states, by ab- 
 scess formations in the legs when the patient was about fifteen months 
 old. In two or three years the toes began to ulcerate and come off, 
 and then the hands became involved. The flesh ulcerated from the 
 fingers, leaving the blackened, dry bones exposed, and these she per- 
 sistently drummed on the tables and chairs until her mother cut them 
 off with shears. 
 
 " She menstruated, though irregularly, after she was fourteen 
 years of age until about one year ago, when the menses ceased. 
 
 " January 18th, 1895, 1 saw her again. At that time she was sweat- 
 ing freely, though the house was cold, and her pulse was accelerated. 
 She complained of pain in the neck and left leg, from which she had 
 been suffering much. Her mother said she had lately fallen several 
 times, limp and motionless, and that she had been having some sort of 
 choking spells. The hand was still further separated, so that it hung 
 downwards when the arm was raised. On the back of the hand was 
 an extensive gangrenous blister, due to the pressure of splints used to 
 hold the hand in position. The epidermis covering the remainder of 
 Vol. XVIII.— 34 
 
530 MOKEOW — LEPROSY. 
 
 the hand had been recently shed and replaced by the formation of 
 new. The blister on the elbow had healed and the skin marking its 
 location was papery and harsh, and completely insentient to touch or 
 pain. The plantar ulcer was healing and covered by a thick, black, 
 offensive crust. 
 
 " February 15th I next saw her. At this time there was a large 
 ulcer, with sharplj- defined edge, on the back of the hand, correspond- 
 ing in size and location to the blister seen on a former visit. Since 
 my previous visit there had appeared for the first time in the history 
 of the case — so far as I was able to learn — an eruption on the left side 
 of the neck and on the front of the left leg. The eruptive spots were 
 not raised, were dark j'ellowish-browu in color on the leg and darker 
 on the neck. They were thickly set, and made with the surrounding 
 skin a dappled appearance, which shows fairly well on the leg in the 
 I^hotograph. Since the appearance of the erui)tion there have been 
 no choking or fainting spells. The plantar ulcer, after a duration of 
 about five j^ears, was now healed. At this time the negatives were 
 obtained from which the photograph was made (Fig. 11) and the 
 hand was removed and sent away for bacteriological examination. 
 
 " Sections from this specimen were stained for lepra bacilli with 
 negative results. The sections containing giant cells were also stained 
 for tubercle bacilli ; none were found. 
 
 " Her younger sister Hattie, eight years of age, has been afflicted 
 for about three years. Her feet are clubbed and legs stocky. The 
 great toe of the left foot is off at the middle of the proximal phalanx. 
 There is a dark crust on the lower part of the stump. The distal phalanx 
 of the second toe is lost. The right great toe is like the left. The nail 
 is lost from the second toe, and the ulcer which was present on the top of 
 this toe is now healed. The little toe has been entirely destroyed and 
 a healthy stump remains. There is some anaesthesia of the feet and 
 legs. There was a moderately indurated swelling on the outer front 
 side of the leg just above the ankle, which has almost disappeared. 
 
 " The hands are also affected. They are thickened and chubby. 
 The thumb nails show evidence of disease. The ends of the index-fin- 
 gers are off, and here an apology for nails is offered in the existence 
 of small, dark, horn}' thickenings on the centres of the ends of the fin- 
 gers. On the radial side of the wrist the skin is rough, and here are a 
 number of small wart-like elevations. There are a number of blisters 
 on the palmar surfaces of the hands. These are accounted for by 
 the fact that she is fond of parching corn in a skillet on the stove, and 
 her touch cannot appreciate a destructive degree of heat ; consequently 
 her hands are frequently burned. She is unable to appreciate any 
 difference between the feel of a bottle filled with hot and another filled 
 with cold water. Her eyes are red and tearful. Her voice is coarse 
 and croaks, and she has a croupy cough at night. 
 
 " Both have suffered at times from painful nerves, and when deep 
 abscesses formed, or when amputations began in the bones, they suf- 
 fered from them. But the ulcerations, though reaching deep into the 
 tissues or even destroj'ing a member, have not been painful. 
 
 " Hannah walked with little discomfort on the plantar ulcer, and 
 during the later stages of the destructiye process that robbed her of 
 her hand she suffered none, and laughed when it was being cut away. 
 
SYMPTOMS OF ANESTHETIC LEPROSY. 
 
 531 
 
 " The motlier insists that tlie ulcerations are always tlie result of 
 some accidental injury. They sometimes heal kindly after a variable 
 duration, and sometimes go on to complete destruction of the part." 
 
 In a recent communication (May 12th, 1899) Dr. McDougall states : 
 " Hannah continued losing remnants of her fingers and toes and hav- 
 ing plantar ulcers until she died from pneumonia this spring. The 
 living girl has suffered some further mutilation of the feet since I last 
 saw her. The first, second, and fifth toes are now gone from the left 
 foot. There is also a deep ulcer in the plantar surface at the middle 
 of the heel. It is indolent, dark, and deep, and rather dry so one can 
 see into it. It would admit a 
 lead pencil nearly an inch. The 
 mother says it came a number 
 of weeks ago from stepping on 
 a nail. The foot is also swol- 
 len and inflamed from the for- 
 mation of an abscess which has 
 opened through a round hole 
 in the top of the foot an inch 
 from the base of the second 
 toe. The discharge is thin, 
 purulent, and offensive. Not- 
 withstanding the condition of 
 the foot she walks and runs 
 with no sign of pain except a 
 moderate limp. The mother 
 says the gathering was caused 
 by the ' mare ' stepping on the 
 foot. Thermal anaesthesia 
 seems complete about the external malleoli and for a little way above. 
 We filled a two-ounce bottle with hot water and one with cold, and 
 grasping them with her hands, she could not distinguish them. 
 There is quite marked thickening of the left ulnar nerve." 
 
 These sisters have never been outside the State of Ohio. Both 
 parents and all the grandparents were natives of Ohio, and belonged 
 to healthy, long-lived families. The parents were married in 1866. 
 There are eight children, and all are healthy except Hannah, the 
 fourth born, and Hattie, the last born. The mother is forty-four 
 years old and healthy. The father, who was a soldier during the 
 War of the Rebellion, is reported as having died of some brain trou- 
 ble March 10th, 1893. He had an offensive discharge from the nose and 
 an eruption on the upper lip and the end of the nose. This trouble 
 developed shortly after marriage, and was never recovered from. 
 The regiment of which he was a member was stationed, during the 
 few months it was in service, at Nashville, Tenn., and at Dalton, 
 Kingston, and Macon, Ga. 
 
 Fig. 12, 
 
 -Spontaneous Amputation of the Toes 
 Anaesthetic Leprosy. 
 
 Perforating Ulcer.— Tlho, plantar ulcer which is so common and 
 characteristic a symptom of this form of leprosy is only a deep-seated 
 necrosis due to trophic disorders, the starting-point of which may be 
 an injury of the integument. It occurs most frequently among lepers 
 
532 MORROvr — leprosy. 
 
 who go barefoot, and is often due to a stone bruise or other injury. It 
 usually begins as a circumscribed callosity which appears over the 
 sole of the foot or palm of the hand or upon any portion of the meta- 
 tarsus or metacarpus. It rarely affects the phalanges or bones which 
 are easily detached, but more often bones which are firmly impacted 
 and cannot readily be dislodged. The epidermal thickening is usu- 
 alh' uplifted in the form of a bleb or blister and gradually breaks and 
 becomes ulcerated. The ulcer increases in depth until it finall}* 
 reaches the bones, which it slowly disintegrates and destroys. These 
 ulcers are essentially atonic and may persist for months and years 
 with but little change. It has been found that if a necrosed bone is 
 cut down upon and removed the ulcer heals. These perforating ulcers 
 
 Fig. 13.— Plantar Ulcer. 
 
 lead to various mutilations and often necessitate the amputation of 
 the member. In other cases the lesion can scarcely be described as 
 an ulcer, but rather as a sinus leading from an aperture in the centre 
 of the callosity down to the necrosed bone. The walls of the sinus 
 are lined with fungoid granulations, which may be found protrading 
 from the opening. Around the granulations is found a flattened area 
 of whitish-yellow, thickened epidermis. 
 
 Spontaneous Resorption of Bones. — In another class of cases the 
 disappearance of the bones is a phenomenon of absorption. It has 
 been described as a species of rarefying ostitis, giving rise to what 
 may be fitly termed leprous osteomalacia (Leloir). It is more apt to 
 affect the contracted fingers in cases of main en grife. The phalanges, 
 or the bones of the metacarpus and metatarsus, gradual!}- atrophy and 
 melt away until only the fibrous tissue which formerly enclosed them 
 remains. This also shrivels up and becomes mummified until the fin- 
 gers maj' be no thicker than a pencil. The process usualh' first at- 
 tacks the second phalanx. One phalanx after another may be removed 
 in the manner described until the i>halanges of the fingers and toes 
 
SYMPTOMS OF ANESTHETIC LEPEOSY. 533 
 
 are all destroyed. It may affect one phalanx and respect the others. 
 Thus the second phalanx may be destroyed, leaving the first and third 
 intact; or the second or third may be destroyed, and the first may 
 rest upon the metacarpus. 
 
 The nail seems to be endowed with a remarkable power of resist- 
 ance. As one bone after another is destroyed the fingers shrink and 
 shriyel up until nothing may be found except the nail occupying the 
 metacarpal or metatarsal bone corresponding to the phalanx. In 
 rare cases the terminal portion of the phalanx may be encircled by a 
 fissure which gradually deepens until the constricted portion in front 
 becomes swollen to twice or three times its normal size and is attached 
 only by a narrow pedicle suggesting a similitude to certain cases of 
 ainhum. Although the nails are seen to be endowed with a wonder- 
 ful resistance even at an advanced stage of the disease, they may suf- 
 fer in their nutrition. The dystrophic changes are seen in thinning 
 of the nail and more or less complete exfoliation, with degeneration 
 of the matrix. In some cases the end of the finger is seen capped 
 with a slight rudimentary vestige of a nail. 
 
 The mutilations of leprosy which represent the profoundest grade 
 of leprous destruction may in some cases coexist with a condition of 
 comparative health. The patient may live for many years in this 
 stunted and maimed condition, although practically helpless. Ordi- 
 narily in the advanced stage of the disease there develop certain con- 
 stitutional disorders. Morbid stomachal conditions lead to emacia- 
 tion and the general health gradually fails, with a tendency to visceral 
 complications. 
 
 Patients complain of sensations of chilliness and cold. This form 
 of subjective sensations constitutes one of the most constant and dis- 
 tressing symptoms. Patients hug the stove or fire in their ineffectual 
 efforts to keep warm, and to this is often due the frequent occurrence 
 of burns among lepers.* 
 
 Hillis, as well as Daniellsen and Boeck, have observed that the 
 body temperature is several degrees below normal in the advanced 
 stages of the disease. Coincident with the subnormal temperature 
 the action of the heart is enfeebled, and there is diminution in the 
 frequency of the pulse. 
 
 Sexual Functions. — The inhibitory effect upon sexual desire and 
 capacity is less marked in nerve leprosy than in the tubercular form. 
 In many cases it would appear that this function is at first stimulated 
 and the extinguishment of sexual desire and capacity takes place 
 
 * A similar phenomenon is observed in morphoea of generalized distribution. 
 In such a case under my observation the patient would sit for hours in the sun en- 
 veloped in a blanket or close to a fire in a vain endeavor to keep warm. 
 
534 MOEEOW — LEPROSY. 
 
 more gradually and at a more advanced stage o^ the disease. I may 
 quote from a letter of Mr. Dutton, wlio lias charge of the Home for 
 Leper Boys in Molokai, as to the effect of the two forms of disease upon 
 sexual functions. " Notwithstanding the old belief that in the tuber- 
 cular form this function assumed unusual excitability^ it has always 
 seemed to me that this condition lay with anaesthetic cases, or with 
 the mixed cases. Of home inmates who leave the home to live with 
 women, I should say that they are generally those who have marked 
 anaesthetic features." This result is precisely what would be inferred 
 from the implication of the testicles by the bacilli in the tubercular 
 form, and the comparative exemj)tion of these organs in the anaes- 
 thetic form. It has been demonstrated by Babes and others that the 
 bacilli are found in great abundance and are localized in the connec- 
 tive tissues and seminiferous tubules in the tubercular form. 
 
 The procreative capacity of lepers is not so much impaired as is 
 commonly believed. The statistics of the leper settlement of Cape 
 Town, and of the Norwegian lepers who have emigrated to this coun- 
 try, to which reference is elsewhere made, show that lepers may be 
 quite prolific. 
 
 Menstruation. — In most cases, especially if the disease has existed 
 for some time, the menses become irregular, and in exceptional cases 
 they cease completely long before the normal period of the meno- 
 pause. When leprosy develops in childhood or before puberty the 
 menses rarely appear at all. The disease has an inhibitory effect on 
 this function, as well as a stunting effect upon the growth, arresting 
 the development of the normal bodily functions. The aspect of pre- 
 cocious senility, the nervous trouble culminating in contractures, ul- 
 cerations, and consecutive mutilations with progressive emaciation, 
 form an easily recognized picture of leprosy in childhood. 
 
 Termination. 
 
 The lamentable aspect presented by trophoneurotic lepers at an 
 advanced stage of the disease has been thus graphically described by 
 Leloir : 
 
 "The anaesthesia may occupy the entire body. In any case it 
 has invaded the upper and lower limbs completelj^ the face, etc. 
 The facial mask is immobilized by paralysis and muscular atrophy, 
 and in this yellowish, waxy, cadaveric, emaciated and deformed im- 
 mobile mask one sees two large eyes, open, fixed, but white, dull, 
 without light, for the unfortunate is blind. Saliva constantly flows 
 from the corners of the paralyzed mouth. The nose is sometimes 
 deformed ; the sfense of smell has disappeared partially or altogether, 
 likewise the taste ; the hairs of the face have fallen. 
 
TEEMTNATION OF AlJiESTHETIC LEPEOSY. 535 
 
 " Tlie hands and feet are liorriblv deformed and mutilated, and 
 have no longer a human appearance. The muscles of the limbs are 
 atrophied. Ulcerations, more or less vast, have denuded the bones 
 of the limbs and secrete an indescribable humor. The patient exhales 
 a sweet, unsavorr odor analogous to that of the warm cadaver. He 
 is in a state of profound depression ; deprived of appetite, tormented 
 by insatiable thirst, sometimes again by frightful neuralgic pains ; 
 he remains lying or sitting entire days, without occupying himself 
 with that which is passing around him. One is obliged to feed him, 
 put him to bed, carry him. He appears plunged in a profound stu- 
 por and witnesses indifferently the progressive mutilation of his body. 
 Neverthless, if one interrogates him, one perceives that his intelli- 
 gence is rather dulled than lost." 
 
 Patients die of marasmus or exhaustion consequent upon long- 
 continued digestive disorders, colliquative diarrhoea, of amyloid de- 
 generation of the kidneys and internal organs, or of some inter- 
 current disease. They rarelj- die of tuberculous complications. 
 Such complications are as uncommon in this form of leprosy as is 
 amyloid degeneration in the tubercular form. 
 
 The average duration of life in the anaesthetic form is said, by 
 Daniellsen and Boeck, to be from eighteen to twenty years. In some 
 cases this period is prolonged to twenty, thirty, or forty years or 
 longer. The transition of the anaesthetic into the tubercular form 
 will be considered in connection with the mixed type of leprosy. 
 
 Instead of proceeding to this fatal termination, anaesthetic leprosy, 
 after attaining a certain degree of development, may be apparently 
 arrested. All the symptoms abate, the spots gradually clear up, the 
 bullae cease to appear, even the sensibility of the skin, which was in 
 abeyance for a long time, becomes reestablished. While the pa- 
 tient may show in his atrophied and paralyzed muscles, his maimed 
 and mutilated limbs, the vestiges of the disease which has occasioned 
 them, there is no evidence that the bacilli are present or likely to be 
 awakened into activity. The patient may live to quite an advanced 
 age, and finally die of intercurrent disease. 
 
 This arrest may take place at any time during the course of the 
 disease, and it is a question of great practical importance whether such 
 cases can be considered cured. Impey says that in every leper es- 
 tablishment there may be found cases of cured leprosy. In his opin- 
 ion these stigmata of the disease have the same significance as the 
 scars of syphilis, and as a practical outcome of this belief he insists 
 that it is wrong to confine such cured cases in close association with 
 tubercular lepers as they are liable to be reinfected. A number of 
 cases are instanced in which he thinks reinfection has taken place, 
 
536 MORROW— LEPEOSY. 
 
 the patient again exhibiting the early and late phenomena of the dis- 
 ease precisely as if he had never had it. To this Ashmead replies : 
 "How can immune tissue be inoculated? Certainly the anaesthetic 
 leper would be more liable to be contaminated in his healthy parts 
 by autoinfection than by other lepers. If the cutaneous tissues of 
 the anaesthetic leper are immune, how can they be inoculated at all?" 
 To this it may be replied that it is quite possible that the few bacilli 
 in an old case of nerve leprosy may have lost their infective capacity, 
 while a plentiful supply of bacilli from a fresh source and of a more 
 virulent type might inoculate previously immune tissues. 
 
 Personally, the writer believes that there are a great many cases 
 of anaesthetic leprosy which are abortive or which are spontaneously 
 cured. On the other hand it is to be borne in mind that anaesthetic 
 leprosy, instead of running a distinct course to the end, may take on 
 the severer and more rapidly fatal characteristics of tubercular lep- 
 rosy. Fortunately, the transformation of the milder anaesthetic form 
 into the severer tubercular is comparatively rare. 
 
 Tubercular and Anaesthetic Leprosy Contrasted. 
 
 In order to bring into strong relief the clinical contrasts between 
 tubercular and anaesthetic leprosy, the more distinctive characters of 
 each may be thus formulated ; 
 
 Tubercular Leprosy. Anesthetic Leprosy. 
 . Bacilli Bacilli 
 Abundant , found in the cutaneous and Comparatively few ; found in nerves 
 mucous-membrane lesions, physio and sheaths, sparingly and not con- 
 logical secretions, inguinal glands, stantly in cutaneous and mucous- 
 and the internal organs. membrane lesions. 
 
 Mode of Infection 3fode of Infection. 
 
 Unknown, probably multiple. Unknown, probably multiple 
 
 Period of Incubation. Period of Incubation, 
 
 From several months to few years. Months and years, relatively longer. 
 
 Prodromes. Prodroines. 
 
 Fever, malaise, epistaxls, systemic dis- More localized, hyperaesthesia, neuralgic 
 turbance. pains, and other sensory disorders. 
 
 Early Eruptive Stage. Early Eruptive Stage 
 
 Erythematous and pigmented spots, cir- Erythematous, pigmented, and achromat- 
 
 cular in outline, reddish in color, ic spots ; bulla?, spots more numerous 
 
 which is more pronounced in the and more irregular in shape, smaller 
 
 centre, fading towards the circum- at first, with a tendency to spread 
 
TUBEECULAE AKD ANESTHETIC LEPEOSY CONTEASTED. 
 
 537 
 
 ference ; edges not raised, spots pale 
 on pressure, transient in duration, 
 may appear and disappear a number 
 of times before becoming the seat 
 of tubercular nodules ; eruption 
 more frequently appears on the an- 
 terior aspect of the body. 
 
 Tvhercular Stage. 
 
 Development of tubercles in skin and 
 mucous membranes, which may 
 come out in successive crops, remain 
 permanently or disappear by inter- 
 stitial resorption, undergo fibroid 
 degeneration, or become ulcerative. 
 
 Ulcerative Stage. 
 Softening and breaking down of tuber- 
 cles, disappearance by purulent dis- 
 solution or by resorption ; leproma- 
 tous infiltrations of internal organs. 
 
 Mucous Membranes. 
 Seat of diffused and nodular infiltra- 
 tions followed by ulceration; mu- 
 cosa of eye, nose, pharynx, larynx, 
 seat of nodular infiltrations followed 
 by ulceration. 
 
 Secretory Glands. 
 
 Sebaceous and sweat secretions, first ex- 
 aggerated, later diminished. 
 
 Hair Follicles. 
 Loss of eyebrows, alopecia of all pilous 
 surfaces the seat of tubercular infil 
 tration. 
 
 Nails. 
 Often affected by tuberculous infiltra- 
 tions of matrix or ungual borders, 
 followed by ulceration, simulating 
 syphilitic onychia and paronychia. 
 
 peripherally and serpiginously and 
 form by coalescence large patches 
 which are white and depressed in 
 the centre, with raised, well-defined 
 hyperchromatic borders. These 
 patches are permanent, and remain 
 as long as the disease lasts. They 
 are more numerous on the back than 
 on the front of the body. 
 
 Atrophic Stage. 
 
 Muscular atrophies, tendinous retrac- 
 tions, deformities, paralyses, with 
 sensory disorders, anaesthesia, etc. 
 
 Mutilating Stage. 
 Osseous degeneration, loss of members 
 by resorption of bone, ulceration, 
 gangrene, perforating ulcer, etc. 
 
 Mucous Membranes. 
 Mucous membranes not so frequently 
 affected ; changes not neoplastic, but 
 essentially dystrophic ; eye, nose, 
 pharynx, and larynx more fre- 
 quently exempt. 
 
 Secretory Glands. 
 Primary exaggeration of function with 
 secondary atrophy and suppression 
 of function 
 
 Hair Follicles 
 Loss of eyelashes, bleaching and falling 
 out of hairs from atrophy of the 
 follicles 
 
 Nails. 
 Changes chiefly atrophic , the nails pre- 
 serve their autonomy in most sur- 
 prising manner. 
 
 Sensory Disorders. 
 
 Disorders of sensation not so marked ; 
 anaesthesia, if present, is usually lo- 
 calized, limited to the tubercles or 
 surrounding regions ; probably due 
 
 Sensory Disorders. 
 
 Hypersesthesia, pruritus, and pain pro- 
 nounced during the early irritative 
 stage, succeeded by numbness and 
 anaesthesia, more pronounced in mac- 
 
538 
 
 MOREOW — LEPROSY. 
 
 to pressure upon the terminal fila- 
 ments of the nerves by leprous in- 
 filtration. 
 
 Sexual Functions. 
 Sexual desire and capacity soon lost ; im- 
 potence from azoospermia. 
 
 Inguinal Glands. 
 
 Changes constant and characteristic ; 
 thought to constitute centres of auto- 
 infection. 
 
 Internal Viscera. 
 Seats of leprous infiltration as "well as of 
 tuberculous and other terminal in- 
 fections. 
 
 Course and Duration. 
 Disease more severe, more rapidly pro- 
 gressing to fatal termination. Av- 
 erage duration, eiglit to ten years. 
 
 Termination. 
 Tuberculous complications, exhaustion 
 from leprous ulcerations, nephritis, 
 colliquative diarrhcea, septic infec- 
 tions ; suffocation from atresia of air 
 passages. 
 
 It may be observed that while the clinical pictures of the two 
 principal forms of leprosy present many features of difference in their 
 fully developed stage, the lines of demarcation between them are not 
 always so clear or sharply drawn as would appear from the above 
 differential table. 
 
 Certainly during the invasion period the prodromal symptoms are 
 not sufficiently distinctive to enable us to forecast the form the dis- 
 ease will eventually assume. With the advent of the eruptive stage 
 the divergence between the two forms becomes more marked. But 
 even when we recognize a predominance of the tegumentary lesions 
 on the one hand or the marked implication of the nervous system 
 on the other we cannot say that there will be a fixation of one form or 
 the other. 
 
 In order to bring the distinctive differences of the two forms of 
 leprosj' into more prominent relief a typical picture of each form, 
 one beside the other, may be seen in Fig. 14. In one it is to be ob- 
 served that the visage is covered with nodular masses, marked by 
 
 ular patches, but may affect surface 
 of entire limbs ; disassociatiou of 
 modes of sensation, due to more or 
 less complete degeneration of the 
 peripheral nerves. 
 
 Se.nial Functions. 
 Sexual desire at first exaggerated, sug- 
 gesting satyriasis ; sexual capacity 
 continued longer. 
 
 Inguinal Olands. 
 Enlargement of glands exceptional, not 
 probably due to leprous virus. 
 
 Internal Viscera. 
 Amyloid degeneration more common. 
 
 Course and Duration. 
 Disease milder, less progressively ac- 
 tive ; duration indefinite, fifteen to 
 twenty years or longer. 
 
 Termination. 
 
 Amyloid degeneration of internal organs, 
 albuminuric nephritis, rarely phthi- 
 
TUBEECULAE AXD ANAESTHETIC LEPEOSY CONTBASTED. 
 
 539 
 
 deep corrugations, the lobes of the ears are enlarged, flabby, and 
 pendulous, but the integrity of the extremities is completely pre- 
 served; in the other the bridge of the nose is sunken from osseous 
 
 Fig. 14.— Contrast between Tubercular and Anassthetic Leprosy, as Exhibited in the Face, 
 
 Hands, and Feet. 
 
 absorption, the features are drawn by facial paralysis, the fingers are 
 distorted and mutilated, and the feet are mere stumps, with partial 
 vestiges of the toes remaining. 
 
 But to demonstrate the substantial identity of the two forms, a 
 picture of mixed leprosy is shown in Fig. 15, in which may be 
 observed, in addition to the mutilating changes in the nose, hands, and 
 feet, tubercles on the cheek and ear. This case was primarily anaes- 
 thetic, but after a certain time tubercular changes supervened. 
 
640 
 
 MORROW — LEPROSY. 
 
 Fig. 15.— Mixed Leprosy, Primarily of the Anaesthetic Type with Tubercular Changes 
 
 Supervening. 
 
MIXED OR COMPLETE TYPE OF LEPROSY. 541 
 
 Mixed or Complete Type of Leprosy. 
 
 Under tliis designation are included certain cases in which the 
 characteristic lesions of both the tubercular and anesthetic forms ap- 
 pear either simultaneously or successively. 
 
 (1) Symptoms peculiar to both forms may be present from the 
 first in consequence of simultaneous invasion by the bacilli of the 
 cutaneous and nerve tissues, the course of the disease being influenced 
 favorably or unfavorably according to the predominance of the nerve 
 or cutaneous lesions. 
 
 (2) The bacilli may first attack the peripheral nerves and the ini- 
 tial symptoms be those of anaesthetic leprosy. After the disease has 
 run a certain course it may become complicated by the development 
 of tubercles and correspondingly intensified in severity from the inva- 
 sion of the integument by the bacilli. 
 
 (3) The leprous virus may first affect the skin and mucous mem- 
 branes with the production of tubercles and other changes peculiar to 
 the tubercular form, but in the course of its evolution the bacilli 
 leave the integument and invade the peripheral nerves. The disease 
 then exhibits the milder symptoms of the anaesthetic form, which is 
 less progressively active and the duration of life is considerably pro- 
 longed. 
 
 According to Leloir there may be a coincident development of 
 both forms, a transformation or a gradual transition of one form into 
 the other, and also a complete substitution of one form for the 
 other; the symptoms of one form replacing those of the other pre- 
 cisely as if a new infection had taken place. In the latter case it is 
 assumed that the bacilli, having exhausted the tissue soil in which 
 they first find lodgment, invade new tissues which were previously 
 immune. 
 
 It is probable that in all of the cases of reputed transformation or 
 substitution, the symptoms of both forms may have coexisted without 
 recognition, the manifestations of the predominant form masking 
 those of the other. 
 
 The lines of demarcation between tubercular and anaesthetic lejD- 
 rosy are not so distinct and sharply drawn as to enable us to separate 
 and classify them on the basis of their pathogenic mode. The inti- 
 mate sympathy existing between the cutaneous and nervous systems 
 in their nervous and nutritive relations explains the similarity in the 
 morbid phenomena exhibited by each ; the more especially as these 
 phenomena are due to the same pathogenic factor. 
 
 The proportion of mixed cases varies in different countries. In 
 
542 MOKROW — LEPROSY. 
 
 Norway the i)roportion of nervous leprosy' was 33.3 per cent., mixed 
 leprosy 15.1 per cent., tubercular lepros}^ 51.6 per cent. In 188 
 cases in British Guinea tabulated by Hillis there were found 84 
 cases of tubercular, 51 of mixed, and 103 cases of nerve leprosy. In 
 India Carter's tables of the relative frequency of the different forms 
 show that 9 per cent, were tubercular, 21 mixed, and 61.9 anaesthetic. 
 Impey's tables show that of 703 patients admitted into the Robbeu 
 Island Asjdum, Cape Colonj', South Africa, there were 369 anaesthetic 
 cases, 238 tubercular cases, 81 mixed, and 15 syphilitic, making a per- 
 centage of 52.48 anaesthetic, 33.86 tubercular, 11.53 mixed, and 2.13 
 syphilitic cases. 
 
 Taking the observation of ten hundred and fifty cases which I saw 
 in the Molokai settlement in 1889 as a basis of calculation, it may be 
 roughly computed that one-half were tubercular, one-third anaesthetic, 
 and the remaining one-sixth of the mixed type. Since then the rela- 
 tive proportion of anaesthetic and mixed cases has largely increased. 
 
 The Survival of Leprosy in Modified Forms. 
 
 It is generally accepted that leprosy practically disappeared from 
 Europe during the fifteenth and sixteenth centuries, and that within 
 the last two or three centuries cases of this disease met with in central 
 Europe have been imported cases. Nevertheless, it has been contended 
 by certain authors of more or less note that certain rare forms of dis- 
 ease occasionally met with in leprosy-free countries, and which have 
 been classed as distinct morbid entities, represent survivals of leprosy. 
 
 Erasmus Wilson, the distinguished English dermatologist, in his 
 text-book on skin diseases (1865), discusses the question whether the 
 leprosy of the Middle Ages is gone and left no remains behind. 
 "Are there no traces of the great leprosy at the present day?" To 
 this he answers : " It would be contrary to all analogy to suppose 
 that it has so totally passed away as not to leave a trace ; and yet no 
 sign exists in the records of medicine to tell us that such is not the 
 case. But although the sign may be absent in the records of medi- 
 cine, the infallible sign remains imprinted on man. Leprosy remains 
 among us still, but only as a faint trace of a worn-out disease or as 
 an ember of the burnt-out fire. God forbid that the spark should be 
 rekindled ! I repeat that elephantiasis still exists among us in this 
 country as a faint trace of its former self, and the observation of that 
 trace, however faint, becomes a matter of interesting search. Although 
 a mere shadow in comparison with the parent disease, it is neverthe- 
 less sufficient to occasion considerable annoyance to the sufferer and 
 to bring him not unfrequently under the inspection of the medical 
 
THE SURVIVAL OF LEPROSY IN MODEFIED FORMS. 543 
 
 man. Now when once pointed out can the medical man doubt or an 
 instant tlie nature of the disease which he has before him? There is 
 the insensibility, the deposition, the blanching, the exhaustion of 
 function, and the atrophy of the parent malady with all their original 
 distinctness ; indeed, one complete symptom of the pure elephantiasis 
 preserved unchanged as it existed among the Jews and as it is to be 
 found at this moment on the shores of Norway, the symptom which 
 was called by the ancients morphoea." 
 
 He declares that the various forms of morphoea which he describes 
 under the definition of morphoea alba ladarcea, morphoea alba atro- 
 phica, and morphoea nigra are remains of that bygone scourge, the 
 great leprosy. He also declares that alopecia areata is a morphoea 
 of the scalp and the hair-bearing skin, and that this morphoea bears 
 the same relation to elephantiasis as the morphoea already described. 
 
 Kaj)osi also includes the different varieties of morphoea in his 
 description of the macular form of leprosy. He states that the 
 several forms of this spotted or macular leprosy may exist alone for 
 years as the chief signs of the disease and constitute two different 
 types. " Thus, for instance, (a) they may exist as such for years, or 
 either terminate as such without ever undergoing any further altera- 
 tion. To a certain extent they represent local forms of lepra, since 
 during their entire period of existence, as well as after they have 
 passed away, the system does not become in the least affected by 
 them. Or (b) they may last for a long time uncomplicated; but 
 sooner or later the whole system becomes affected, and the series of 
 symptoms characteristic of anaesthetic lepra make their appearance, 
 among which the sj^mptoms of maculated lepra occupy only a subor- 
 dinate place." 
 
 At the present day the most prominent advocate of the survival of 
 leprosy in Europe and elsewhere under the form of rare diseases is 
 Zambaco Pacha. In his paper before the Berlin Leprosy Congress 
 he has endeavored to widen the pathological field of leprosy by bring- 
 ing within its domain syringomyelia, Morvan's disease, scleroderma, 
 sclerodactylia, Raynaud's disease, morphoea, ainhum, and progressive 
 muscular atrophy of the Aran-Duchenne type. 
 
 He claims that in Europe, and in countries where leprosy has 
 ceased to exist as an endemic, it still survives in a degraded form, 
 and that the above-mentioned diseases constitute attenuated or abor- 
 tive types of leprosy ; in other words, they represent a leprosy " lar- 
 vee," modified and attenuated in its manifestations. He asserts that 
 the universal belief that leprosy has disappeared for two centuries 
 from Central Europe and the non-recognition of the numerous varie- 
 ties of this disease which have been modified by the progress of civi- 
 
544 MORROW — LEPROSY. 
 
 lization Lave contributed to engender errors, and that these surviving 
 forms of lepros}' have been designated under the title of cases of rare, 
 nameless, and undescribed forms of disease. While their resem- 
 blance to leprosy has attracted the attention of many distinguished 
 observers, all have refused to recognize the true nature of these dis- 
 eases upon the ground that they cannot be leprosy, since this affec- 
 tion does not exist in Europe, and that the patient has not been in 
 any leprous locality where he could have contracted the disease. 
 
 Zambaco declares that Morvan's disease is nothing less than lep- 
 rosy, and that syringomyelia and Morvan's disease constitute one 
 and the same thing. He thinks that there have been confounded 
 under the title of syringomyelia numerous cases of leprosy exhibit- 
 ing the anaesthetic form of the disease. Progressive muscular atro- 
 ph}' of the Aran-Duchenne type embraces also different diseases, 
 among which figures lei^rosy. Raynaud's disease and symmetrical 
 gangrene depending upon nervous troubles, circulatory and trophic, 
 present the closest relations with certain forms of lex)rosy. He de- 
 clares that one may place with certainty among them many cases of 
 leprosy. He thinks it probable that future research M'ill demonstrate 
 that they are no more than new morbid states of a leprosy- modified 
 and attenuated in its manifestations. The ainhum of authors, when 
 affecting the hands or feet is, according to Zambaco, a form of muti- 
 lating leprosy. The morphcea of modern writers and the mori)hoea 
 of ancient writers should not be separated from classical leprosy. 
 Scleroderma and sclerodactylie seem to him to be only a modified 
 leprosy, if not an unmistakable leprosy as one sees in so many of the 
 published cases. All of these diseases he regards as more or less de- 
 generated forms of the ancient leprosy, and he endeavors to establish 
 their identity by grouping them under the generic name of leprose. 
 Although these various diseases differ in appearance, and are some- 
 times quite dissimilar in their extreme symptoms, yet they approach 
 and blend in their common sym^jtoms and permit a pathogenic uni- 
 fication. He takes the ground that the absence of anaesthesia and of 
 the lepra bacillus in these diseases is not sufficient to make us reject 
 the diagnosis of leprosy. The symptomatology of these newly created 
 diseases is merely an expression of the polymorphism of leprosy. 
 
 It is not possible within the limits prescribed for this article to 
 enter into an exhaustive study of the question of the identity of these 
 diseases with leprosy. It is sufficient to say that the views of Zam- 
 baco Pacha were not shared by the great majority of the leprologists 
 present at the Leprosy Congress. 
 
 It may be said that the above-mentioned diseases are by no means 
 uncommon in the United States, where leprosy has never existed 
 
THE SUEVIVAL OP LEPROSY IN MODIFIED FORMS. 545 
 
 except in sporadic and imported cases. The ancestry of many in- 
 dividuals exhibiting these diseases may be traced back several gen- 
 erations, and found to be free from all leprous taint, while the pa- 
 tients themselves have never been exposed to contact with lepers. 
 To speak of a survival of a disease which has never existed, in this 
 country at least, is a contradiction of terms. The assumption that 
 these diseases are expressions of leprosy involves the theory that the 
 leprous germs must have had their origin in a remote ancestry and 
 remained latent for several generations and then have been trans- 
 mitted in this modified form, which is stretching the theory of atavism 
 to an impossible degree. 
 
 In commenting upon the disappearance of leprosj- from Europe, 
 Jonathan Hutchinson says " it is very important to remark that, so 
 far as our knowledge at present goes, it has left nothing behind it. 
 Vv"e have no half cases or slight forms or modified maladies. Its 
 manifestations seem to be somewhat more definite and positive than 
 those of tuberculosis. It is either leprosy or nothing. Nor are there 
 any sporadic cases springing up here and there in communities which 
 have long been free. " The results of the recent congress at Berlin 
 have strongly confirmed these statements. No examples were pro- 
 duced, with one possible exception from a town in Brittany, show- 
 ing that the disease had occurred sporadically in inland communities 
 otherwise free. But many examples were produced showing that the 
 disease is and has been for a long time prevalent to a slight extent 
 in localities not previously recognized as its haunts. 
 
 The most convincing argument, however, which may be adduced 
 in refutation of the views of Zambaco Pacha is the absence in all these 
 diseases of the lepra bacillus. It is generally recognized that the 
 presence of Hansen's bacillus constitutes the distinctive essential 
 auatomicopathological characteristic of leprosy. It is the pathogno- 
 monic sign, and while it is not always practicable to demonstrate its 
 presence in nerve leprosy during life, it is always found at autopsy. 
 
 The more important differential features which distinguish these 
 diseases from leprosy are considered in the section on. Diagnosis. 
 
 PATHOGENY AND GENERAL PATHOLOGY. 
 
 Infection hy the Bacillus. — As in the case of other granulomatous 
 processes, Hansen's bacillus attacks the various cellular elements of 
 the body and is able to penetrate readily every variety of cell. Speak- 
 ing generally, the changes induced in the latter consist principally of 
 enlargement, vacuolization, segmentation of the nucleus, disappear- 
 ance of pigment. Multinuclear and giant cells are formed at times. 
 YoL. XVIII.— 35 
 
546 MORROW — LEPROSY. 
 
 Homogeneous yellow masses are formed at the exjoense of the cellular 
 contents, and the protoplasm of the cell may be wholly replaced by 
 the bacilli. The latter are situated both within and between the 
 cells. The bacilli in time show degenerative changes, and we may 
 see side by side degenerated bacilli in apparently healthy cells and 
 young fresh bacilli in degenerated cells ; these phenomena are held 
 to be illustrations of Metchnikoff's doctrine of phagocytosis and of 
 the war to the death between the bacilli and cells (Babes). Of all 
 prominent histologists, Uuua alone puts forward the claim that the 
 bacillus is entirely extracellular. Unna claims that the regular and 
 constant seat of the lepra bacilli is extracellular, their habitat not 
 being in the protoplasm of the cells, but in the intercellular and 
 interfascicular spaces- — the lymi:)hatic spaces in other terms. Almost 
 all other histologists who have investigated the matter maintain that 
 the mass of bacilli found in sections or from scrapings of the le- 
 promes are bacilli-bearing cells — the leprous cells of Virchow. They 
 see one or many nuclei more or less altered and a vacuolized proto- 
 plasm containing parasites — where Unna describes a "gloea," a gelat- 
 inous or mucous substance, the product of the secretion or degenera- 
 tion of the bacilli having englobed the nuclei of the cells which limit 
 the spaces in which the " gloea" is developed. It is probable that the 
 bacilli may be either intracellular or extracellular, may be comprised 
 in the preformed canals in which are moulded the mass of bacilli 
 comprised in the sheath; from this result the "globi" which have 
 been mistaken for cells. 
 
 During its period of incubation or latency Hansen's bacillus is 
 believed, purely from analogy, to lie within the lymph ganglia. 
 
 At the moment when the bacillus is about to attack the tissues it 
 is agreed by most authorities that it occupies the lymph spaces and 
 makes its first assaults upon the endothelia of these cavities. The 
 endothelia and perithelia of the lymph and blood capillaries are, ac- 
 cording to Babes, specially subject to attack, and the lumen of these 
 vessels often shows the presence of the parasite. The fixed connec- 
 tive-tissue cells, wandering leucocytes, plasma cells, etc., are in turn 
 attacked. Wherever the parasite begins its assaults an inflammatorj^ 
 focus slowly forms, consisting of round cells with a single nucleus. 
 While the cells which lie within the focus soon take on those peculi- 
 arities of size, shape, and texture which appertain to the specific 
 lepra cell, and which have already been indicated, there is an outly- 
 ing zone of ordinary round-cell infiltration which is common to all 
 chronic inflammation. 
 
PATHOLOGY OF TUBEKCULAR LEPEOSY. 547 
 
 Tubercular Leprosy. 
 
 In this variety, wliicli is essentially an affection of the skin and 
 mucosa, there is present a more or less diffuse infiltration which 
 extends to the subcutaneous or submucous tissues. 
 
 With regard to the skin, there is an obvious but ill-defined distinc- 
 tion between ordinary tubercular or mixed leprosy and the purely 
 neurotic form which is accompanied by certain secondary cutaneous 
 lesions. While some of the latter are non-specific and, as might be 
 expected, contain no bacilli (such, for example, as the pus from a 
 perforating ulcer of the foot), others undoubtedly do contain the para- 
 site ; this has been found in the hypersemic areas of acute lepra, 
 which often accompany the neurotic form and in which Philippson 
 found bacillary emboli. 
 
 In the fresh eruption of anaesthetic leprosy bacilli have been found 
 both in and beneath the skin and also in the cutaneous nerves, both 
 superficial and deep. Babes believes that the bacilli are originally 
 present in all the cutaneous lesions in nerve leprosy, but that they 
 disappear later. Darier has studied the structure of the erythemato- 
 pigmentary macules, the so-called "leprides," and their contained 
 bacilli. He demonstrates a more or less abundant infiltration of cells 
 disposed in the form of cylinders around the blood-vessels, which in 
 certain regions may become confluent en nappe. These are, in the 
 majority, small connective-tissue cells with which are mingled in 
 variable jjroportions white corpuscles, plasma cells, some mastzellen, 
 and in rare cases giant cells. In nine cases which he examined he 
 found in all but one the presence of bacilli, whether the patches were 
 recent or ancient, erythematous or purely pigmentary. The bacilli in 
 some cases were scarce, in others almost innumerable. Darier claims 
 that the almost pathognomonic structure of the macules, and the 
 almost constant presence of the bacilli in their interior permit of an 
 early diagnosis, which is scientifically certain. 
 
 In tubercular leprosy proper the anatomical appearances vary 
 considerably in proportion as the deposit is recent or old. Young, 
 fresh nodules lie somewhat removed from the epidermis, a broad stra- 
 tum of normal skin intervening. The infiltration begins, as do similar 
 granulomatous processes, about the pilosebaceous follicles, vessels, 
 nerves, and sweat glands ; and one or the other of these structures 
 forms the centre of the future nodule. Besides these specific foci the 
 skin in general about the latter is the seat of ordinary simple round- 
 cell infiltration. This infiltration may be diffuse without a marked 
 nodular disposition. Sections of recent leprous tubercles show the 
 
548 MORROW — LEPROSY. 
 
 layers of the epidermis perfectly preserved and normal. The papilleo 
 are somewhat hypertrophied and filled with small round cells. In 
 old tubercles the papillary outlines liave disappeared and the entire 
 stratum is replaced by a uniform layer of small cells. The entire der- 
 mal tissue is infiltrated with round or ovoid cells which are here and 
 there grouped in illy defined masses and penetrate into the cellular 
 adipose tissue. The adventitious tunics of the blood-vessels, as also 
 their internal layers, are thickened and their calibre is narrowed. 
 The sebaceous and sudoriparous glands are implicated and choked 
 by the production of small cells formed at their periphery and end by 
 atrophying and finally disappearing. 
 
 The bacilli are found not only in the blood-vessel cells, but also 
 outside of cellular formations in the lymphatic spaces. The cells 
 designated as " lepra cells" by Virchow are found in the dermal groups 
 of old tubercles. These voluminous cells possess several nuclei; 
 they are ovoid, spherical, or irregular, and sometimes as large as the 
 giant cells of tuberculosis, with which they may be confounded. In 
 old tubercles the epidermis is thinned, the i3apillary layer is effaced, 
 and no trace of the glands or hair follicles remains. 
 
 As the nodules progress they approach nearer to the epidermis, 
 increasing at the periphery, while degenerative changes take place io 
 the characteristic cells and the centre becomes necrotic. The casting 
 out of this slough leaves an ulcer. The slough is made up of degen- 
 erated cells and colonies of bacilli and is due to the action of the tox- 
 ins formed by the latter. The ulcer may readily heal, or the outlying 
 inflammatory zone may undergo the leprous transformation, so that 
 the ulcer may increase in size and depth. 
 
 Appendages op the Skin. 
 
 Next should be considered the action of the bacillus upon the hair 
 follicles, vessels, nerves, epidermis, and sweat glands. 
 
 The bacillus appears to have a special x^redilection to settle about 
 the hair follicles, and perifollicular foci of disease result, with exten- 
 sion of the process through the wall of the follicle. The bacilli are 
 also encountered in the hair papillae, and hair formation is arrested, 
 causing the loss of hair on the surface of the body and especially the 
 falling of the eyebrows. The bacilli are also found in the sebaceous 
 glands which communicate by their excretory ducts with the hair fol- 
 licles. It results from this disposition that the bacilli situated in the 
 sebaceous glands, in the hair papillas, and in the sheath of the fol- 
 licle may migrate along the follicle and thereby reach the free surface 
 of the skin. It is possible that they may penetrate the skin from the 
 
PATHOLOGY OF TUBERCULAR LEPROSY. 549 
 
 outside by the same channels. The follicle is very little altered by 
 the disease, but its epithelia show slight proliferation, which accords 
 with the action of the bacilli upon other epithelial tissue. The bacilli 
 are not invariably found in the hair follicles or the sebaceous glands 
 in connection with them ; Cornil and Babes, indeed, say that they are 
 encountered there but rarely. With regard to the sebaceous glands 
 in general, the epithelia at first proliferate, but the glands are ulti- 
 mately destroyed. Bacilli are not found in the interior of the sudo- 
 riparous glands. 
 
 Aside from the phenomena of essential nerve leprosy, the terminal 
 nerve fibres within the skin, being an integral part of the latter, un- 
 dergo special alterations during the general infiltration of tubercular 
 leprosy. These terminal nerves are, like the hair follicles, predilec- 
 tion tissues of the bacillus. Both afferent and effereiit nerves and 
 Pacinian corpuscles are attacked and at times undergo remarkable 
 changes, the smallest fibres becoming thick cellular cords, and all 
 these structures show an invasion of bacilli with new formation of 
 connective tissue and blood-vessels and degeneration of the essential 
 nerve substance with occasional regeneration. In mixed leprosy these 
 phenomena are associated with secondary changes in the terminal 
 nerves due to disease of the parent trunk. 
 
 When the bacilli reach the epidermis and attack it directly, we 
 have, according to Babes, proliferation of the keratogenous cells alone 
 or of the mucoiDapillary layer. In the former case leprous tylosis 
 results, and in the latter leprous warts develop. 
 
 Still more remarkable is the action of the bacillus upon the sweat 
 glands. Side by side with proliferation of the interstitial connective- 
 tissue stroma of the gland we see new formation of the glandular epi- 
 thelia, and we are therefore justified in speaking of leprous adenoma 
 or adenoleproma. The fact that the bacillus is able to cause prolifera- 
 tion of all epithelial tissues, as well as of the fibrous tissues, seems 
 to justify the claim that the action of the bacillus in a leper may be 
 sufficient to cause epithelioma, which is occasionally observed. 
 
 It is thus seen that, while the maximum intensity of the toxins 
 tends to cause destructive lesions through terminal necrosis of the in- 
 filtration leading to ulceration, every variety of constructive lesion 
 may coexist, due to proliferation of most of the anatomical elements 
 of the skin. Further, some of the destructive lesions undergo partial 
 repair (cicatrization of ulcers, sclerotic changes, regeneration of 
 nerves), and when we add trophic alterations due to disease of the 
 nerve trunks and centres and the results of the action of associated 
 microorganisms (pyo'genic cocci, etc.) it becomes evident that the 
 pathology of cutaneous leprosy is extraordinarily complex. 
 
550 MOKEOW — LEPROSY. 
 
 The Mucous MEiiBRANEs. 
 
 Following the law that the parts most frequently affected are also 
 earliest affected, we must regard the nasal and laryngeal mucosae as 
 specially predisposed to leprosy. The structures about the fauces 
 possess more immunity, and the posterior wall of the pharynx most 
 of all. 
 
 Leprous changes are most characteristically seen in the nasal 
 mucous membranes, and the pathological alterations in these now to 
 be described will apply, with certain modifications due to peculiari- 
 ties of anatomical structure, to the mucosa of the upper air pass- 
 ages. 
 
 Leprosy in this locality is characterized not only by its early and 
 almost constant appearance, but by its very rajjid course, which leads 
 to destructive lesions at a stage when alterations of other tissues of 
 the bod^" are in their formative period. 
 
 Authorities dift'er very widely as to the pathology of nasal lepra, 
 and these differences of oj^inion, taken in conjunction with the recently 
 asserted claims of the existence of primary leprous foci in the nose, 
 tend to give the entire subject a uuiciue irapoi-tance. 
 
 Kaposi regards the pathological alterations in this locality as 
 symptomatic rather than specific. Some regard the specific infiltra- 
 tion as confined to the anterior portion of the nose, and others find it 
 everywhere. 
 
 It has usually been stated that while the cartilages are almost con- 
 stantly attacked the bones are never directly affected, biit Gliick's 
 numerous autopsies show that every bone in the osseous nasal frame- 
 work may suffer directly. The same observer also refutes the preva- 
 lent view that the nose is not affected in anaesthetic leprosy. During 
 the first outbreak of tubercular leprosy anterior rhinoscopy reveals a 
 shining and congested mucous memljrane. As there appears to be 
 a great discrepancy of opinion as to this stage of leprosy, it may be 
 well to follow Babes, who states that the initial manifestations consist 
 of a diffuse and hardly perceptible leprous infiltration i)rincipally 
 affecting the mucosa of the septum and lower turbinate body ; this is 
 accompanied by redness, induration, and increased secretion, and the 
 latter may rapidly dry and contain abundant bacilli. 
 
 As for the subsequent stages of complete infiltration with partial 
 resolution, destructive terminal alterations and collateral attempts at 
 repair, hardly any two authorities draw the same picture. We may 
 feel assured that the early infiltration may vary greatly. The deposit 
 may be miliary or pea-sized, or may even exceptionallj- consist of a 
 
PATHOLOGY OF TUBERCULAR LEPROSY. 551 
 
 single leprous tumor large enough to block the nostril and push the 
 septum over into the ojjposite nasal chamber. This single large 
 leproma is, of course, analogous to the tuberculous tumor described 
 by rhinologists. 
 
 From analogy there can be little doubt that in an organ like the 
 nose there must be two sets of manifestations, one specific and the 
 other symptomatic. With regard to the leprous nodules, if they are 
 small and scattered, it doubtless follows that a certain amount of reso- 
 lution takes place. While the course of leprosy in the nose is acute, 
 authorities appear to agree that leprosy here, as elsewhere, may 
 occur in successive outbreaks, and that the earlier infiltration may 
 be absorbed or may at any rate stop short of ulcerative or retrograde 
 changes. 
 
 During this benign cycle the nasal mucosa can hardly avoid ex- 
 hibiting evidences of symptomatic rhinitis. The localized leprous 
 deposit must certainly be surrounded by areas of simple infiltration 
 with thickening and increased secretion — in a word, hyperplastic 
 rhinitis hardly differing from the same condition as it occurs under 
 very different circumstances; and this hyperplastic stage must inev- 
 itably be followed by induration and sclerotic changes. All this is 
 very obvious from the repeated statements of some authors, that nasal 
 leprosy may occasionallj'- terminate in a general sclerosis of the 
 mucosa, without entering into any ulcerative or destructive lesions. 
 Other authors speak of simple atroph}^ of the turbinates and amplifi- 
 cation of the nasal chambers. In a word, in these benign and self- 
 limited cases we have a picture not unlike ordinary hyperplastic and 
 atrophic rhinitis. It is probable that this condition is exceptional, 
 for a number of authorities do not describe it. The course of nasal 
 leprosy being acute and quasimalignant as a rule, it is evident that 
 the leprous infiltration tends to be extensive and that the specific 
 manifestations usually predominate over the symptomatic. We may 
 assume that the leprous nodules are prone to excoriation and later 
 to ulceration, and that there is a discharge which is largely derived 
 from these excoriated or ulcerated surfaces, and w^hich may tend to 
 form bloody, adherent crusts, which may occlude the nostrils and be 
 detaclied with difficulty, or may occasionally flow from the nose. 
 One of the results of this stage or degree of leprous rhinitis which is 
 generally spoken of is the destruction of the columnar epithelia of 
 thelia of the nasal mucosa ; and after this stage of the disease, no 
 matter to what further length it proceeds, the lining membrane un- 
 dergoes a so-called "cutisation" which is almost universally men- 
 tioned in describing the nose in cases of inveterate leprosy — the 
 membrane taking on the appearances of the skin. 
 
552 MORROW — LEPROSY. 
 
 This "cutisation" inaj not differ esseutiallj' from the sclerosis 
 which has been mentioned as accompanying a relatively benign termi- 
 nation of the disease in so far that both processes involve a transfor- 
 mation of the columnar epithelial elements into the squamous form ; 
 but the former seems to result purely from specific changes and to 
 accompany every case of inveterate leprosy, whereas the other process 
 does not differ materially from that observed to follow simple hyper- 
 plastic rhinitis followed by sclerotic changes, and is evidently of 
 exceptional occurrence. 
 
 Given that sooner or later in the typical case the nasal mucosa is 
 largely occupied by a diffuse granulomatous infiltration chiefly spe- 
 cific in nature, the terminal lesions of the disease depend wholly upon 
 the i^redominance respectively of the destructive or conservative proc- 
 ess. If the granulation tissue tends to increase with only superficial 
 ulceration, and with more or less cicatricial and sclerotic change, the 
 nasal chambers are gradually occluded by the neoplastic tissue so 
 that the so-called concentric narrowing of the nasal fossae results. 
 Here the mucosa of the septum, floor, and turbinates is equally en- 
 larged and the nasal passage is largely obliterated. The phenomena 
 of concentric narrowing and cutisation are mentioned by authors in 
 large numbers of clinical histories of old leprosy. Another even 
 more characteristic phenomenon has not yet been referred to, viz., 
 absorption of more or less of the septal cartilage, which is extremely 
 common. While this may be due also to other causes, it undoubtedly 
 is often due to pressure upon both sides by the fungatiug granulo- 
 matous mass which has infiltrated the mucosa. Atresia of the nostril 
 may be brought about in a manner similar to occlusion of the nasal 
 fossae, and it appears that all the foregoing changes of concentric nar- 
 rowing, occlusion of the nostril, absorption of the septal cartilage, 
 cutisation, etc., may occur without previous extensive ulceration, 
 which latter phenomenon is somewhat less typical. 
 
 While a moderate degree of ulceration is sufficient to perforate 
 the septum in many cases when the disease is by no means far ad- 
 vanced, these shallow ulcers which often heal over would not mate- 
 rially alter the picture which has already been described. More ex- 
 tensive forms of ulceration, however, occur at times, the ulcers being 
 larger and deeper, and under these circumstances the turbinated 
 bones maj' be destroyed outright, and extensive destruction of any of 
 the hard and soft parts may result ; and when these large and deep 
 ulcers cicatrize, we may have deformity of the nostrils or adhesions 
 between the outer and inner walls of the nasal fossae. 
 
 All these tj-pes of advanced lesions of the inner aspect of the nose 
 have their counterpart in infiltrating and destructive lesions of the 
 
PATHOLOGY OF TUBERCULAR LEPROSY. 553 
 
 outer nose ; Gliick lias described and illustrated several types of de- 
 formity due to botli external and internal lesions: the nose may be 
 twisted to one side, it may be flattened like tlie negro nose, or it may 
 overliang tlie upper lip. 
 
 The Internal Organs. 
 
 Lymioh Ganglia. — The cervical, axillary, and inguinal glands are 
 most commonly affected, with occasionally the visceral (mediastinal 
 and retroperitoneal). The ganglia are enlarged and show cheesy or 
 hyaline foci, and in old cases chalky deposits with sclerotic changes. 
 The adenoid tissue wholly disappears. 
 
 Blood-vessels. — Peri- and endoarteritis and phlebitis occur, with 
 resulting narrowing of the lumen and at times thrombosis. These 
 changes are usually due to the proximity of leprous foci, but the fact 
 that vessels become leprous when no such foci are near appears to 
 show that metastases must occur through the circulation. Gliick has 
 called attention to the lesions of the large subcutaneous veins, which 
 he declares are by no means rare. Leprous phlebitis is manifest in 
 the form of a nodose tract, distinctly limited, sometimes without 
 any connection with neighboring tubercles, occupying any portion of 
 the vein which may be healthy above or below; sometimes a series 
 of nodose lesions may be observed u^Don the same vein. Upon histo- 
 logical examination after excision, there are found thickening of the 
 adventitia, with infiltration of small cells in the muscular coat, and 
 considerable thickening of the endo-vein wdth new formation of the 
 capillaries. In all the tumors, and even in the endothelium, bacilli 
 are abundantly present with their characteristic disposition. Gliick 
 contends that the bacilli may penetrate the walls of the vessels from 
 without. 
 
 Spleen. — Bacilli are always present here, even when no pathologi- 
 cal changes are evident. When the spleen is structurally altered the 
 lesions are analogous to those observed in the lymph ganglia. Joseph 
 found large quantities of bacilli in the spleen in cases in which the 
 most minute research could not detect them in the liver, kidneys, or 
 other viscera. He suggests a relation between the abundant pres- 
 ence of the bacilli in this organ and its function in the formation of 
 blood. 
 
 Bone llarroiv. — The fatty tissue disappears and the marrow be- 
 comes firm and takes on the appearance of hsematopoiesis. Hsemato- 
 blasts, new-formed capillaries, nucleated red blood corpuscles, prolif- 
 eration of large round cells, and myeloplaxes occur. 
 
 Lungs. — The lungs of lepers are either normal or exhibit the 
 
554 MORROW — LEPROSY. 
 
 lesions of tuberculosis. Leprous foci may, however, occasionally 
 occur. They consist of thickening of the interstitial tissue with 
 compression and obliteration of the alveoli. 
 
 Intestine. — The intestinal ulcers often found in leprosy are tuber- 
 culous, but occasionally true leprous lesions have been met with 
 (eroded nodular areas) . Bacilli have been found in ordinary intes- 
 tinal mucus. 
 
 Liver. — In the liver we get increase in the volume of the intersti- 
 tial tissue, with new formation of the radicles of the bile ducts. 
 Amyloid degeneration has occasionally been recorded. 
 
 Kidneys. — Bacilli have been foimd in the tumefied endothelium of 
 the vessels of the kidney, especially in the glomeruli and also in the 
 suprarenal bodies. 
 
 Babes has found the bacillus in the brain, pancreas, hypophysis 
 cerebri, thyroid, prostate, and in tissues which were apparently alto- 
 gether healthy. 
 
 Female Breast. — In tubercular leprosy the bacillus has been found 
 in the milk. In cutaneous lepros}^ the infiltration extends inwards 
 along the ducts, and often penetrates the membrana propria and 
 epithelial layer. Bacilli have been found free in the acini and 
 ducts. 
 
 Testicle. — This is a locality of early and constant implication. 
 The gland is often affected when apparently normal, and its fnuction 
 may be compromised or entirely destroyed during the first or second 
 year of the disease. In a typical case the changes are chiefly inter- 
 stitial — proliferation of the intercanalicular septa and membrana 
 propria, with resulting compression of the canaliculi. Necrotic foci 
 may appear in the infiltration. The cord remains intact for a long 
 time. 
 
 Ovaries. — Bacilli have been found, but not under such circum- 
 stances that sexual infection could be assumed. There are but few 
 bacilli to be found and few anatomical changes. 
 
 Anaesthetic Leprosy. 
 
 The appearance of the nerves in leprosy varies extremeh' accord- 
 ing to the kind of leprosy, stage of the disease, and size of the nerve 
 invaded. Even in ordinary leprosy of the skin, when the terminal 
 nerves are involved as part of the general infiltration, bacilli may be 
 found higher up in the course of the nervo trunks, while in certain 
 infiltrated patches of skin the bacilli and neoplastic tissue may be 
 confined to the skin and their immediate periphery. 
 
PATHOLOGY OF AX^STHETIO LEPEOST. 655 
 
 The diseased nerves appear greatly tliickened, both the peri- and 
 endoneurium having undergone proliferation. This infiltration is 
 characterized by the presence of large, round, or elongated cells, con- 
 taining the bacilli more or less abundantly. Between the atrophy- 
 ing nerve fibres or replacing them are found large fusiform spaces, 
 which are replete with colonies of bacilli. In the smaller peripheral 
 nerves, then, we fijid proliferation of the epi- and endoneurium, with 
 retrograde changes in the nerve fibres. 
 
 In the large trunks, such as the median, we find proliferative 
 changes in the epineuiium, in the connective-tissue septa, between 
 the bundles of nerve fibres, and, finally, in the special investment of 
 individual fibrillfe. The cellular elements arise chiefly from the endo- 
 thelia of the vessels and fixed connective-tissue cells. The bacilli in 
 the nerves lie between rather than within the cells, and may be found 
 within Schwann's sheath. The nerve elements proper show numer- 
 ous retrograde changes. 
 
 Spbwl and Sympathetic Ganglia. — Bacilli occur within the large 
 cells of the spinal ganglia, lying within vacuoles. They are less 
 numerous in the sympathetic ganglia. Nearly all the bacilli lie 
 within the cells, but in certain cases the capsule and interstitial con- 
 nective tissue are affected, and the ganglia in these cases are thick- 
 ened. A remarkable fact is that the nerve fibres which are continu- 
 ous with the ganglia as well as the blood-vessels appear to be free from 
 bacilli. 
 
 Spinal Cord. — Single bacilli may occur in perfectly normal gan- 
 glionic cells ; eventually they lead to disappearance of the chromatic 
 substance and pigment, and of the nucleus itself. Vacuolization is 
 general throughout the cell. 
 
 The presence of bacilli in the cord is not known to cause any spe- 
 cial symptoms. Babes found bacilli in the cord in nine cases, three 
 times in the anterior horns ; in pure lepra nervosa the bacilli have 
 never been found in the cord. On the other hand, the spinal ganglia 
 are almost invariably implicated in nerve lepra. Owing to the exten- 
 sive implication of the peripheral nerves, it is difficult to determine 
 the influence, if any, of ganglionic leprosy. The presence of bacilli 
 in the spinal cord has naturally an important bearing in connection 
 with the origin of syringomyelia and also in the interpretation of 
 the pathogeny of the habitual symmetry of anaesthesia and the amyo- 
 trophic disorders of leprosy. 
 
 Jeanselme, in two out of five autopsies, found a pronounced 
 degeneration of the posterior column, and in one of the cases similar 
 changes in one of the lateral columns. The topographic disposition 
 explains, he thinks, certain tabetiform troubles which havo been 
 
556 MORROW— LEPROSY. 
 
 observed in leprosy. The whole question of the relations of the lep- 
 rous process to disorders of the central nervous system is unsettled 
 and involved in much obscurity. There is a marked divergence of 
 opinion between histologists as to the interpretation of the nervous 
 manifestations. Dehio, Looft, and others claim that the nerves are 
 always invaded by their peripheral extremities, and that their infec- 
 tion as well as their degeneration always follows a centripetal course, 
 with successive imi)lication of the motor and sensory collateral 
 branches. Darier has suggested the probability that the patho- 
 genic process is not the same in all cases — that sometimes the centres, 
 sometimes the peripheral nerves may be primarily invaded by the 
 bacillary proliferation. 
 
 DIAGNOSIS. 
 
 A retrospective diagnosis of the diseases formerly classed as 
 leprosy would show that a vast number of ordinary dermatoses were 
 included in this category. In the light of our present knowledge it 
 would appear that the leprosy of Mosaic times embraced vitiligo, 
 psoriasis, scabies, certain forms of eczema, and perhaps other dis- 
 eases. 
 
 In the Middle Ages the greatest chaos and confusion prevailed in 
 the classification of diseases of the skin. On account of the vague- 
 ness of the terms then used in describing skin diseases, and the dif- 
 ference in the signification attached to them in modern dermatological 
 nomenclature, it would be impossible to indicate accurately what the 
 leprosy of that period included. It is very jjrobable that the popula- 
 tion of the iiumerous leproseries which were established in various 
 parts of Europe during mediaeval times was largely swollen by the 
 inclusion of a vast number of persons suffering from diseases of the 
 skin of an entirely different character— many of them not in the re- 
 motest degree contagious. It is very certain that manj' types of dis- 
 ease which have recently been recognized as distinct morbid entities 
 were confounded with leprosy, such, for example, as syringomyelia, 
 morphoea, scleroderma, mycosis fungoides, and Raynaud's disease. 
 It is \erj probable that psoriasis, pemphigus, pellagra, scrofula, lu- 
 pus, syphilis, aad other diseases which presented some objective 
 resemblance to lei)rosy were classed with the latter disease. 
 
 One of the most mysterious problems in the history of medicine, 
 which has not yet received a definite solution, was the sudden appari- 
 tion of syphilis in Europe towards the close of the fifteenth century, 
 and the displacement of leprosy by the new disease. There can be 
 no doubt that the multitudinous cutaneous manifestations of syphilis 
 and their similitude to leprosy, a similitude rendered more striking 
 
DIAGNOSIS. 557 
 
 by tlie epidemic violence -with wliicli syphilis then raged, furnished 
 an admirable field for error, and that syphilitics contributed a large 
 contingent to the resident population of the leper houses. Guy 
 Patin tells us that at the beginning of the sixteenth century "the 
 leproseries were filled with syphilitics." The extent to which leprosy 
 prevailed in Europe during the Middle Ages and the actual number 
 of lepers imprisoned in the nineteen thousand leper houses were 
 doubtless magnified by the indiscriminate segregation of all per- 
 sons whose symptoms bore any resemblance to those of leprosy. 
 
 The clinical picture of leprosy which is drawn by text-book writers 
 of the present day is that of a disease which is as readily recognizable 
 by its typical features as it is repulsive by its hideous deformity. 
 This common conception is derived from examples or representations 
 of the disease in its fully developed or final stage. With its initial 
 manifestations and the varied phenomena exhibited in the earlier stage 
 of its evolution, few medical men except those resident in leprous 
 countries are familiar. While it is undoubtedly true that the clinical 
 features of a case of tubercular leprosy, typical in its development 
 and advanced in its evolution, are so striking and characteristic as to 
 be absolutely pathognomonic, it is equalh^ true' that in its earlier 
 stages, and even in fully developed cases with atypical manifestations, 
 there is no disease in the entire domain of pathology more difficult 
 of recognition. 
 
 This observation applies with still more force to anaesthetic lep- 
 rosy. Reference has already been made to many forms of disease 
 which have but recently been recognized as distinct types, but which 
 imitate the phenomena of nerve leprosy so accurately that the differ- 
 entiation cannot always be established from the objective characters 
 or the sensory disorders. This similitude is so marked that certain 
 leprologists maintain that these diseases are survivals of leprosy and 
 represent abortive or degraded forms of the disease. Even so distin- 
 guished an authority as Erasmus Wilson declared in 1862 that the 
 various forms of morphoea and alopecia areata are manifestations of 
 leprosy. Kaposi also describes morphoea as a form of macular 
 leprosy. Eastlander regards mal perforant as the last vestige of lep- 
 rosy in France. 
 
 The difficulties which attend the diagnosis of leprosy depend upon 
 its prolonged period of incubation, the absence of any initial lesion 
 that might connect it with a known exposure, the indeterminate char- 
 acter of its prodromal symptoms, and finally the multiplicity and 
 banality of its manifestations. The fact that leprosy is essentially a 
 proteiform malady is not sufficiently appreciated. While syphilis 
 may surpass it in the number and variety of its eruptive elements, 
 
568 MORROW — LEPROSY. 
 
 the cutaneous manifestations of leprosy most accuratel}' imitate 
 many of the ordinary dermatoses. This imitation is carried into the 
 realm of neuropathology, nerve leprosy simulating most decej)- 
 tively the manifold forms of neuritis of toxic, traumatic, and con- 
 stitutional origin. 
 
 The earh- manifestations of leprosy, unlike those of syphilis, are 
 in no sense peculiar to the leprous process. There is nothing regular 
 in their mode of evolution, nothing constant in their appearance, 
 nothing distinctive in their morjihological characters. They are so 
 variable, uncharacteristic, and absolutely indefinite that they would 
 never be ascribed to leprosj' in any country where the disease was 
 not endemic, or where there were not decided reasons for suspecting 
 its presence. This emphasizes what may be considered a point of 
 cardinal importance in the diagnosis of leprosy. Since leprosy is 
 exclusively human in its origin, the history of known contact with a 
 leper or residence in a leprous country is of the greatest diagnostic 
 worth. 
 
 Obvioush' enough the difficulties of diagnosis are increased in 
 non-leprous countries where an opinion must be based upon the 
 objective characters alone and where the absence of a history of 
 known exposure withholds the necessary confirmation of its correct- 
 ness. This fact has been forcibly impressed upon me in the case of 
 the patient pictured in Fig. 11, in which there was no clear history of 
 exposure. The attending physician, Dr. MacDougall, in sending the 
 additional notes of the case, remarks : " In connection with the diag- 
 nosis of these cases I am inclined to believe that some censure is due 
 leprologists for their positive statements that the manifestations of 
 the disease, when at all advanced, are so characteristic that there can 
 be no mistake." 
 
 Incidentally it may be said that a picture of these patients was sub- 
 mitted to a number of si^ecialists in skin diseases, none of whom 
 would admit the diagnosis of leprosy because there was no clear his- 
 tory of exposure, and yet if they had lived in a lej^rous country there 
 could have been little doubt as to the nature of the trouble. 
 
 Erasmus Wilson cites a case of a medical man in the Indian army, 
 himself a leper, but who with other medical men in India regarded 
 his case as syphilis. A case of Hutchinson was treated for several 
 years for rheumatic gout. The man had j)ricking pains in the fingers, 
 as well as numbness and insensibility, and was unable to write. 
 Another of Hutchinson's patients was treated for two years by nerve 
 specialists for paralysis affecting the ulnar nerve. 
 
 Thin cites numerous examples of cases erroneously diagnosed 
 by observers experienced in dermatology; for example, that of 
 
DIAGNOSIS. 559 
 
 a patient with a well-developed nerve leprosy, wlio was sent liome 
 from India as a case of lupus erythematosus; two other cases in 
 which typical anaesthetic patches with pigmentary changes were 
 wrongly diagnosticated. 
 
 A case of Abraham was for a long time confounded with carcinoma. 
 
 Instances might be multiplied of cases of leprosy which exhibited 
 sensory and even advanced trophic changes, the nature of which was 
 unrecognized. A patient of mine was for several months under the 
 care of one of the most distinguished leprologists of Europe without 
 his suspecting the nature of the disease, until his perceptions were 
 quickened by accidentally learning of the patient's former residence 
 in a leprous country. 
 
 Mistakes in diagnosis are by no means confined to physicians in 
 non-leprous countries. Even so competent a clinician as Beaven 
 Rake, whose long residence in Trinidad made him familiar with every 
 possible feature of the disease, reports a case in which leprosy was by 
 him mistaken for syphilis, an error which was confirmed by the tem- 
 porary disappearance of the tubercles under mercury, but which was 
 connected by the subsequent redevelopment of the tubercles with other 
 unmistakable signs of leprosy. 
 
 In attending numerous examinations of persons arrested as lepers 
 in the Hawaiian Islands and sent to Honolulu to be examined by the 
 examining board, I was impressed by the large proportion of cases 
 placed in the category of " suspects," embracing those presenting sus- 
 picious symptoms, but in whom evidences of the disease were not 
 sufficiently clear and unequivocal to warrant their consignment to the 
 leper settlement of Molokai. Although the examining board was 
 made up of physicians presumably familiar with every phase of the 
 disease and who were especially selected for their diagnostic ability, 
 there was in many cases much confusion as to the nature of the erup- 
 tion, especially when in the early erythematous stage. There is no 
 doubt that it requires a nice judgment and a thorough acquaintance 
 with the incipient evidences of the disease to discriminate between 
 leprous macules and an erythematous eruption due to other causes. 
 Notwithstanding the precautions taken to avoid an erroneous diag- 
 nosis it frequently happened that persons were wrongly declared 
 lepers, and in order to rectify possibly unjust sentences a medical 
 commission was appointed by the board of health to visit the leper 
 settlement at stated intervals and reexamine persons enrolled on the 
 list of lepers who claimed that they did not have the disease. 
 
560 MORROW — LEPROSY. 
 
 Tubercular Form. 
 
 The prodromal symptoms which precede the eruptive stage of the 
 tubercular form possess but little diagnostic value. Similar symp- 
 toms may be present in the secondary incubation of syphilis or other 
 infectious diseases. The initial pyrexial symptoms present nothing 
 distinctive. The attacks of fever succeeded by profuse perspiration 
 are frequently mistaken for ague. If the fever be followed by an 
 erythematous eruption which tends to become j&xed, suspicion should 
 be excited, especially in a country where leprosy is prevalent. The 
 significance of other prodromal symptoms, as epistaxis, cephalalgia, 
 general malaise, etc., is seldom recognized until objective signs of the 
 disease are manifest, and then they are, of course, valuable as a retro- 
 apective aid in diagnosis. The sensory disorders which form so val- 
 uable an element in the diagnosis of anaesthetic leprosy frequently fail 
 in the tubercular form, and their presence or absence may be disre- 
 garded. Among the diseases with which the tubercular form of lep- 
 rosy may be confounded are certain dermatoses of the erythematous 
 type, various pigmentary afi'ections of the skin, acne indurata and 
 rosacea, sycosis, erythema nodosum, moUuscum, psoriasis, syphilis, 
 lupus, mycosis fuugoides, etc. 
 
 Erythema. — The macular lesions which ordinarily constitute the 
 first cutaneous manifestations of leprosy present nothing absolutely 
 distinctive either in their objective characters or course. Leprous 
 roseola at its first apjiearance may be mistaken for a variety of simi:)le 
 erythematous eruptions. Lailler, one of the most experienced French 
 dermatologists, says that he has mistaken a case of leprous erythema 
 for the erythema produced by the ingestion of strawberries. The 
 error was cleared up only by the persistence of the eruption. 
 
 The §xanthem sometimes resembles that of the eruptive fevers. I 
 have recenth^ seen»a case in which the initial rash had been diagnos- 
 ticated as measles, from which it was differentiated by its persistence. 
 During three years it faded and reappeared a number of times in the 
 form of erythemato-papular lesions before the characteristic tubercu- 
 lation took place. 
 
 Chronic dermatitis is distinguished from leprosy by the more gen- 
 eral and uniform thickening of the skin and the absence of tubercles. 
 
 Parasitic Affections. — Ringworm and chromophytosis may be mis- 
 taken for leprous spots. In tropical countries, as in Hawaii, para- 
 sitic skin affections often exhibit a luxuriant development i^nknown iu 
 cold or in temperate climates. Not infrequently parasitic diseases 
 coexist with leprosy and may mask the manifestations of the latter 
 
DIAGNOSIS. 561 
 
 disease. An examination of the scales and scrapings will always 
 identify tlie parasites if present. 
 
 Acne Indurata and Rosacea. — Hebra instances cases in whicli lep- 
 rosy has been mistaken for these forms of skin affection. Impey, who 
 has had large opportunities of studying the clinical aspects of leprosy 
 in South Africa, says : " I know of no other disease which may be so 
 readily mistaken for leprosy as rosacea. " The eruption of gutta rosea 
 is to be distinguished by its localization on the chin, cheeks, and nose 
 and the exemption of the eyebrows. In rosacea there is a more uni- 
 form thickening of the skin over a large area — the color of the erup- 
 tion is more uniform than in leprous erythema, the hairs are not lost, 
 and the scales are more abundant. In leprous erythema there are no 
 enlarged vessels to be seen, the color of the patch is of a darker hue 
 in the centre and gradually fades into the surrounding skin, the hairs 
 are soon lost from the leprous patch. 
 
 Sycosis is another affection of the face for which leprosy may be 
 mistaken when the tubercles are limited to the hairy parts of the face. 
 
 Liclien Planus. — When the neoplasms are small, flattened, and 
 closely aggregated tubercular leprosy has been confounded with lichen 
 planus. 
 
 Molluscum Fibrosum. — One of my colleagues in New York ex- 
 hibited a case in which leprous nodules had been mistaken for the 
 tumors of molluscum. 
 
 Keloid has been confounded with leprosy. It is to be distinguished 
 by its hard, fibrous base, its resemblance to a cicatrix, and other ob- 
 jective characters, besides being commonly unilateral. 
 
 Erythema Nodosum.— \^\ien the nodules are situated along the ex- 
 ternal malleolus and the front of the leg, they bear a most deceptive 
 resemblance to the nodules of erythema nodosum. Leloir mentions 
 cases in which the size, shape, and disposition of the lepromata were 
 strikingly suggestive of this disease. The more or less rapid involu- 
 tionary changes of the nodules in the latter disease would, of course, 
 soon clear up the diagnosis. 
 
 Psoriasis was at one time considered a form of leprosy. It may 
 be admitted that there was perhaps a superficial basis for this erro- 
 neous view in the objective resemblance between psoriasis gyrata and 
 the circinate lesions of leprosy. The tendency of psoriatic patches 
 to enlarge peripherally and form by their confluence circular and 
 gyrate forms gives them a configuration not unlike the circinate and 
 concentric bands, especially seen in the anaesthetic form of the disease. 
 Circinate psoriasis is, however, readily differentiated by its tendency 
 to epidermic proliferation in white or grayish scales, distinctly imbri- 
 cated, which, when removed, show a well-defined infiltration elevated 
 Vol. XVIII.— 36 
 
562 MORROW — LEPROSY. 
 
 at the border, depressed in the centre, with a hypersemic, readily 
 bleeding surface. From the exceeding commonness of psoriasis in all 
 countries and in all ages, it is evident that sufferers from this disease 
 must have figured largely in the population of leper houses. 
 
 Syphilis. — The old view that "syphilis was the daughter of lep- 
 rosy," which was based ui)on the fact that an ei)idenuc of syi^hilis 
 made its appearance at a period corresponding to tlie decline of 
 leprosy in Europe, has been long exploded. We now recognize that 
 the relation was coincidental rather than causal, and that each is a 
 disease sui generis. That they are totally unrelated to each other is 
 proven by the independent development and coexistence of the two 
 morbid states in the same j:>atient, each running its own course. 
 That " leprosy is more common in the children of syphilitic parents," 
 as has been maintained by many authorities, may be admitted on the 
 ground that a native debilit}' in the offspring of syphilitics, like any 
 other ancestral cause of weakening, may predispose to leprosy. 
 
 Syphilis presents many clinical analogies with leprosy, both in the 
 polymorphous character of its manifestations and their mode of evo- 
 lution. In both, the general accidents develop after a i)rolonged 
 period of incubation. Syphilitic roseola has its analogue in leprous 
 erythema ; syphilitic pigmentation in the pigment spots of leprosy ; 
 syphilitic alopecia in the alopecia of leprosy. The papules and tu- 
 bercles of syphilis have their counterpart in the dermic and hypoder- 
 mic nodules of leprosy. In both, the neoplasms follow a similar 
 course of involution ; they maj^ undergo resorption, or they may soften 
 and suppurate and disappear by a process of ulceration, sometimes 
 involving extensive surfaces and leaving characteristic cicatrices. 
 Their points of dissimilarity are, however, too numerous and obvious 
 to merit mention. 
 
 The erythematous syphilide maj- be distinguished from leprous 
 erythema by the smaller size and fainter coloration of the lesions, 
 their absence from the face and limitation to i^arts habitually covered 
 by the clothing, and their more rapid disappearance. The er3'them- 
 atous patches of leprosy are larger, more diffuse, and more perma- 
 nent. The pigmentations of leprosy are readily distinguished from 
 the posthumous iDigmentations of syphilitic infiltrations. The len- 
 ticular tubercles of leprosy, when they are disseminate, small, slighth' 
 elevated, with moderate desquamation, may resemble absolutely a 
 papular syphiloderm. It is, however, the tubercular form of syphilis 
 which bears the most deceptive resemblance to leprosy. 
 
 The clinical features of the case of tubercular leprosy represented in 
 Fig. 3, are seen to simulate almost accurately a tubercular syphilide. 
 The syphilitic nodules are more circular in outline, more reddish- 
 
DIAGNOSIS. * 563 
 
 brown or coppery in color, more apt to be grouped in circular and 
 crescentic forms, and more rapid in involution. TLe ulcerations of 
 sypliilis are more rounded, less circumscribed in extent, tlie crusts 
 are thicker, liarder, and of a brownisli, blackish, or greenish tint. 
 Leprous ulcerations progress more slowly than those of syphilis, and 
 they do not present a serpiginous mode of extension. The extensive 
 superficial infiltrations of leprosy are not seen in syphilis. Leprous 
 neoplasms are larger in volume, more protuberant, and crowded upon 
 an infiltrated base, with oedema of the skin and ganglionic enlarge- 
 ments. Their seats of predilection are the facial mask, the lobes of 
 the ears, backs of the hands, and forearms, more rarely disseminated, 
 while the nodules of syphilis are indiscriminate in their location and 
 may come where leprous tubercles rarely or never appes.r. The leon- 
 tiasis of leprosy is much more pronounced than that of sj' philis. The 
 enormous nodular masses, the deep orbital and supraorbital furrows, 
 the pillowy-like protuberances of the cheeks, with loss of the eye- 
 brows, are never observed in syphilis. Still, in many cases of less 
 exaggerated development the facies of leprosy may simulate most 
 closely that of syphilis. 
 
 Lupus Vulgaris. — This form of cutaneous tuberculosis shares with 
 leprosy the j^athological peculiarities of cell infiltration of the connec- 
 tive tissues of the skin, followed by disintegration of the morbid 
 products and ulceration. Leprosy maj' be mistaken for lupus vul- 
 garis, especially when the leprous lesions consist of small brownish- 
 red tubercles grouped upon a reddened infiltrated base and localized 
 upon the cheeks and face ; the frequent involvement of the lobe of the 
 ear in lupus heightens the similitude. Lupus is distinguished b}^ its 
 occurrence in the form of isolated patches and its more limited locali- 
 zation; it is commonly unilateral and not accompanied by disorders 
 of sensation. In all doubtful cases of tubercular leprosy the demon- 
 strable presence of the bacilli in the tissues or liquid exudates estab- 
 lishes the diagnosis. 
 
 Lupus erythematosus may also be mistaken for leprosy. I have 
 been consulted by a leprous patient, the right side of whose forehead 
 and cheek was occupied by slightly raised erythematous patches of a 
 sombre red color simulating perfectly lupus erythematosus. The lat- 
 ter disease may be usually distinguished by the configuration of the 
 patches which often assume a butterfly shape, by the central depres- 
 sion of the plaque and the greasy adherent scales which often dip down 
 into the follicles, and by its limitation, as a rule, to the face. 
 
 Blycosis Fangoides. ^On account of the numerous and marked 
 analogies between this disease and leprosy in their evolutionary mode 
 and the objective character of their phenomena, mycosis fungoides 
 
564 * MORROW — LEPROSY. 
 
 has been not inaptly designated by Bazin as indigenous leprosy. Both 
 diseases are characterized by an eruption of erythematous spots or 
 patches, which may appear and recede a number of times before be- 
 coming permanent. These patches are the seat of the neoplastic for- 
 mations i)eculiar to each disease. 
 
 In the premycosic stage the efflorescences are at first transitory, but 
 they grow more and more persistent until they become permanently 
 established under the form of reddish, slightly scaly, or lichenoid 
 plaques. After the lapse of time more or less variable these plaques 
 become the seat of red or violaceous tumors, isolated or grouped, 
 which may remain stationary, undergo involution by a process of 
 resorption and become effaced without leaving a trace, or break 
 down and become fungous and ulcerating. A further similitude to 
 leprosy may be noted in the sensory disorders which are frequently 
 manifest. The surface sensibility is sometimes markedly diminished, 
 the hairs may become atrophied and disappear ; the lymphatic glands 
 become tumefied and swollen. Both diseases almost invariably pro- 
 gress to a fatal termination. The resemblance to leprosy is most 
 marked when the lesions of mycosis are localized upon the face. As 
 differential jooints may be mentioned the constant and intolerable 
 pruritus of mycosis, which is almost invariably present. In the 
 tumor stage the soft, dough-like masses with their fungating, tomato- 
 like ax)pearance present a picture unlike that of leprosy. The pres- 
 ence or absence of the bacillus leprae will set aside all doubt as to the 
 diagnosis. 
 
 31uUipIe sarcomata have been mistaken for leprosy. The develop- 
 ment of these tumors is rarely preceded by the appearance of ery- 
 thematous patches, and their localization is different. 
 
 Alopecia. — The alopecia of leprosy is characterized by the atrophy 
 and disappearance of the eyebrows and lashes, the vibrissse, and the 
 hairs from other portions of the body the seat of leprous lesions, 
 while the hair of the scalp is not much affected. 
 
 Leprosy op the Mucuous Membranes. 
 
 A new and unique interest has been given to the diagnosis of lep- 
 rosy of the nasal mucous membranes owing to the now generally 
 recognized precocity of their appearance. Leprosy in the early stage 
 often simulates catarrhal inflammation of the nose. Since leprous 
 rhinitis is dependent upon the presence and local action of the bacilli 
 upon the Schneiderian membrane, the diagnosis may be established 
 by bacteriological examination of the nasal secretions which, espe- 
 cially in the tubercular form, contain them in large numbers. Epi- 
 
DIAGNOSIS. 565 
 
 staxis is a more constant accompaniment of tlie leprous process than 
 of an ordinary rhinitis. 
 
 The diseases affecting the mucous membranes of the mouth, nose, 
 and throat which may be confounded with leprosy in a more advanced 
 stage are few. They all belong to infectious diseases of the granu- 
 loma type, and while offering a great similarity of aspect, they are 
 distinguished by certain special characters. 
 
 Syphilis. — Syphilitic infiltrations of the nasal mucous membranes 
 bear a deceptive resemblance to those of leprosy. They affect the 
 framework of the nose and are often followed by extensive destruc- 
 tion of the tissues and resulting deformities. S^^philis is, however, 
 more liable to attack the osseous framework of the nose, producing a 
 sinking in or falling of the bridge of the nose. The deformation of 
 the nose in leprosy is commonly due to a destruction of the cartilag- 
 inous septum which leads to flattening and broadening of the alse, 
 which fall and become spread out from the loss of natural support. 
 Syphilis may also occasion destruction of the septum. 
 
 A rhinoscopic examination of the leprous nose in the tubercular 
 form will reveal the presence of small tubercles disseminated upon 
 the septum, sometimes over the turbinated bones, with ulceration. 
 The presence of anaesthesia also serves to indicate the leprous nature 
 of the changes. 
 
 The syphilitic affections of the tongue, the buccopharyngeal cav- 
 ity, and the larynx often bear a deceptive resemblance to those of 
 leprosy. Leloir has called attention to the occurrence of forms of 
 leprous glossitis which recall similarly appearing sclerogummatous 
 infiltrations of syphilis. 
 
 Leprosy of the mouth and throat exhibits in the localization and 
 size of the tubercles, which are usually small and disseminate, certain 
 objective characters not seen in syphilis. The ulcerations of syphilis 
 are more profound and extensively destructive and the ulcerative proc- 
 ess is more acute. The complete abolition of ordinary sensibility 
 and the conservation of the sense of taste in its integrity are charac- 
 teristic of the leprous process. 
 
 Lupus produces alterations of the nose quite different from those 
 occurring in leprosy. Lupus exhibits a marked tendency to implica- 
 tion of the soft tissues with more or less infiltration and sclerosis. 
 The alas of the nose are nibbled by ulcerations, and the nose itself is 
 shortened and thinned, contrasting with the nose en Im^gnette of lep- 
 rosy. Even when lupus destroys the septum, the sclerosed tissues 
 support the structure and prevent the falling and flattening observed 
 in leprosy. Besides, the lupous process is more chronic and persist- 
 ent in its morbid pertinacity, rarely relaxing its work until the cu- 
 
566 MORROW — LEPROSY. 
 
 taneous covering of the cartilaginous segment of tlie nose is entirely 
 destroye'd. 
 
 Glanders, which is comparatively rare in the human subject, may 
 also simulate leprosy of the mucous membranes in the production of 
 small barley- to pea-sized tubercles, isolated or confluent and dissemi- 
 nated over the cartilaginous septum and the turbinated bones. These 
 may break down and ulcerate with the production of a purulent or 
 mucopurulent secretion. Similar processes may also affect the mu- 
 cous membranes of the eye, the mouth, and the throat. Glanders 
 may always be identified by the presence of the bacillus mallei, which 
 is readily inoculable to animals. 
 
 In the differentiation of leprosy from the above group of diseases, 
 the history, the concomitant evidences of skin trouble peculiar to 
 each disease, and the presence or absence of anaesthesia, which is 
 pathognomonic of leprosy, are usually quite sufficient, independent of 
 a bacteriological examination of the secretions. 
 
 In addition the obstruction of the nostrils, the harsh, raucous, or 
 croaking voice of leprosy, the difficulties of deglutition and respira- 
 tion, and the jieculiar, foul leprous odor exhaled by the breath are 
 all characteristic features. 
 
 The Anesthetic Form. 
 
 The prodromal symptoms are much more variable, but scarcely 
 more characteristic than those of the tubercular form. The sen- 
 sory disorders, hyperaesthesia, formication, pruritus, and sensations 
 of burning and tingling, have little diagnostic value, as they may be 
 present in irritative neuritis from other causes. The pain and motor 
 weakness often present are commonly ascribed to rheumatism or neu- 
 ralgia. At a more advanced stage the presence of anassthesia consti- 
 tutes an almost invaluable diagnostic element as the identification of 
 the bacillus in the tissues is rarely practicable in nerve lepros3\ 
 
 The erythematous spots of the anaesthetic form are characterized 
 by their permanence, their tendency to clear in the centre while spread- 
 ing peripherally, their achromatic changes, and at a more advanced 
 period by their anaesthetic centres. 
 
 Chromophytosis.- — The pigmented spots may be yellowish or fawn 
 colored, giving quite a deceptive resemblance to chromophytosis. 
 The patches of the latter are furfuraceous and may readily be removed. 
 
 EpheJides. — In one of Hutchinson's cases the first S3^mi)toms were 
 large freckles on the forehead, followed by a general exanthem and 
 dulled sensation. 
 
 Chloasma has been confounded with the pigmented patches of 
 
DIAGNOSIS. 567 
 
 leprosy. Quite recently a case came under my observation in wliieli 
 tMs mistake had- been made. 
 
 Pellagra, acrodynia, and chronic ergotism may be mistaken for tke 
 pigmentations of leprosy. In pellagra the brownisb-red, erythem- 
 atous patches, the appearance of bullae, the atrophic changes, and 
 paralysis of the third nerve make up a clinical picture which bears a 
 most deceptive resemblance to certain phases of leprosy. 
 
 Scleroderma and sclerodaciylie , that form of the affection in 
 which the atrophic troubles are limited to the extremities, may be 
 confounded with leprosy. Scleroderma is characterized by indu- 
 ration followed by atrophy of circumscribed portions of the skin 
 which are more or less diffused and symmetrical. The patches are 
 white, often of a yellow or old-ivory color, the secretions of the seba- 
 ceous and sudatory glands are diminished, as in leprosy, and the sen- 
 sibility is first increased and then diminished. Subcutaneous tuber- 
 cles have been observed in a few cases. The objective differences 
 between leprosy and this form of the disease are so marked as scarcely 
 to permit of the possibility of a mistake in diagnosis. 
 
 The trophic changes met with in sclerodaciylie, characterized by 
 distortion of the phalanges, alterations of the nails, and the ulcera- 
 tions which are not uncommon, present a much greater similitude 
 with leprosy. They are to be differentiated by the absence of the 
 concomitant signs of leprosy. 
 
 Morplioea. — Erasmus Wilson describes morphoea alba, lardacea, 
 and nigra as forms of local leprosy. Kaposi has followed his exam- 
 ple in identifying these varieties of morphoea with macular leprosy. 
 While morphoea may present a certain resemblance in color, form, 
 and distribution with the sclerotic patches of leprosy, yet it is readily 
 diff'erentiated. The plaques of morphoea are lardaceous or wax-white 
 in appearance, of a hard, unyielding consistence, and surrounded 
 with a violet or lilac ring which is most characteristic, and in addi- 
 tion the sensory disorders of leprosy are absent. Some three years 
 ago a case of morphoea came under my observation which had been 
 diagnosticated by a number of physicians as indigenous leprosy. 
 
 Vitiligo. — The achromatic spots of nerve leprosy may be mistaken 
 for vitiligo. The patches of vitiligo are of an irregular shape, of a dead- 
 white color, perfectly smooth surface, and with margins convex and 
 clearly defined against the surrounding pigmented border, which has 
 a tendency to spread peripherally. With the exception of the dys- 
 chromia the skin is unaltered in structure and the sensibility is un- 
 changed ; the hairs of the affected surface are often white, but do not 
 fall. In leprous leucoderma, which is most often seen in dark races, 
 the spots are grayish-white and not so sharply defined in contour. 
 
568 MORROW — LEPROSY. 
 
 The skin is altered iu structure with atrophy of its glandular appa- 
 ratus, atroj)hic, depressed, sometimes corrugated, and commonly com- 
 pletely anaesthetic. The hairs are not invariably white and often fall 
 from the patch. The evolutionary mode is entirely different. While 
 the leprous achromatic spots may appear as such from the first, they 
 are ordinarily formed by a pigmented patch becoming white in the 
 centre with coincident loss of sensation. 
 
 Femjjhigus Vulgaris. — The pemphigus blebs which characterize 
 nerve leprosy may be mistaken for pemphigus vulgaris. The bullae 
 of leprosy may be distinguished by their sparser numbers, their more 
 superficial characters, their localization, their tendency to come out 
 in successive crops, their characteristic cicatrices Avhen they become 
 ulcerated, and by the sensory disorders which ordinarily accompany 
 or succeed them. 
 
 In many cases leprosy pursues an anomalous course. The macu- 
 lar, pemphigoid, and other trophic changes may be absent, and motor 
 and sensory disturbances constitute the only manifestations. There 
 are many diseases depending upon lesions of the peripheral nerves 
 and cord the symjitoms of which may be accurately simulated by 
 leprosy. When these neuritic changes are accompanied by tlie pres- 
 ence or history of leprous exanthems, or phenomena of hyperesthesia 
 and anaesthesia, swelling of the nerves, disturbances of the sweat func- 
 tion, leprous coryza, etc. , there is no difficulty in diagnosis ; but when 
 such concomitant evidences fail, and the paralytic and atrophic 
 changes constitute the sole objective signs, remaining stationary and 
 persisting for months or years, the diagnosis may become exceedingly 
 difficult. 
 
 The phenomena of leprous neuritis constitute a distinctive feature 
 of great diagnostic importance. The ulnar nerves are usually pri- 
 marily involved, but not invariably, as affections of the nerves of the 
 legs may be first manifest. In many cases patients complain of 
 numbness and weakness in the muscles of the foot and extensors of 
 the toes, which are due to beginning atrophy of the peronei and ex- 
 tensors. In the majority of cases the ulnars are the first to manifest 
 evidences of inflammatory and degenerative changes accompanied 
 by the atrophic changes in the hands and forearms already described. 
 
 The paralysis may in some cases appear first in the orbicularis 
 palpebrarum and other muscles supplied by the cranial nerves, render- 
 ing it impossible to close the eyes, or the face may be drawn to one 
 side. 
 
 Progressive muscular atrophy may be confounded with leprosy. 
 There is the same wasting of the interossei, of the thenar and hy- 
 pothenar muscles, with paralysis of the extensors resulting in the main 
 
DIAGNOSIS. 569 
 
 en griffe characteristic of leprosy, biit the muscular atrophy is differ- 
 entiated br the absence of anaesthetic patches and thickening of 
 the nerves. 
 
 Paralysis agitans is another affection for which leprosy has been 
 mistaken. Impey mentions a case he found in the leper ward of this 
 form of paralysis. The patient was unable to walk or even leave 
 her chair. Constant friction had caused extensive ulceration of one 
 foot. Both feet were much deformed and the hands were contracted 
 but there were no anaesthetic patches and the eyes were unaffected. 
 
 Multiple neuritis of toxic or malarial origin presents many analo- 
 gies with the earlier stage of anaesthetic leprosy, but is distinguished 
 by its more acute course and the absence of anaesthetic patches. 
 
 Arthritis Defonnans. — The characteristic deformities of the hands 
 and feet caused by chronic rheumatism have been confounded with 
 those of leprosy. This mistake is all the more liable to occur as the 
 muscular pains and other early phenomena of leprosy are often at- 
 tributed to rheumatism. The swollen joints of arthritis do not occur 
 in leprosy, and there is an absence of localized morbid deposits, the 
 changes in leprosy being essentially atrophic. 
 
 Perforating Ulcer. — The plantar ulcer of leprosy beara a most de- 
 ceptive resemblance, both in objective characters and course, to the 
 mal perforant, which may be due to atheromatous changes or of purely 
 nervous origin. In the latter affection the concomitant symptoms of 
 leprosy are absent. 
 
 The lesions of the bones and joints with deformities and mutila- 
 tions which commonly occur in the advanced stage of nerve leprosy 
 can scarcely be confounded with the changes occasioned by other dis- 
 eases. Yet Impey reports that he found in the Eobben Island Asy- 
 lum one patient who had lost his toes from the necrosis of frostbite; 
 another had been sent there because he had lost his feet by gangrene. 
 " The latter patient was kept in the leper asylum for many years with- 
 out any suspicion having apparently been raised as to the true nature 
 of the disease or deformity." 
 
 Syringomyelia. — This disease, which may no longer be considered 
 a pathological rarity, presents the closest clinical analogies with nerve 
 leprosy, and their differentiation may be difficult or impossible. 
 There is such a striking similitude in their course and symptoms that 
 the error of confounding them is almost inevitable in the absence of 
 the prior manifestations and etiological history of leprosy. Leloir 
 and Dejerine have reported cases in which the diagnosis was extremely 
 difficult. It is only in the anaesthetic period of leprosy that confusion 
 is likely to arise. 
 
 The more prominent and distinctive clinical features of syringe- 
 
570 MORROW— LEPROSY. 
 
 myelia may be thus summarized. There is an absence of surface dis- 
 colorations or characteristic spots ou the skin ; a complete integrity of 
 the muscles of the face; a conservation of the integrity of the pilous 
 system; a disassociation of the different modes of sensation; the 
 sensibility to pain, to heat, and cold is abolished, with integrit}^ of 
 the tactile sensations. In addition there is frequently a deviation 
 of the vertebral column. 
 
 In leprosy, tactile sensibility is most frequently abolished ; there 
 are atrophy and paralj^sis of the superficial muscles of the face ; dou- 
 ble paralysis of the orbicular muscles ; thickening of the nerve trunks, 
 especially the ulnars, with nodular swellings ; pigmented or achromatic 
 patches which may be anaesthetic, dystrojihia of the extremities ; spon- 
 taneous loss of the phalanges, alterations or loss of the nails, and alo- 
 pecia. The difficult}' of diagnosis is complicated by the fact that it 
 is not always possible to demonstrate the presence of the bacillus in 
 nerve leprosy. 
 
 While the sensory disorders in leprosj- and syringomyelia present 
 numerous points of resemblance, their distinctive characters have 
 been thus differentiated by Jeanselme : 
 
 "The anaesthesia of leprosy is always symmetric, at first ribbon- 
 like, later segmentary, imperfecth' disassociated and of an intensity 
 gradually decreasing in going from the surface of the skin to the 
 deeper portions and from the free extremity of the limbs to their root. 
 The anaesthesia of syringomyelia is often asymmetric, segmentary 
 from the first, in general perfectly disassociated and separated hj a 
 sharp limitation of the superficial and subjacent sensible regions. 
 
 Finally may be mentioned those atypical forms of the disease in 
 which a deviation from the normal plan of evolution introduces an ele- 
 ment of confusion in diagnosis. While as a rule the lesions of lep- 
 rosy are more or less syinmetrical, cases are met with in which the 
 manifestations are strictly unilateral. I have had under observation 
 a case in which twelve years after infection the only symptoms were 
 dystrophia and anaesthesia of the right hand, forearm, and ankle; 
 another of ten years' duration in which the manifestations were lim- 
 ited to three or four erythematous patches with anaesthetic centres on 
 the left side ; still another of mixed leprosy in which the sole signs of 
 the disease were a single tubercle on the right cheek and anaesthetic 
 changes in the right hand. 
 
 Quite recently I have seen a case in which the erythematous 
 patches were symmetrical, but the trophic changes were absolutely 
 unilateral and limited to complete disorganization of the right ulnar 
 nerve, the parts supplied by which were insensitive to pressure, 
 atrophied, and wasted, and there was a characteristic claw-like defor- 
 
PEOGNOSIS. 571 
 
 mation of the right hand. The left ulnar nerve was apparently 
 normal, and the muscles of the left hand and arm were unaffected. 
 There was no appreciable involvement of the nerves or the muscles 
 of the face. Even the eyelashes were conserved in complete integrity. 
 
 While the cases seen in non-leprous countries are perhaps more 
 apt to exhibit atypical manifestations, yet even in countries where 
 leprosy is endemic the same peculiarity is manifest. In the leper 
 settlement of Molokai, according to Mr. Dutton, " quite a number of 
 cases would never exhibit to an ordinary observer any peculiarit}'^ 
 indicating leprosy in more than one or two phases, as in a hand or 
 foot. Some ot these cases, what we may term localized cases, remain 
 in much the same state — outwardly viewed — for ten years or more." 
 
 From what has been said, it is evident that in countries where 
 leprosy is not endemic, but is only occasionally met with, its diag- 
 nosis is beset with greater difficulties. In such cases an incxuiry into 
 the history and antecedents of the patient may give a clew to the 
 nature of the suspicious symptoms. Possible exposure, either by con- 
 tact with a leper or by residence in a country where leprosy prevails, 
 is, of course, a sine qua non of contagion. 
 
 The modes of infection in leprosy are so many and mysterious 
 that the mere fact of residence in a leprous country, even without 
 known contact with lepers, is sufficient presumptive proof of conta- 
 gious exposure. 
 
 PROGNOSIS. 
 
 The experience of all ages is that leprosy is a practically incurable 
 disease. With rare exceptions it progresses to a fatal termination. 
 The prognosis in a given case is therefore unfavorable. 
 
 As regards the more or less rapid evolution of the disease, the 
 prognosis is influenced by the constitutional vigor of the patient, ex- 
 pressed in the power of resistance of his tissues to the inroads of 
 the bacilli, by climatic conditions and hygienic surroundings. 
 
 There is no infectious disease, of a necessarily fatal character, 
 that is so protracted in its incubation, so mild in its initial manifesta- 
 tions, so prolonged in its exemption from serious accidents, and which 
 grants its victim so long a lease of life as leprosy. Even after the 
 characteristic evidences of the disease are manifest, the patient may 
 live in comparative health for many years, with faculties unimpaired 
 and capacity of usefulness and work practically undiminished. This 
 is especially true of nerve leprosy. 
 
 In anaesthetic cases the entire symptomatology, for five or ten years, 
 or longer, may be limited to a few erythematous patches and occa- 
 sional neuritic pains. I have had under my observation three 
 
572 MORROW — LEPROSY. 
 
 patients with unmistakable signs of anaesthetic leprosy, two of twelve 
 years' duration and one of seven years. In one case there has been a 
 marked retrogression in the sj'mptoms with apj)arent cure; in the 
 other two the symptoms have remained practically stationary. It is a 
 matter of common observation that in countries where the disease is 
 eudemic its course is much more rapid than when the patient is re- 
 moved to a temperate climate where it does not prevail. Whether 
 the abatement is due to the climate, the food, or the changed habits 
 of living, there is commonly observed, for a time at least, an arrest 
 or retrogression of the manifestations. Unfortunately this lull in the 
 manifestations is, as a rule, not of long duration, and after a tempo- 
 rary truce tha force of the disease reasserts itself and the patient 
 finally succumbs. Lepers coming to this country, for example, al- 
 most iuvariabl}^ improve, for a time at least, and the disease pursues 
 a milder and longer course. 
 
 As regards the duration of life, the prognosis is much more unfa- 
 vorable in the tubercular than in the r.nsesthetic form. When there 
 is a transition of one form into another the prognosis is more or less 
 favorable, according as the prominent symptoms of one or the other 
 gain the ascendency. As Leloir somewhat paradoxically johrases it, 
 " the worst that can happen to a trophoneurotic leper is to become a 
 tubercular leper. The best that can happen to a tubercular leper is 
 to become a trophoneurotic leper." 
 
 Abortive Cases. — The occasional occurrence of a spontaneous cure 
 of leprosj' must be considered in connection with i^rognosis. There 
 is a sufficient number of cases on record to prove that the disease 
 may not onh'^ be arrested, but that all evidences of its active existence 
 may definitely disappear. As compared with the vast number of 
 cases that end fatally, the abortive cases are few in number, but in 
 every country where leprosy prevails we have well-authenticated rec- 
 ords of patients who have shown characteristic and unmistakable 
 signs of the disease, experiencing a complete and i:)ermanent cessa- 
 tion of all manifestations. This exemption has been observed to con- 
 tinue for ten, twenty, thirty years, or longer, and the patients finallj' die 
 of some other disease. This spontaneous cure may take place at any 
 period of the disease. Most of the cases reported as cured are ad- 
 vanced in their evolution, and apparently the reparative process takes 
 place after more or less damage to the tissues. 
 
 In a recent communication, Hansen, of Bergen, Norway, states 
 that, of the 8,453 lepers who have been recorded in the leper statistics 
 of Norway, from 1856 to 1895 there are one hundred and twenty-six 
 cases tabulated as being cured. Hansen throws doubt upon the 
 authenticity of cure in some of these cases. 
 
PROGNOSIS. 573 
 
 Thin says : " If a patient loses all symptoms of tubercular leprosy 
 and enjoys good health, but retains some slight symptoms of nerve 
 leprosy of an unprogressive character, the case may be considered as 
 much a case of cure as a case of phthisis in which all symptoms have 
 become arrested, although the patient is left with a patch of fibroid 
 tissue in his lung, in which doubtless the spores of tuberculosis are 
 embedded." Arning reports that he has cognizance of a neurosis, in 
 which the nerves were particularly affected, in which only one or 
 more of the usual symptoms were present and when the condition of 
 the patient would not have excited the slightest suspicion of leprosy 
 in any other than a specialist. Such he regards as instances of abort- 
 ive leprosy. Although such cases are well attested, many medical 
 men, while admitting that the disease is permanently arrested, deny 
 that the patients are cured, insisting that unless it can be proved by 
 microscopical examination that no bacilli exist in any of the tissues 
 of the body the case cannot be pronounced cured. 
 
 Even cases conforming to this crucial test are not wanting. Hal- 
 lopeau reported to the Berlin Leprosy Congress the case of a young 
 Haytien who had been affected with a severe form of nerve leprosy, 
 and who succumbed to a pulmonary tuberculosis. A most careful 
 bacteriological examination practised by M. Jeanselme after death 
 demonstrated the complete absence of bacilli although they had been 
 found abundantly some time before, showing that the patient was 
 cured. There remained only the secondary stigmata of the disease. 
 
 Impey, who has had a large personal experience with leprosy in 
 South Africa, is a strong believer in the curability of leprosy. He 
 states that in anaesthetic leprosy the natural course of events is for 
 the disease to expend itself, and if patients could only stand the ter- 
 rible battle for life they would all become cured, but unfortunately 
 the strain is too great and most patients die before the bacilli are able 
 to work out their own destruction. He believes that the interstitial 
 inflammation to which the nerves are subjected leads to a contraction 
 and fibroid degeneration of their tissues, so that the sclerotic condi- 
 tion of the fibrous baud or filament which represents the former nerve 
 trunk presents an effectual bar to any further growth of the bacilli, and 
 these, being deprived of nourishment, die. Likewise he believes that 
 in tubercular lejjrosy the repeated attacks of congestion to which the 
 tubercles are subjected in the course of the disease produce, in like 
 manner, a sort of fibroid degeneration of tissues and this sclerotic tis- 
 sue becomes firmer and denser in consistence and thus less able to 
 support a mass of living organisms. He believes that we can, in 
 cases not too far advanced, expedite this fibroid degeneration of the 
 tissues and thus cure tubercular leprosy. 
 
574 MORROW — LEPROSY. 
 
 The commission appointed to investigate leprosy in the Cai)e of 
 Good Hope reported (1895) that they believe leprosj^ is in some cases 
 spontaneously arrested for longer or shorter periods, and in a small 
 proportion of cases the arrest is permanent. There is no specific 
 sign by which permanent arrest can be recognized, but the healing of 
 ulcers, a quiescent state of the skin, a general appearance of good 
 health, increase of weight, the absence of au}^ indication of active dis- 
 ease, either external or internal, during two jears may be regarded 
 for all practicable purposes as an arrest of the disease. 
 
 I believe abortion of the disease occurs in the early stages much 
 ofteuer than is generally supposed; leprosy jjresentiug in this 
 respect a striking analogy with tuberculosis. In all lej^rous couu- 
 tries the number of "suspects" — that is, persons who x^resent sus- 
 picious but not positive unequivocal signs of the disease — is very 
 large. Manj^ such cases are classed as cases of lejirophobia. 
 
 The natural process of cure is influenced by various conditions. 
 In lepros3% as in other infectious diseases, morbid processes are de- 
 termined largely by conditions of aptitude inherent in the individual. 
 Thus the question of soil as well as of seed has to be considered. If 
 the soil is unfavorable as a culture medium, the bacilli die of inani- 
 tion. The only explanation of this spontaneous cure is that the tis- 
 sues of these individuals are endowed with an unusual capacity of 
 resistance to the germination and growth of the lepra bacilli. 
 This capacity of resistance may be strengthened by change of climate 
 and other measures to be considered in connection with hygiene and 
 treatment. 
 
 TREATMENT. 
 
 The verdict of experience is that leprosy, in the vast majority of 
 cases, is an incurable disease. Of the large number of remedies and 
 methods of treatment employed none has been proved to possess a spe- 
 cific curative action upon the leprous process. In reviewing the litera- 
 ture of treatment we find that many drugs have been credited with exer- 
 cising such action, but when this clinical testimony is analyzed it is 
 found to be of the most conflicting and contradictory character. 
 
 In estimating the value of treatment certain possible sources of 
 error should be considered. The study of the natural history of lej)- 
 ros}', abandoned to its own evolution and uninfluenced by treatment, 
 shows that it does not pursue a progressive, uninterrupted course : 
 the morbid process alternates between activity and repose ; it often 
 presents remissions sufficiently i)rolonged and complete to give decep- 
 tive indications of a cure. It may be formulated as a general law 
 that recessions are the rule in lepros}', especially in the earlier stages. 
 
TEEATMENT. 575 
 
 If a remedy happens to be given wlien such a remission is about to 
 occur, the observer is apt to attribute the spontaneous subsidence of 
 symptoms to the treatment employed. On the other hand, if the treat- 
 ment is instituted coincidently with an exacerbation or new outbreak, 
 it is condemned as a failure. In the writer's opinion, the claims of 
 most of the remedies which have been vaunted as " specifics" in leprosy 
 are largely based upon post hoc conclusions as to results, which, right- 
 fully interpreted, are mere coincidences. Again, all observation 
 proves that under the sole influence of climate and hygienic treatment 
 the general condition of leprous patients is notably improved. 
 
 In this country and Europe the therapeutic problem is compli- 
 cated by the modifying influence of climate upon the course of the 
 disease. It is a matter of observation that most lepers who come to 
 this country get better for a time at least, with or wiihout medica- 
 tion, and when treatment is employed it is difiicult to differentiate 
 between its effect and that of climate and improved modes of living. 
 Thus in a case of pronounced tubercular leprosy referred to me some 
 two years ago by a colleague in New York, the cutaneous manifesta- 
 tions entirely disappeared within a few months under the influence 
 of large doses of Chaulmoogra oil internally, with daily baths and 
 inunctions of Gurjun oil. In another patient referred to me several 
 years ago by Dr. Besnier, of Paris, there has been an apparent cure 
 from the use of phosphide of zinc and strychnine. It is difiicult to 
 determine what precise measure of curative influence should be 
 ascribed to the drugs in these cases, since in another case under obser- 
 vation for two years there was an arrest of the symptoms under the 
 influence of hot baths, massage, and general hygienic measures — no 
 drugs whatever having been administered. 
 
 It is not intended to jjass in review the innumerable drugs and 
 methods of treatment employed in the treatment of leprosy. It would 
 simply serve to illustrate the fact that the more intractable the dis- 
 ease the more numerous the remedies advocated for its treatment. 
 The early methods of treatment possess an antiquarian rather than a 
 practical interest. But as the history of leprosy is embraced within 
 the scope of this article, it will be necessary, for the sake of complete- 
 ness, to make some reference to the methods of treatment employed 
 in ancient times. 
 
 In Mosaic times the treatment was altogether of a prophylactic 
 character. In the Hebraic conception of the disease leprosy was 
 regarded as a punishment for sin and an evidence of divine displeas- 
 ure, and the only hope of cure was through divine intervention. The 
 Levitical code gives no indications of the employment of any treat- 
 ment directed to a cure of the disease. 
 
576 MORROW — LEPROSY. 
 
 At the time of Galen the treatment consisted in keeping the skin 
 soft and moist with oily applications and suitable exercise. Swim- 
 ming was particularly recommended as combining exercise with 
 bathing. 
 
 Aretseus, whose graphic description of leprosy is quoted below in 
 the section on History, lays down as the proper plan of treatment the 
 practice of frequent and copious venesection, followed by the use of 
 purgatives, baths, and inunction of fat, associated with a plain nutri- 
 tiou3 diet. The i)urgative most preferred was colocynth. Among 
 the medicines he had experience of may be mentioned gum vernix, 
 brassica, sideritis (ironwort) trefoil with wine and honey, shavings of 
 elephants' teeth in wine. The flesh of vipers formed into pastils 
 was also to be used to season the food. The compound medicine 
 was made from levigated alcyonium, natron, sulphur viuum, costus, 
 iris, and pepper, " these all to be mixed together in each case 
 according to the power, but in proportionate quantities, and this com- 
 pound to be sprinkled upon the body and rubbed in. For the callous 
 protuberances of the face we are to rub in the ashes of vine branches 
 mixed with the fat of wild beasts, as the lion, tiger, panther, bear, 
 etc. , or, if these are not at hand, of the fat of the barnacle goose ; for 
 like to the unlike, as the ape to the man, is most excellent. If the 
 flesh be in a livid state, scarifications are to be previously made for 
 the evacuation of the humors. Continued baths are ordered for the 
 purpose of humectating the body. There is further recommended 
 natural hot baths of a sulphurous nature and protracted residence in 
 the waters and a sea voyage. White hellebore is recommended above 
 all other things; for in power white hellebore resembles fire, and 
 whatever fire accomplishes by burning still more does hellebore efi'ect 
 by penetrating internally — out of dyspnoea inducing freedom of 
 breathing, out of paleness good color, and out of emaciation plump- 
 ness of flesh." 
 
 Etius follows the general plan of treatment described by Aretaeus, 
 adding that amongst the Indians it was customary to exhibit as " a 
 medicine the urine of the ass, probably on account of its diuretic 
 effects, and prescribe as an article of diet the flesh of the crocodile." 
 Serpents and reptiles seem to have acquired their reputation, in this 
 disease and other diseases in which the skin is affected, from their 
 periodical exuviation of the cuticle and the magistral inference that 
 their flesh, partaken by man, would enable him to throw off, by a 
 similar process of exuviation, the sordid covering of morbid secretions 
 and the scales which are apt to form in these diseases (Wilson). 
 
 Paulus ^gineta recommended practically the same treatment to 
 be employed three or four times a year. In his list of medicines are 
 
TREATMENT. 577 
 
 mentioned squills, cumin, calamint, hartshorn, theriac of salmis, 
 and theriac of vipers. As a part of the hygienic treatment he recom- 
 mended various forms of gj^mnastic exercise, particularly leaping, the 
 body to be then anointed with the fat of some animal, as of the boar, 
 wolf, goat, or bird, or with butter. After inunction the patient should 
 take a bath and be rubbed with some stimulating juice or spirit, such 
 as fenugreek, or gum ammoniac dissolved in vinegar. After the 
 bath he is to be anointed with a solution of gum ammoniac and alum 
 in white wine, or with some gently stimulating and aromatic oil, such 
 as that of myrtle. 
 
 Rhazes, the Arabian physician, commences his treatment with 
 emetics and reserves venesection for cases of severity or of long 
 standing. He combines turbith with colocynth as a purgative and 
 favors excitation of the skin by means of friction and hot baths, and 
 further by the help of a liniment composed of onions and fennel, or 
 of a lotion of strong acetic acid in which madder root has been for a 
 time digested. If the powers of the constitution be reduced by the 
 treatment, he recommends the use of good white wine (Wilson). 
 
 Daniellsen and Boeck give a summary of the treatment recom- 
 mended by Schilling, towards the end of the eighteenth century. The 
 diet during the first three months must be plain. At the commence- 
 ment of the cure, so long as the " obstruction" lasts, milk must not 
 be taken; later it may be allowed. Mercurials are abstained from 
 because they always produce in lepers violent accidents and very often 
 a dangerous diarrhoea. When signs of plethora are present, the pa- 
 tient must be well bled. 
 
 Warm baths should be employed, but carefully in advanced stages 
 of the complaint, as being apt to occasion palpitations of the heart, 
 convulsions, and fainting fits. He encourages exercise for the pro- 
 duction of perspiration. As diluents he recommends barley water, 
 gruel, and resolutive herbs, such as agrimony, ground ivy, fumitory, 
 arbrotanun, veronica, etc., and tisanes, to which are sometimes added 
 demulcents and purgatives, such as mallory, rhubarb, aniseed, pelli- 
 tory, senna leaves. For six weeks the patient should drink eight 
 pounds of these liquids daily, and as the state of the patient or the 
 disease indicates he bleeds, purges, or adds tonic extracts to the pre- 
 ceding decoctions. After the above preparatory course of six weeks, 
 the more powerful alteratives and sudorifics are ordered, especially 
 soapwort, sarsaparilla, sassafras, china root, juniper, serpentary, 
 scolopendrium, pareira brava, and other similar herbs. The greater 
 the consumption of these decoctions, he claims, the more prompt 
 and complete the cure. The body, however, he remarks, is apt to 
 become weak under this treatment, and for this reason good and nour- 
 VoL. XVIII.— 37 
 
578 MORROW — LEPROSY. 
 
 isliing food and good wines should be partaken of. He prohibits 
 acids and spirits during the treatment, as being liable to cause febrile 
 action. After having employed these remedies for about three months 
 it is advantageous to practise bleeding and to take as much blood as 
 the strength of the patient will allow. If the j^atient makes use of 
 these curative means, he should avoid cold air, as it maj- happen that 
 a critical perspiration is suppressed by the cold, causing severe 
 diarrhoea. 
 
 The treatment should be pursued for some time after patients 
 have recovered and be discontinued by degrees. 
 
 It will be perceived that many of the methods of treatment em- 
 ployed in ancient times, and even now in certain countries, seem more 
 like incantations than rational procedures. In Amoy in China, for 
 example, " the leper is enclosed in the carcass of a freshly eviscerated 
 bullock, where he remains an hour or more."' A snake, the flesh of 
 a dead child, a cooked placenta (human) are among the edibles lauded 
 by the Chinese for the cure of leprosy. In Fatshan, near Canton, 
 according to Dr. McDonald, " lepers have a notion that eating the 
 flesh of a dead child will cure them." 
 
 There is a belief prevalent in Canton and elsewhere that a leprous 
 woman can rid herself of the disease by having connection with 
 a healthy man. The woman by connection hopes to get rid of the 
 disease by handing it over to the man. This curious practice is 
 termed " selling off leprosy." Another curious belief prevailing in 
 China is that sexual intercourse will act as a prophylactic against 
 leprosj". Thus a woman having a leproiis husband, but who herself 
 shows no manifestations, will trj- to have a healthy man have con- 
 nection with her, thereby lessening her chances of becoming infected 
 at all. 
 
 Dr. Cantlie reports as the result of his investigations of leprosy 
 in China (1) that no European records a single case of cure; (2) that 
 no native drug has been found to be curative. 
 
 Simpson refers to a certain Christian Livingstone in the sixteenth 
 century, who " took a reid cock, slew it, baked a bannock (cake) 
 of the blood of it, and gave the same to a leper to eat. " Michael 
 Scott's cure is given as follows : " It ought to be known that the blood 
 of dogs and of infants two years old and under, when diffused through 
 a bath of heated water, dispels leprosy without a doubt" (Thin). 
 
 According to Erasmus Wilson, one of the specific remedies ad- 
 vocated in the treatment of elephantiasis was castration, under the 
 impression that the stimulus given to the blood by the generative sys- 
 tem was an excitant of the disease. Patients have relieved themselves 
 of these glandular organs, but without any benefit whatever. 
 
TREATMENT. 579 
 
 In tlie Middle Ages plilebotomr was recommended to expel the 
 excess of melancholy, one of tlie foiu- liumors wliicli instead of going 
 to tlie spleen was, in leprosy, diffused tlirongliout the entire body. 
 In conjunction with bleeding the use of laxative medicines and fumi- 
 gations, with nasal instillations to combat the nasal deformities, were 
 employed. This treatment was, however, considered only adjuvant 
 to the specific treatment which consisted in the administration of the 
 ilesh of vipers. These serpents were especially prepared and the 
 flesh served up in various appetizing ways — in bouillon, with chicken, 
 etc. ; " in a word, it was to be absorbed in every possible way^in 
 electuary, in distillation, in maceration." This mediaeval practice 
 has been mentioned only to show that the belief upon which it was 
 based, viz., that there exists in the serpent tribe an "antivenom" 
 which is antagonistic to the virus of leprosy, has prevailed in all ages, 
 and it still survives at the present day. According to Ashmead, the 
 antivenom treatment, which consists " in dissolving the snake mamuslie 
 in wine and using the dissolution internally," has been known in 
 Japan for a thousand years. In China from time immemorial the 
 flesh of the hungshe, a very rare snake, dissolved in strong wine and 
 taken internally has been regarded as a cure for leprosy. 
 
 In South America, especially among the Brazilians, there is a 
 widespread faith in the saving efficacy of the bite of serpents against 
 leprosy. Dr. Carreau, in 1892, reported the case of a leper bitten by 
 a viper, in whom there was a remarkable disappearance of the tuber- 
 cular lesions, which he attributed to the increase of hsemoglobin in 
 the blood. 
 
 According to Dr. Laverde, lepers in Colombia cause themselves to 
 be bitten by venomous serpents, scorpions, hornets, etc., but we 
 possess only vague information as to the results of this barbaric 
 therapeutics. It is certain that the result is often fatal, but when the 
 patient suiwives there is a remarkable amelioration in the symptoms, 
 and in some cases a permanent cure has been reported. The serpent 
 corral, whose bite is rarely fatal, is most frequently selected for this 
 hazardous procedure. This belief in the immunizing effect of snake 
 poison forms the basis of the treatment of lej^rosy by the antivenom 
 serum of Calmette and Fraser, which will be again refeiTed to. 
 
 The treatment instituted by Daniellsen at the Lungegaards Hospi- 
 tal, Bergen, was based on the theory that in leprosy there is an excess 
 of albumin and fibrin in the blood and that the abnormal constitution 
 of this fluid could be best corrected by vegetable diet, sulphur baths, 
 phosphoric acid, tarti^ate of antimony, iodide of potassium, iodide of 
 iron, chlorine, and remedies of this class. Arsenic was used spar- 
 ingly and in small doses. Mercury was regarded as not only useless 
 
580 MORROW— LEPROSY. 
 
 but injurious. In some cases venesection was employed. In the 
 local treatment of the tubercles acid nitrate of mercury or solution of 
 caustic potash was used for their destruction, or recourse was had to 
 caustic or sulphuretted baths. Daniellsen also employed syphiliza- 
 tion on the theorj' that the syphilitic poison might prove superior to 
 that of leprosy and the production of a sjq^hilitic dj'scrasia might trans- 
 form or annihilate that of leprosj' ; the result was that the syphilitic 
 process went on while the leprosy remained unchanged. Iodide of 
 potassium was extensively experimented with by Daniellsen with good 
 results in the tubercular form. Leprous patients were soon found to 
 be peculiarly susceptible to its irritant effects upon the skin, and, ac- 
 cording to Daniellsen, it affects them both as a powerful poison and a 
 means of cure. He found the salicylate of sodium effective and use- 
 ful in both forms of lepros}'. In the tubercular form the newly formed 
 nodules disappear, but old nodules of long standing were not appar- 
 ently affected. The external application of a concentrated solution 
 caused the nodules to disappear partialh', Viut when the application 
 was discontinued the nodules again became apparent. Chaulmoogra 
 oil was used with the most unsatisfactory results, as it seemed to 
 bring out severe eruptions of nodules. The use of salicylate of mer- 
 cury, though this was borne better than other mercurial prepara- 
 tions, was followed by no improvement. 
 
 Daniellsen summarizes the results of his long and extensive ex- 
 perience as follows: "I have employed in mj^ services all the med- 
 icaments which have been so much vaunted in the treatment of lep- 
 rosy—all, from the iodide of potassium to that of chaulmoogra, 
 gurjun oil, creosote, etc. They have been sent to me from all coua- 
 tries. I have oftentimes had moments of hope, but I have been 
 forced to the conviction, which I must again repeat, I do not know of 
 a medicament which cures leprosy." 
 
 Oil of Casheiv Hiit (Anacardium occidenfale) . — A plan of treat- 
 ment which attracted considerable attention some thirty years ago was 
 that known b}^ the name of its author as the Beauperthuy treatment. 
 In addition to a careful diet, daily baths, etc. , he sought to correct 
 the dyscrasia by the administration of the bichloride of mercury in 
 small doses. The external applications were liniments to cure the 
 eczematous and other eruptions, and for the active removal of the 
 tubercles a strong solution of nitrate of silver and copper formed 
 by dissolving silver coin in .concentrated nitric acid and diluting 
 with an equal bulk of distilled water; but principally the oil of 
 cashew nut (anacardium occidentale) was employed for this purpose. 
 The oil of cashew was applied with a sponge, or a needle dipped into 
 it would be used to puncture a tubercle in order to set up suppuration. 
 
TREATMENT. 581 
 
 This treatment did not fulfil tlie high expectations which had 
 been formed of its curative value. It was tried in India, Norway, 
 and elsewhere and abandoned. The cashew nut is still extensively 
 employed in the local treatment of leprous, nodules. 
 
 Hydrocotijle asiatica was introduced by Dr. Brileau, of Mauritius, 
 himself a leper, who claimed to have cured himself and many others 
 with this drug. According to Dr. Lepine, the properties of the plant 
 are due to an active principle which he terms vellarine. It appears 
 to have a i^eculiar action on the capillaries of the mucous surfaces and 
 upon the skin; it causes first a sensation of heat in the stomach and 
 at the same time a prickling in the extremities and then over the skin 
 of the whole body, followed by increased transpiration, etc. From 
 its stimulatiag effect on the circulation it is considered to be espe- 
 cially indicated in the anaesthetic form of the disease. 
 
 The three vegetable remedies which have been most highly vaunted 
 as specifics and which have been generally held in highest repute are 
 chaulmoogra oil and gurjun oil and Hoang-nan. 
 
 CJiaulmoogra oil, expressed from the seeds of the Gynocardia odo- 
 rata, which probably enjoys the highest degree of professional confi- 
 dence, was first used by Le Page, of Calcutta, in the treatment of lep- 
 rosy. It is given in doses varying from five to eighty drops three times 
 a day, in emulsion or in capsules. The best results are obtained when 
 large doses, two hundred to three hundred minims dailj'^, are admin- 
 istered. Unfortunately, the oil is very irritant to many stomachs; 
 some cannot tolerate it even in the smallest doses. I have a patient 
 in whom a dose of two or three minims invariably causes anorexia, 
 disagreeable eructations, and sometimes vomiting. In cases in 
 which the oil is not well supported, Yidal has recommended its ac- 
 tive principle, gynocardic acid, in the form of gynocardate of mag- 
 nesium or sodium, given in capsules, containing 20 to 30 cgm. each. 
 Of these, ten to twenty may be taken each day. Externally chaul- 
 moogra oil may be used in the proportion of one part of the oil to five 
 or fifteen parts of olive or cocoanut oil, or in the form of an oint- 
 ment of gynocardic acid. Under the prolonged use of chaulmoogra 
 oil it is claimed that there is a notable amelioration of the symptoms 
 ■ — the skin becomes soft and supple, discolorations clear up, leprous 
 nodules undergo involution, ulcers heal, disorders of sensibility are 
 corrected, the general nutrition improves, and the patients gain 
 in weight. Numerous physicians have published cases in which 
 decided benefit was derived from the use of this drug. It seems 
 to have the best effect in tubercular cases. Beaven Rake, Carter, 
 and many physicians who have largely experimented with the 
 drug, testify that under its use the nodules in the skin subside and 
 
582 MORROW — LEPROSY. 
 
 the sensory nerves more or less regain their function. Other ob- 
 servers, after an extensive atrial, have not been impressed with the 
 vahie of this remedy. 
 
 Gurjioi oil, derived from the Dipterocarpus turhinatiis, first recom- 
 mended by Dr. Doiigall, has a high repute in India. It may be given 
 in an emulsion, e<]ual parts of the oil and lime water, the dose of which 
 is frcnn oue to four drachms. As a local application it may be used 
 in the proportion of oue part of the oil to three parts of lime water or 
 olive oil. To secure the best results the oil should be rubbed in thor- 
 oughl3% two hours each da}' being emploj'ed in the process, after which 
 a bath should be taken, and the inunction repeated every day. Dr. 
 Hillis states that the gurjun oil seems to exert a specific action on the 
 sweat glands, evidenced by the increased perspiration and return of 
 sensation in ansTesthetic areas, and that it is a most valuable agent in 
 all forms of leprosy-. He further claims that hy the use of the gurjun 
 oil in suitable cases the disease may be arrested, and that in a few 
 instances there has been no return of the disease for over two years ; 
 but it may, nevertheless, be i)remature to sa\' that a cure has taken 
 place. In a later report he says : " In gurjun oil we appear to have a 
 most valuable medicine for the treatment of leprosy in all its forms^ 
 one capable of retarding the ravages of the disease and in some cases 
 of apparent!}' curing it." 
 
 In India a number of medical officers, Dr. Neve and others, report 
 that patients improved under the action of gui*jun oil, and that ulcers 
 and cracks of -the integument particularly healed under its application. 
 
 On the other hand, many other observers have tried it and found it 
 of no particular value. Bidenkap states that he has tried it without 
 result, although the frictions connected with its use seem to have a 
 favorable influence upon the affections of the cutaneous nerves. 
 Beaven Rake considers that the value of gurjun oil has been greatly 
 overrated, although he concedes that its external application is of 
 use in removing scabs or desquamation. Vandyke Carter also de- 
 preciates its value, declaring that the results are disappointing. 
 
 Hoang-nan (Strychnos gaultheriana) is a remedy which has been 
 highly extolled in China and other countries where leprosy prevails. 
 It comes in the form of a reddish powder from the bark of a tree 
 found in the forests of Annam. This is made up in the form of pills 
 with gluten. Duriug its administration all alcoholic drinks are sup- 
 pressed and a simjjle diet, preferably a milk diet, is recommended. 
 The remedy should be used with care, as it is claimed its injudicious 
 use may be followed by tetanoid symptoms. I have known of one case 
 in the leper settlement of Molokai of advanced nerve leprosy in which 
 the anaesthetic symptoms cleared up under the use oi Hoang-nan, 
 
TREATMENT. 583 
 
 aud the improvement has contiuued for several j-ears. The jiatieut 
 regards himself as practically cured. In other cases the beneficial 
 effects of the remedy have been i)ronounced and positive. 
 
 Stryc/niine, the active principle of nux vomica, is probably closely- 
 allied in its action to Hoang-nan and has been largely employed, 
 and with excellent results, in the treatment of the anaesthetic form 
 of leprosy in this countrj'. 
 
 Ivhtlnjol. — Some ten years ago Unna claimed to have cured two 
 cases by the internal administration of ammonium sulphoichthyolate 
 and the external use of certain reducing agents, as chrysarobiu, 
 resorcin, pyrogallol, salicylic acid, etc. The reducing agents he 
 asserted to be most effective when used in a weak strength, in five- 
 to ten-per-cent. ointments. In some cases strong ointments of chrys- 
 arobiu or plaster mulls containing forty parts each of creosote and 
 salicylic acid were applied to the leprous nodules with a view of 
 exciting an inflammation of the skin and effecting an elimination of 
 the bacilli. The claim that the i)atients were cured was premature, 
 as both died of the disease, one of them within twelve months. A 
 more extensive clinical experience by others, instead of confirming the 
 value of this method of treatment, has demonstrated it to be a failure. 
 
 Salol, which has been highly recommended by certain observers, 
 has been found utterly useless by others. The value of salol was 
 highly extolled b\' Lutz, He claimed that in large doses the leprous 
 fever is arrested aud the eruption retrogresses with the healing of the 
 ulcers; anaesthetic patches again become sensitive, and the scaly, 
 shining apjjearance of the skin gives way to a moist, healthier look. 
 On the other hand. Dr. Cook, superintendent of the Government 
 Leper Hospital of Madras, after an extensive experience with this 
 drug, declares that " salol, in ni}^ opinion, is of no therapeutic value 
 — in fact, I consider it a decided failure." 
 
 Salicylicate of sodium and salicylic acid were extensively employed 
 by Daniellsen and Kobner, who state that these remedies are effec- 
 tive in both forms of leprosy. In the tubercular form the fever is 
 lessened, the eruptive period shortened, and some nodules disap- 
 l^ear. The sodium salicylate was given in doses of from 3 ss. to 3 iss. 
 (2 to 6 gm.) daily. Bidenkaj) has seen more harm than good result 
 from the use of salicylate preparations. 
 
 Creosote ai)d Carbolic Acid. — Langerhans and Perez claim to have 
 had excellent results from the internal administration of creosote. 
 Bidenkap and others found in their experience creosote and carbolic 
 acid powerless. 
 
 Europhen. — Dr. Goldschmidt, of Madeira, claims to have cured 
 incipient tubercular leprosy by the application of europnen oil 
 
684 MORROW — LEPROSY. 
 
 (iodine in a nascent state). In cue case, after six years there had 
 been no return of the disease. Alvarez, of Honolulu, tried the euro- 
 phen treatment with "negative results." Havelburg, of Rio Ja- 
 neiro, has used europhen, formalin, and nosophen internally and 
 locally as salves or injected into tumors, as he declares, without any 
 real effect (Ashmead). 
 
 Crude Petroleum. — Kalindero has been most favorably impressed 
 with the use of crude petroleum from which he has observed a marked 
 amelioration of the leprous symptoms. 
 
 Chlorate of Potassium. — From the well-known action of this drug 
 in causing a rapid increase of haemoglobin in the blood, Dr. Carreau, 
 of Guadeloupe, used it in large doses, gr. cl. to clxxx. He reports 
 remarkable results from its employment, shown in the disappearance 
 of the nodules as well as in the thickening of the integument and resto- 
 ration of sensibility. Beaveu Hake experimented with chlorate of 
 potassium, but with unsatisfactory results. As the bacilli are not 
 found in the blood it is difficult to see how a modification in the 
 composition of the blood affects the life of these organisms. 
 
 Airol (oxyiodogallate of bismuth). — On account of the well- 
 known microbicidal action of this agent, Fornara emploj'ed it in the 
 treatment of leprosy. He injected it in emulsion (one-tenth airol with 
 one-third glycerin or olive oil previously boiled) in tubercles, plaques, 
 swellings, and anaesthetic areas, graduating the dose from one drop to 
 a Pravaz syringeful, according to the extent of the lesions. If the eyes 
 were attacked, it was instilled several times a day into the conjunctival 
 sac. If the nose and throat were involved, the powdered drug was 
 snuffed up like tobacco, the object being to saturate the tissues with 
 airol. In some cases chaulmoogra oil was also used internally and an 
 ointment of the oil externally. Fornara reports seven cases in which 
 there was either a cure or a marked amelioration of all the symp- 
 toms. 
 
 Formalin has been extensivelj^ employed in the treatment of lep- 
 rosy on account of its germicidal properties. It has been used exter- 
 nally as a caustic and in frictions rubbed up with lanolin, and has also 
 boen injected into the tubercles. When it is thus employed the tumor 
 hardens as if tanned and is eliminated. It is not regarded, however, 
 as superior to other caustics for the destruction of the pathological 
 formations of leprosy. 
 
 PyoManin is another bactericide which has been experimented 
 with in the treatment of leprosy. The tumors into which it was 
 injected assumed a blue color, small abscesses were formed, and the 
 necrotic masses were eliminated, but it was found to have no effect 
 on the general manifestations or course of the disease. 
 
TREATMENT. 585 
 
 Thyroid extract is a remedy which has been experimented with on 
 the supposition that from its effect in reducing mvxoedematous infil- 
 trations it might be useful in the diffuse and oedematous infiltrations 
 of leprosy. It has been tried extensively in South America and by 
 Alvarez, of Honolulu, who claims that it has a remarkable efficacy in 
 dissipating the oedematous swellings of leprosy. Its continued use 
 does not, however, modify the genera;l condition of the patient. 
 
 Tuhercidin.— The treatment of leprosy by injections of tuber- 
 culin, which was introduced some years ago, is mentioned only 
 to be condemned. It was extensively experimented with, but the 
 results have been invariably disappointing. The intense vascular 
 disturbance produced by the injections is so marked as not onlj- to 
 render more prominent existing leprous infiltrations, but to cause 
 new manifestations of the disease in parts previously exempt. In a 
 case reported by Abraham, after the third injection two large swell- 
 ings resembling nodes apj^eared, one in front of each tibia ; several 
 tuberc]es made their appearance on the face, forearms, and elsewhere, 
 and some of the older tuberosities became more swollen. In a case 
 of mixed leprosy under my observation there was a marked aggrava- 
 tion of all the eruptive features with the development of new foci of 
 the disease. In another of my cases (anaesthetic) there was no change 
 in the condition of the patient beyond the febrile reactionary effects. 
 The concurrent testimony of almost all observers is to the effect that 
 the action of tuberculin is positively pernicious in determining the 
 development of new foci of the disease. 
 
 Injections of Bovinine, Meat Juice, etc.— J. A. Voorthuis reports 
 experiments with Unna's method of treatment of lepra v»'hich was 
 employed in the cases of four Chinesei coolies in Deli (Sumatra) ; this 
 consisted in intravenous injections of Valentine's meat juice thinned 
 with an equal part of artificial serum, 0.2 to 1 c.c. every two days. 
 In all cases there was a bettering of the general condition with red- 
 dening and swelling of the nodules, which then softened and were 
 resorbed or were emptied by incision. This method of treatment is 
 based upon the ground that the muscular tissue which is dissolved in 
 meat juice is the only particular substance of the body which is 
 immune to the lepra bacilli. 
 
 Intramuscular Injections of PercMoride of 3Iercu7-y.— Although. 
 mercury has been commonly credited with exercising a positively 
 injurious action in leprosy, exception being, perhaps, made for 
 cases in which there is a combination with syphilis, Crocker re- 
 ports five cases in which a striking improvement was manifest after 
 intramuscular injections of perchloride of mercury. He is positive 
 that the improvement was not a matter of chance, but was the direct 
 
586 MORROW — LEPROSY. 
 
 effect of the treatment. The dose is cue-fourth of a grain, which is 
 injected twice a week. Crocker notes as a curious circumstance that 
 none of the patients suffered from salivation, nor does the drug ap- 
 pear to have had a depressing effect when used twice a week for 
 many months. One phenomenon of special interest was observed 
 in all cases, viz., the aj^pearance in different parts of the limbs of 
 hard, pea-sized nodules, sometimes cutaneous, sometimes subcuta- 
 neously seated, which were unlike the leprosy nodules. They were 
 tender at first, later they became jjainless ; some persisted for months, 
 others disappeared in a few weeks or days. 
 
 Formamide of Mercury. — Hasland, of Copenhagen, has reported 
 remarkable results in a case of tubercular leprosy from injections of 
 formamide of mercury. One injection of 1 cgm. of the drug was given 
 daily, except when the treatment was interrupted temporarily by in- 
 tercurrent diarrhoea, until fifty-two injections had been made. The 
 patient received six times daily a tablespoonful of a solution of salicy- 
 late of sodium (10 : 300). He also received later oleum gynocardii, 
 beginning with five-drop doses three times daily and increasing. 
 Externally an ointment of ichthyol-salicylated vaseline was used. 
 The ulcerations were cured, the tubercles diminished in number, 
 and the mucous membranes of the nose and pharynx became entirely , 
 smooth. Later there was a relapse. The same patient was seen 
 later by Ehlers, when tubercles, spots, ulcerations, and swelling of 
 the ulnar nerve were found. 
 
 Ehlers, of Copenhagen, has tried the injections of soluble salts of 
 mercury in many cases. The treatment is followed by immediate 
 good results, but it does not prevent recurrences. 
 
 Antivenene Treatment. — Dr. Dyer, of New Orleans, impressed with 
 some respect for the popular superstition among the natives of South 
 America and the West Indies, that the bite of a venomous snake 
 would cure leprosy, experimented with Calmette's antivenene in five 
 cases of leprosy. The injections were made everj' other day at first, 
 subsequently every day. The dose varied from 1 to 11 c.c. The 
 total number of injections in each case varied from ten to forty -two. 
 The regions selected for the injections were the gluteal or interscapu- 
 lar; in some instances the injections were made in the nodular lesions 
 themselves. Wherever this was done the lesions injected disap- 
 peared. In four out of the five cases treated by antivenene there was 
 marked improvement ; in one there was a practical disappearance of 
 the lesion i^resent and of other evidences of the disease. "Cold 
 sweats" was the most characteristic feature of the constitutional re- 
 action following the injections. 
 
 Erysipelas and its Toxins. — Eeference has already been made to 
 
TEEATMENT. ' 587 
 
 the observation tliat an intercurrent attack of erysipelas lias a mark- 
 edly modifying effect upon tlie manifestations of leprosy. So long 
 ago as 18h2 Campana inoculated two leper patients with the products 
 of erysipelas. The lepers were not cured, but all the other pa- 
 tients in the ward contracted erysipelas. In 1891 Havelburg, of Rio 
 Janeiro, tried injections of cultures of the streptococci of erysipelas. 
 He found that the reaction, both local and general, was so violent 
 that the experiments had to be discontinued. A serum obtained 
 from animals immunized against erysipelas, prepared by Emmerich 
 and SchoU of Berlin, was then substituted for the erysipelas cultures 
 and tried in the cases of five lepers. The injections were made two or 
 three times a week in the lepromata and circumjacent tissues, and each 
 patient received from fourteen to eighteen injections. The effects 
 were variable. Sometimes no local reaction whatever -was produced; 
 at other times phlegmons and abscesses formed precisely as after 
 injections of pyoktanin, alcohol, or phenic acid. The treatment was 
 discontinued on account of the unsatisfactory results. 
 
 Quite recently H. D. Chapin, of New York, has published the re- 
 sults of his treatment of four lepers in the City Almshouse by the 
 injections of the mixed unfiltered toxins of the streptococcus of ery- 
 sipelas and the bacillus prodigiosus made from cultures grown to- 
 gether in bouillon. The injections, beginning with one minim and 
 gradually increasing to twenty-two minims, were continued almost 
 daily for about two months. The injections produced the character- 
 istic reactions and temperature changes, but had no effect upon the 
 course of the disease. 
 
 Impey thinks that the good effects of an attack of erysipelas are 
 due not to an antagonism of germs, but to the intense inflammation 
 which brings about sufficient degeneration of the tissues to bar the 
 further growth of the bacilli if it does not actually cause their 
 destruction. 
 
 Alvarez, of Honolulu, has been experimenting with injections of 
 cultures of the bacillus prodigiosus, but without curative result. 
 
 Serum Therapy. — Among the more recent methods of treatment 
 which were presented and discussed before the Berlin Leprosy Con- 
 gress may be mentioned the serum treatment of Carrasquilla with 
 its numerous modifications by other experimenters. This method 
 of treatment was invested with an especial interest as the latest 
 and perhaps most promising therapeutic novelty. To Dr. Juan de 
 D. Carrasquilla, of Bogota, Colombia, is due the credit of introduc- 
 ing the serum treatment of leprosy. His serum is prepared as fol- 
 lows : A leper in the active stage of the disease is bled, preferably 
 during one of the periodical exacerbations ; the blood is allowed to 
 
588 MORROW— LEPEOSY. 
 
 coagulate, and the clear serum is drawn off. This serum is pre- 
 served with camphor and injected into a horse ; three injections of 
 30 c.c. each being given at intervals of ten days. The horse is bled 
 ten days after the last injection, after which Carras(iuilla repeats the 
 same process, obtaining at the end of each month a progressively 
 more active serum. He begins by injecting into a leper 1 to 3 c.c. 
 of the camphorated horse serum, gradually increasing the dose to 
 5 c.c, and injecting on alternate days. 
 
 He claims that in the subjects of his experiments improvement 
 began in a week and was marked at the end of a month. He de- 
 scribes in detail a number of cures, over two hundred in all, and 
 sums up the benefit of his treatment as follows: (1) Eeestablish- 
 meut of sensation ; (2) decoloration of blotches ; (3) disappearance 
 of oedematous tubercles; (4) healing of ulcerations; (5) shrinking 
 of the distorted face. He maintains that the morbid process ceases 
 after the first injection. 
 
 J. Olaya Laverde, of Socorro, one of the most enthusiastic advo- 
 cates of the employment of serum in leprosy, has introduced certain 
 modifications in the method of its preparation. He injects asses 
 and goats with tlie morbid products of leprosy, and claims that he 
 thus obtains a more active serum. He collects 15 gm. of blood, 
 25 gm. of lejiromes which he triturates and adds 20 gm. of steril- 
 ized water, 40 c.c. of which is at once injected under the skin of a 
 goat in the scapular or pectoral region. The animal usually suffers 
 some febrile reaction lasting several hours. At the end of six 
 or eight days the animal is bled and the serum is injected into the 
 patient, the quantit}' varying from 5 to 20 c.c. The injection pro- 
 duces a febrile reaction more or less marked, sometimes headache 
 and wandering pains in the lumbar or epigastric region, followed 
 by an abundant transpiration. 
 
 Laverde has treated about sixtj^ patients, many of them receiving 
 from thirty-five to forty injections. He reports that the therapeutic 
 results are most satisfactory, the infiltrations are resorbed, the thick- 
 enings clear up, the spots and pigmentations gradually fade out, 
 the tubercles are either absorbed or break down and disappear by 
 suppuration. The anaesthesia, pain, mucular paresis, and other 
 neuritic symptoms are effaced, the patients regain the use of their 
 limbs, etc. 
 
 On the other hand, Putnam, of Colombia, has tried the Carras- 
 quilla treatment on forty lepers without success. 
 
 The Oarrasquilla serum was distributed to leprologists for ex- 
 periment in various countries, almost all of whom reported adversely 
 at the meeting of the Berlin Leprosy Congress. 
 
TBEATMENT. 589 
 
 Hallopeau treated six cases in the Hopital St. Louis witli nega- 
 tive results. Besnier regarded it as generally unsatisfactory, as it 
 produced no sensible modification of the disease. 
 
 Alvarez, of Honolulu, employed the treatment in fourteen cases, 
 two of which were improved. He often observed new eruptions dur- 
 ing the progress of the treatment, contrary to the statement of Car- 
 rasquilla, that after the first injection no new manifestations of the 
 disease appear. He observed in two cases severe attacks of as- 
 phyxia after the injections. 
 
 Barillon, Dehio, Brieger, Arning, Doutrelepont, and others ob- 
 served no favorable result whatever from the serum of Carrasquilla, 
 but many times febrile reactions more or less intense. 
 
 A. Griinfeld employed an antileprous serum prepared at the lab- 
 oratory of E. Merck, of Darmstadt, after the method described by 
 Carrasquilla. This serum was injected into two lepers for six months. 
 Dr. Griinfeld reported a notable amelioration of the general condition 
 of his patients after the use of the serum. He recommended as a 
 necessar}^ condition of success that the treatment should be continued 
 for a long time. 
 
 Herman procured the clear serum from leprous nodules by 
 clamping, incising, and pressing out the exudation. This leprosy 
 exudate was injected into a horse every week until he received ten 
 injections. The horse was bled and the serum collected in the usual 
 way. This serum was used in five or six cases. One patient was 
 thought to be improved, but the results could by no means be con- 
 sidered as brilliant. 
 
 Atherstone and Sinclair Black, of the Robben Island Asylum, 
 made a number of experiments with the Carrasquilla serum and 
 the " antileprotic serum" of Herman and at the same time made 
 control experiments by injections in other cases of horse serum, 
 asses' serum, and the serum of patients with arrested leprosy. The 
 results were far from establishing the specific curative action of any of 
 these serums upon the leprous process. The injections were followed 
 by febrile reactions, headache, and profuse perspiration, but " the 
 leprotic process suffered no arrest of a marked character." 
 
 Independent of the constitutional reactions the serum injections 
 are often attended with the formation of painful swellings and 
 abscesses at the points of injection. " The skin after numerous in- 
 jections becomes tender, and the abscesses are very apt to cause 
 great distress to the patient, even when the strictest antiseptic pre- 
 cautions have been employed to prevent such a result." 
 
 The weak point in the serum therapy of leprosy, and which a 
 priori would disqualify it from a scientific standpoint, is that neither 
 
590 MORKOW — LEPROSY. 
 
 the Carrasquilla serum nor any of tlie antileprotic serums cau be 
 considered in any sense as representing a leprous serum. 
 
 Tlie bacilli leprso are not habitually found in the blood. Their 
 presence in the blood current during an attack of leprotic fever is 
 purely hypothetical; therefore in injecting the blood of a leper into 
 an animal there is no i^robability that lei:)rous germs are conveyed. 
 Even when a portion of lepromatous tissue or the serous exudate from 
 a tubercle containing bacilli is introduced there is no assurance that 
 the bacilli can be cultivated in the blood current of the animal, as all 
 experiments prove that animals are refractory. 
 
 Even assuming that a culture of lej^ra bacilli may be made outside 
 the human body and an animal be found susceptible to this culture 
 inoculation, it is questionable whether the serum obtained from this 
 animal would cure leprosy. In the case of tuberculin, all the ideal 
 conditions for the production of a perfect serum have been fulfilled, 
 yet the results of the i)ractical employment of this substance in 
 the treatment of tuberculosis have been most disappointing. 
 
 It is difficult to reconcile the enthusiastic testimony of Carrasquilla 
 and Laverde in favor of the beneficial effects of serum therapy with 
 the almost universal condemnation it has received at the hands of 
 other experimenters. 
 
 The same may be said of the clinical testimony as to the thera- 
 peutic value of a long list of remedies which are highly praised by 
 some observers, and by others equally competent are condemned as 
 useless or harmful. We thus perceive that among men who have had 
 the largest opportunities for experiment there is a most unfortunate 
 lack of unanimity as to the value of any of these various remedies, 
 exception being possibly made for chaulmoogra and gurjun oil and 
 agents of the Strychnos family. 
 
 While many of the remedies and methods of treatment of leprosy 
 are purely empirical and without rational basis, it will be perceived 
 that most of the agents of recent introduction have been employed on 
 account of their bactericidal properties. It is evident, however, from 
 the position of the bacilli in the deeper tissues that no germicidal 
 agent can be brought into direct contact with the pathogenic organ- 
 isms ; and even if this were possible, there is no agent capable of 
 destroying the bacilli without destroying the tissues containing them. 
 The true indication of rational treatment would seem to be to sterilize 
 the tissues so as to render them unsuitable for the growth and multi- 
 plication of the bacilli. 
 
 Many of the agents employed (chaulmoogra, gurjun oil, and many 
 other remedies), it is claimed, so modify the economy as to render the 
 tissues sterile and inapt for the nutrition of the bacilli. 
 
TREATMENT. 591 
 
 From my own observation and experience I am inclined to the 
 ^oelief that clianlmoogra oil exercises a more directly curative action 
 upon the manifestations of tubercular leprosy than any of the numer- 
 ous drugs which have been recommended, although I by no means 
 share the enthusiastic faith of those who claim that it exerts the same 
 specific action in leprosy that mercury does in syphilis. In order to 
 secure the full measure of its therapeutic efficacy it should be given 
 in large doses, even as high as from one to four drachms per day. 
 The oil does not seem to be toxic, but it possesses the unfortunate 
 disadvantage of being extremely nauseating, so that many patients 
 cannot take it, even in small doses, without experiencing disagreeable 
 eructations and sometimes nausea and vomiting. The administration 
 of the oil in capsules, followed by a drink of tea or a little rum, ren- 
 ders the stomach more tolerant of its presence. 
 
 In other cases recourse may be had to its active medicinal prin- 
 ciple, gynocardic acid, combined with sodium or magnesium. I 
 have found the gynocardate of magnesium much better tolerated than 
 the pure oil and apparently equally effective. 
 
 Hot baths and inunctions of gurjun oil with massage will be found 
 useful in both forms of leprosy. Hoang-nan is a remeds^ which finds 
 its special application in cases of the anaesthetic type. As this is 
 not an easily procurable drug in this country, I have treated most 
 anaesthetic cases with preparations of strychnine, which may be used 
 either alone or advantageously combined with phosphorus, iron, and 
 other nerve and ferruginous tonics. 
 
 Electricity is an agent which has proven in my experience espe- 
 cially serviceable in restoring impaired or lost sensibility in anaesthetic 
 areas. The condition of success is, however, that it should be used 
 faithfully and for a long period. 
 
 The case of which a short history is given on page 513 continued 
 under my observation several years, and the results of the treatment 
 were so satisfactory as to justify its description. 
 
 The patient was first given chaulmoogra oil in capsules, but on 
 account of the gastric and intestinal irritation occasioned by the 
 drug its use for any continued length of time was impossible. The 
 gynocardate of magnesium was substituted, but even this occasioned 
 some gastric irritation^ though much less pronounced than when the 
 pure oil was used. For some time the patient received injections of 
 tuberculin; there was some constitutional reaction of a very pro- 
 nounced character, but the influence of the remedy upon the disease 
 seemed to be absolutely nil. Finally the patient was placed upon 
 the phosphide of zinc and strychnine, the use of which was continued 
 with intermissions for two or three years. 
 
592 MOBROtr— LEPROSY. 
 
 Electricity was first employed in order to restore, if possible, the 
 seusation in the ausesthetic patch over the instep. The result waS 
 exceedingh' slow, but quite satisfactory. Th3 normal sensation re- 
 turned in the course of trv-o years. The electricity was also applied 
 along the course of the sciatic and ulnar nerves, which had shown 
 evidence of commencing degeneration manifest in a tendency of the 
 limbs to go to sleep, with more or less numbness and loss of sensi- 
 bility of the hands and feet. 
 
 The patient continued the use of the electricity for three or four 
 years. At the last examination two years ago it was found that the 
 hj'perchromatic margin of the patch over the instep was broken and 
 disappearing at certain points. The other macular lesions were also 
 in process of disappearance. The patient wrote recently (October, 
 1898) that she thought she was entirely well of her trouble. 
 
 As before intimated, patients coming to this country may show 
 signs of improvement, for a time at least, with or without treatment, 
 and it is sometimes difficult to assign the true measure of therapeutic 
 efficacy' to the drugs employed. It is to be observed, however, that 
 although leprosy seems to pursue a milder and a, longer course in this 
 country, it almost invariably progresses to a fatal termination, and 
 due credit should he given to any treatment which arrests its further 
 progress. 
 
 One explanation of the conflicting character of this clinical testi- 
 monj' is found in the nature of the disease. Leprosy always runs a 
 protracted but exceedingly variable course, periods of active invasion 
 being followed by periods of latency and even improvement, and when 
 retrogression of the symptoms occurs it is difficult to estimate the 
 part contributed by treatment to this result. 
 
 Again, in experimenting with a new remedy the physician is apt to 
 select such cases as are not far advanced and in fairly good condition. 
 These patients are commonly placed in good hygienic conditions, 
 supplied with better food, and are the objects of daily individual 
 attention. It is well known that leprous catients often have pe- 
 riods of great improvement and even apparent ari'est of the disease 
 under the influence of hygienic treatment alone; hence there may be 
 a fallacious deduction in ascribing the improvement to the specific 
 action of the remedy employed. 
 
 Another reason of this contradictory testimony as to the value of 
 a special mode of treatment is that one observer may find it beneficial 
 after prolonged use, while another condemns it npon an insufficient 
 test. The more we study leprocy the more we are convinced of the 
 fact that the essential condition of successful treatment is that it 
 should be perseveringly continued for months and years. At one 
 
TEEATMENT. 593 
 
 time a six weeks' and later a six months' treatment of syphilis was 
 regarded as quite sufficient, but at the present we recognize that the 
 treatment should be prolonged for a period of years corresponding to 
 the natural life term of the malady. Doubtless one reason of the 
 almost uniform failure of all treatment instituted for leprosy is that 
 it is not sufficiently prolonged, the recession of symptoms being 
 taken both by the physician and patient as an indication of cure and 
 a signal for the cessation of treatment. 
 
 In most leprous countries it is difficult to subject the patient to a 
 course of treatment sufficiently prolonged and energetically carried 
 out to judge of its value. In leper hospitals and communities most 
 patients are impressed with the futility of all hopes of cure and soon 
 tire of systematic treatment. In the leper settlement of Molokai the 
 resident physician has given it as the result of his experience that 
 " the scientific treatment of leprosy cannot be carried out because not 
 more than ten per cent, of the patients will continue it for six 
 months." 
 
 The "Japanese treatment," which consists of a system of baths 
 and tonics, has been more thoroughly tried in the Molokai settlement 
 than any other method. Dr. Gotto was employed by the Hawaiian 
 Government, and special baths were especially fitted up to enable 
 him to apply his method. The treatment has fallen into disfavor and 
 been practically abandoned. In a letter from Mr. Dutton the effects 
 of this treatment are incidentally referred to as follows : " The Japa- 
 nese so-called ' remedies ' act as a check. For some years the check- 
 ing process continues if the rules as to medication, baths, etc., are 
 closely followed. The pains are lessened at times, but the bodj^ seems 
 to become weaker, and I doubt if the final result is of great benefit. 
 "We still use the hot baths, but not so frequently as the Japanese sys- 
 tem requires — three times a week instead of three times a day. The 
 effects are good in inducing cleanliness and also in causing perspira- 
 tion, if care is taken not to catch cold." 
 
 In addition to the numerous remedies which have been employed 
 on the assumption that they exerted a more or less special action 
 upon the leprous process there are many drugs which have been 
 used in the symptomatic treatment of the disease, and often with good 
 effect, such as quinine, arsenic, opium, antipyrin, and bromide of 
 potassium. The latter drug, according to Besnier, is exceedingly 
 useful as a nervine. Tonics, iron, cod-liver oil, and reconstituent 
 remedies generally are found most serviceable in improving the tone 
 of the system and counteracting the angemic condition so commonly 
 present in this disease. 
 
 The visceral complications of leprosy which ordinarily supervene 
 Vol. XVin.-38 
 
594 MORROW — LEPROSY. 
 
 at a more advanced stage, sucli as broncliial, renal, and gastrointesti- 
 nal disorders, should be treated symptomaticall3^ Paracentesis is 
 occasionally necessary for the dropsy which accompanies the renal 
 disease so common in leprosy. Beaven Rake found the kidneys 
 diseased in twenty -five per cent, of the autopsies on lepers. 
 
 Local Treatment. 
 
 In the systematic treatment of leprosy local applications have 
 proven a most valuable adjunct. Chaulmoogra and gurjun oils are 
 not only applied locally in conjunction with the internal administra- 
 tion of these drugs, but in many cases in which the latter occasions 
 much gastric irritation their use by inunction alone has been found to 
 exercise quite a beneficial influence in causing to disappear the nodu- 
 lar lesions as well as the diffused infiltrations of the integument. The 
 admixture of these oils with vaseline or lanolin in variable propor- 
 tions has been recommended when they are to be applied over a large 
 surface. 
 
 The use of baths followed by inunctions with oils or fats seems to 
 have been practised in all ages. The ancients attributed especial 
 virtues to the fats of certain animals, as the lion, the bear, the boar, 
 and the panther. 
 
 One condition of the good effects of oily preparations is that they 
 should be thoroughly rubbed in and their use continued for a long 
 period. It has been said that to be cured of leprosy one must live in 
 grease for months and years. The external use of linseed oil, cacao 
 butter, or cod-liver oil would probably be followed by equally good 
 results as have been claimed from the use of chaulmoogra or gurjun 
 oil; the chief benefit, in my opinion, being derived from the two 
 hours' daily rubbing required in their inunction. 
 
 The local treatment of the tubercles and ulcers, necrosed bones, 
 and other individual lesions of leprosy should be conducted on gen- 
 eral surgical principles. In allaying inflammation, removing necrosed 
 tissues, and promoting the healing process the resources of modern 
 aseptic surgery may be most advantageously employed. The ex- 
 istence of leprosy can scarcely be considered a contraindication to 
 any required operation, a^ the tissues heal with remarkable facility 
 owing, as has been suggested, to the excess of fibrin in the blood. 
 By Daniellsen and Boeck the proj^ortion of fibrin in the blood of 
 lepers has been estimated from 0.22 to 0.6 per cent. Beaven Bake 
 found in fifty carefully conducted analyses that the percentage ranged 
 from 0.12 to 1.87, the average being 0.76, which is a marked excess 
 over the normal proportion, 0.2 per cent. He attributed the rapid 
 
LOCAL TEEATMENT. 595 
 
 healing of incisions in lepers to the very rapid clotting which takes 
 place in their blood. Tubercles may be excised, ulcers may be 
 scraped, deep incisions made, necrosed bones removed, and amputa- 
 tions performed with the certainty of more or less prompt cicatriza- 
 tion. 
 
 Dressings. — A variety of dressings, both wet and dry, have been 
 emploj'ed for the healing of the ulcerations and for their aseptic 
 properties. Lotions of the sulphate of copper (gr. iv. to 3 i.), of 
 carbolic acid (1 : 40), of corrosive sublimate (1 : 2,000 or 1 : 3,000) have 
 been employed. A lotion of the permanganate of potassium is prob- 
 ably the most extensively used. Many of the powders which are used 
 in the treatment of ordinary ulcerations have been employed for their 
 aseptic and presumed germicidal properties, such as iodoform, iodol, 
 aristol, europhen, saliphen, nosophen, airol, etc. Creolin was re- 
 garded by Beaven Eake as a most excellent stimulant for indolent 
 leprous ulcers. Pure creolin was used by him as a caustic to prevent 
 recurrence of leprous tubercles after excision. 
 
 Ointments are most in favor with leprous patients, as they do not 
 dry, necessitating frequent application, and do not form crusts. 
 Iodoform ointment is declared by many to be the most useful of 
 external applications. It not only acts beneficially upon the open 
 surfaces, but it masks by its penetrating odor the still more disagree- 
 able foetor which arises from the leprous discharges. 
 
 Reference has already been made to the local use of ichthyol, 
 chrysarobin, resorcin, pyrogallol, and other reducing agents in the 
 systematic treatment of leprosy. I have used these agents in a num- 
 ber of cases without being able to satisfy myself that they were pro- 
 ductive of any benefit. In estimating the value of such measures, it 
 is well to bear in mind the spontaneous tendencj^ of the patches to 
 fade with a return of normal sensation and function. In one case I 
 noticed the disappearance of patches under the application of caustic 
 pyrozone, and in another under a strong application of menthol which 
 was continuously employed for a lengthened period. 
 
 Surgical measures play a much more important role in the treat- 
 ment of anaesthetic leprosy than of the tubercular form. Of 1,996 
 operations performed within six years at the Trinidad Asylum, 
 Beaven Eake states that 1,489 were done on anaesthetic males and 88 
 on anaesthetic females. Among tubercular cases there were 83 opera- 
 tions on males and 26 on females. In cases of mixed leprosy the 
 operations on males numbered 300 and those on females 10. The 
 greater preponderance of operations on males is explained by the 
 fact that they are more exposed from their outdoor work tO injuries 
 which result in ulcers and necroses. 
 
596 MORROW — LEPROSY. 
 
 Removal of Tubercles by Excision or Destructive Cauterization. — 
 The obliteration of tubercles lias long been recognized as a correct 
 surgical procedure, especially in the early stages and when they are 
 localized on the face and extremities. Daniellsen was accustomed to 
 effect this by destructive cauterization with caustic potash or the acid 
 nitrate of mercury ; nitric, carbolic, salicylic, pyrogallic acids, and 
 various caustics have been employed for this purpose. Destruction 
 of the tubercles has also been effected by the injection into their sub- 
 stance of various irritant and escharotic substances, as oleum auacar- 
 dii, pyoktanin, alcohol, carbolic acid, etc. The inflammatory reac- 
 tion thus induced proceeds to suppuration, the breaking down of the 
 nodules, and the discharge of their contents, after which cicatrization 
 takes place. 
 
 A very satisfactory method of destroying the nodules is by the 
 use of the thermocautery, either with or without preliminary removal 
 of the mass with the curette. This procedure is preferred by many 
 surgeons, as the operation is easily done, and it gives a better cos- 
 metic result in the shape of a smooth cicatrix. In using potential 
 caustics the depth and extent of the destructive action cannot be so 
 accurately limited. 
 
 I have a number of times excised tubercles or destroyed them with 
 caustic potash, and the wounds healed promptly. The same proce- 
 dure may be emploj^ed in removiug circumscribed masses of tubercles 
 along the superciliary ridge or elsewhere. Unfortunately the tuber- 
 cles may reappear in the skin around tlie cicatrices, but for a time at 
 least the effect upon the patient's general condition is most salutary. 
 In one case I excised a piece of pigmented skin from the back of an 
 anaesthetic patient. Although the line of incision was carried well 
 be^^ond the pigmented border, the pigmentation became a year later 
 well marked in the skin surrounding the cicatrix. 
 
 The occurrence of gangrene, necrosis of bones, perforating ulcers 
 involving not only the extremities, but threatening important organs, 
 as the nose, throat, and larynx, has necessitated a number of surgical 
 expedients. 
 
 An I fi I tat ions through the thigh, knee, leg, ankle, or arm are most 
 frequently performed for leprous gangrene and ulceration of the 
 extremities. 
 
 Perforating Ulcer. — Free incisions down to the bone in perforating 
 ulcers and sinuses leading to dead bone give great relief from pain. 
 In all cases the incision should be sufficient to permit the removal of 
 all necrosed bone to insure healing. 
 
 In perforating ulcers of the sole, Beaven Rake recommends that 
 the bistoury be thrust through the foot from the sole, coming out 
 
LOCAL TREATMENT. 597 
 
 througli the dorsum or between tlie toes ; if the ulcer is near one side, 
 the knife should be brought out laterally, the gaping wound being 
 packed with lint and allowed to granulate. 
 
 In deep ulcerations of the lower extremity, which interfere seri- 
 ously with the patient's comfort and locomotion, the gangrenous flesh 
 should be cut away, any necrosed bone removed, and the parts dressed 
 aseptically. Amputation maj be employed in gangrene of the fingers 
 and toes, as it gives a better result than the spontaneous amputation 
 of nature. 
 
 T\Tien the bone comes away piecemeal, as it often does in these 
 cases, the process is long and painful, and a flail-like condition of the 
 member is apt to ensue. 
 
 Of the 830 removals of bone in Beaven Kake's series of cases, 532 
 were in anaesthetic lepers, 6 in tubercular lepers, and 92 in cases of 
 the mixed type. 
 
 "In diffuse brawny swellings without suppuration of the lower 
 extremities, long free incisions from the knee to the ankle or from 
 the ankle to the toes are recommended, as they relieve pain and ten- 
 sion from the oedematous infiltration. 
 
 Operations on the hands and feet of anaesthetic patients may be 
 performed in many instances without anaesthetics as the parts are 
 devoid of sensation. Patients frequently chop oft^ a useless member 
 without flinching. 
 
 N erve-str etching , for the relief of distressing neuralgia and pain 
 along the course of nerves, and the heahng of perforating ulcers in 
 areas supplied by the nerves, has been practised by Beaven Bake, 
 Neve, and others with good results. 
 
 Neve, of Kashmir, reports that in 100 cases of leprosy the nei-ves 
 were stretched 270 times. Great improvement was noted in the tracts 
 supplied by the nerves, except in the face and parts supplied by the 
 cranial nerves. Neve regards "nerve-stretching most valuable as a 
 palliative." 
 
 Beaven Eake practised this procedure 113 times on lepers in the 
 Trinidad Asylum. He gives detailed accounts of the results in 100 
 operations on 60 patients : the sciatic was stretched 26 times, the ex- 
 ternal popliteal 11 times, the median 14 times, the ulnar at the elbow 
 18 times and above the wrist 4 times, and the supraorbital once. 
 
 The operation was done for ulceration 38 times ; for pain 9 times ; 
 for anaesthesia 33 times; pain vanished at once, with some improve- 
 ment, though not complete or permanent; in tubercular cases 18 
 times; no result. About one-half of the patients were benefited. 
 Eake thought that the chief value of the operation was demonsti-ated 
 in perforating ulcer, some cases of necrosis and pain associated with 
 
598 MORROW— LEPROSY. 
 
 perforating ulcer or peripheral neuritis. He found that the nerves 
 operated on were enlarged in 48 cases. 
 
 Beaveu Rake's theory of the rationale of this operation is that the 
 results are due to changes in the spinal ganglia produced by the 
 stretching. Another theory is that the stretching to which the swollen 
 and congested nerves are subjected empties the blood-vessels and 
 lymphatic spaces of the affected part, and thus relieves the congestion 
 and improves the condition of the patient. 
 
 The ocular lesions of leprosy are very common and most dis- 
 tressing. Leloir noted that of 64 lepers at Molde, in Norway, 41 
 had ophthalmic lesions, 37 in both eyes, while 6 were entirely 
 blind. When there was an invasion of the cornea, Daniellsen and 
 Boeck arrested the progress of the tubercles by cauterizing the 
 conjunctiva or cornea around the tubercles. The tubercles which 
 form on the conjunctiva may be removed from time to time with 
 curved scissors. Kaurin performed keratotomy for the same pur- 
 pose. Ligation of the vessels sup^jlying the tubercles has been suc- 
 cessfully done. The operation sometimes checks the growth of the 
 tubercles temporarily, but it is only palliative. As soon as the col- 
 lateral circulation becomes established the tubercle again increases. 
 Various delicate operations have been successfully^ I)erformed with 
 the object of correcting the epiphora and other disagreeable sj'mp- 
 toms which result from the paralj^sis of the orbicular muscle and con- 
 sequent inability to close the eyelids. For paralytic ectropion Kau- 
 rin performed tarsorrhaphy of the inner third of the eyelids, thus 
 raising the lower lid and permitting their closure. Cataract is 
 common in leprosj^ and extraction maj be successfulh' performed, 
 oftentimes without an anaesthetic, as the parts are devoid of feeling. 
 Iridectomy has also been employed in cases in which total blindness 
 is threatened. 
 
 The lesions of the nose, mouth, and throat, the secretions from 
 which emit a most offensive odor, especiallj^ in the ulcerative stage, 
 and are most deleterious to the patient from being constantly swal- 
 lowed, should be treated with medicated sprays, antiseptic douches, 
 or caustics. For the purpose of destroying leprous lesions of the 
 nasal fossae and of the buccopharyngeal cavity the thermo- or gal- 
 vanocautery will be found most available. In the local treatment of 
 leprosy of the upper air and food passages all the resources of the 
 rhinologist and laryngologist should be brought into requisition — 
 cauterizations, irrigations, insufflations of liquids or powders which 
 are emplo\'ed in the special treatment of affections of these parts. 
 Tracheotomy has been repeatedly performed for dysphagia and ste- 
 nosis of the larynx, due to invasion of leprous neoplasms. In Nor- 
 
HYGIENIC TREATMENT. 599 
 
 way, Abraliam observed one patient who had worn a tube for three 
 years, another for seven years, and another for ten years. In other 
 cases the larynx had become functionally useful and the tubes were 
 discarded. 
 
 Hygienic Treatment. 
 
 Among the means which experience has shown to influence most 
 favorably the course of leprosy are good hygienic conditions. If the 
 interest of the leper alone were to be consulted, his removal to a 
 country where leprosy is not endemic would be recommended. The 
 most favorable conditions comprise residence in a temperate climate, 
 well-ventilated rooms, freedom from exposure to damp and cold, care 
 of the skin by frequent warm baths, massage, warm woollen cloth- 
 ing, exercise in the open air, and an abundance of nutritious food, 
 fresh meat, vegetables, milk, etc. Baths should be especially insisted 
 upon in the ulcerative period, followed by emollient, soothing oint- 
 ments, since on account of the suppression of the functions of the 
 cutaneous glands the skin becomes dry, fissured, and covered with 
 the products of the suppurative lesions. 
 
 Since traumatisms and injuries are often the starting-points of 
 obstinate and destructive ulcerations, we should carefully guard against 
 all exposure to external causes of irritation and wounds of the in- 
 teguments. The eyes should be protected from contact of dust and 
 other irritant particles. 
 
 The individual capacity of resistance should be strengthened by 
 all measures calculated to build up and maintain the general health 
 at the highest possible standard. 
 
 Geneeal Conclusions. 
 
 The following conclusions may be formulated as embodying the 
 author's views upon treatment: 
 
 Leprosy is in the vast majority of cases an incurable disease. 
 
 There is no substance known to science which, introduced into 
 the body, is capable of destroying the bacilli without destroying the 
 living cells which contain them. 
 
 Furthermore, from the nature of the pathological changes and the 
 position of the baciUi in the deeper tissues, it is evident that no ger- 
 micidal agent can be brought into direct contact with the pathogenic 
 organisms, and hence all treatment which has for its object the de- 
 struction of the bacilli is impossible of application. 
 
 The treatment of leprosy has been essentially empirical ; whether, 
 as has been claimed, certain remedies act by virtue of their sterilizing 
 
600 MORROW — LEPROSY. 
 
 properties upon the living tissues, rendering them unsuitable to tlie 
 growth and multiplication of the bacilli, cannot be determined. 
 
 The special remedies which clinical exi)erience would indicate to 
 be of the most value are chaulmoogra oil, gurjun oil, and certain 
 agents of the Strychuos family ; all are, however, more or less disap- 
 pointing in their results. 
 
 All observers agree that in advanced cases, when general dissemi- 
 nation of the bacilli has taken place, curative treatment is absolutely 
 futile. The most favorable conditions are that treatment be instituted 
 early, and that it be prosecuted actively and energeticallj^ during a 
 prolonged period. 
 
 The serum therapy of leprosy, by the injection of the Carrasquilla 
 serum and other antileprotic serums, has not fulfilled the exj^ectations 
 of its value. In the hands of numerous experimenters its use has 
 been condemned by its clinical results. 
 
 The treatment of leprosy bj' injections of tuberculin has been 
 disappointing in its results. Experiment has shown that the action 
 of tuberculin is positiveh' pernicious in setting free the bacilli in 
 the tissues and determining the development of new foci of the 
 disease. 
 
 The more or less rapid development of leprosy depends upon the 
 resistance of the tissues to the inroads of the bacilli. In exceptional 
 but well-authenticated cases, this capacity of resistance is sufiicient to 
 dominate and destroy the pathogenic microbes, as shown by the 
 observation of abortive cases in which indubitable signs of the dis- 
 ease definitely disappear and never recur. 
 
 This capacity of resistance may be strengthened by change of cli- 
 mate, improved habits of living, and measures calculated to build up 
 and maintain the general health at the highest standard. 
 
 Observation shows that the removal of a leper from an infected dis- 
 trict to a more favored climate exerts a marked modification uj)on the 
 course of the disease ; tliere is, for a time at least, an arrest or retro- 
 gression of the symptoms. This lull in the manifestations is, as a 
 rule, disajjpoiutiug in its duration. Of the one hundred and sixty- 
 eight Norwegian lepers who have emigrated to this couutrj-, there is 
 no record of a single definite cure. 
 
 A dry, moderately cool, mountain atmosphere is most favorable in 
 its influence upon the disease. A hot moist climate, or a damj) cold 
 climate are both unfavorable. 
 
 A nutritious diet of fresh meat and vegetables, warm clothing, ex- 
 ercise in the open air, and freedom from exposure to damp and cold, 
 are important elements in the hygienic course of treatment. 
 
 The care of the skin by frequent hot baths, massage, with inunc- 
 
PROPHYLAXIS. 601 
 
 tions of oils, etc., should receive as much attention as the constitu- 
 tional treatment. 
 
 The surgical treatment of leprous sores, necrosed bones, perforat- 
 ing ulcers, the excision of tubercles, amputation of the members, 
 tracheotomy, various delicate operations about the eye, nerve-stretch- 
 ing for the relief of pain, and the removal of threatening complica- 
 tions are of the most signal benefit. 
 
 Finally, we may conclude that while medical science holds out no 
 definite promise of cure to the leper, its resources are sufficient to 
 arrest or retard the progress of his disease, to promote his comfort, 
 and to prolong his life. 
 
 PROPHYLAXIS. 
 
 In dealing with diseases which are confessedly beyond our thera- 
 peutic resources prophylactic measures become magnified in imijor- 
 tance. In the case of leprosy the uniform failure of all specific 
 curative treatment which has been thus far instituted gives an added 
 promineuce to the value of preventive treatment. 
 
 Within recent times the prevention of the spread of leprosy has 
 become a question of live practical' interest to our sanitary authori- 
 ties. The development of new epidemic and endemic centres of the 
 disease in various countries previously exempt, its reawakening into 
 activitj^ in countries where it was supjDOsed to have become extinct, 
 and its undoubted spread in many parts of the world have stimulated 
 a renewed interest in its study, especially of the sanitary measures 
 best adapted for its suppression or control. The principal object of 
 the convocation of the International Congress of Leprologists which 
 convened in Berlin in October, 1897, as set forth in the call, was " to 
 consider the best means for the entire suppression of leprosy." The 
 motive of the call was stated to be the " danger of a new pandemic 
 outbreak of leprosy on the European continent." While a convic- 
 tion of the imminence of such danger is not shared by the writer, it 
 must be admitted that with the beginning of the twentieth century 
 both Europe and the United States are confronted with conditions 
 which may render leprosy a serious menace to the public health of 
 these countries. Some of these conditions may be briefly referred to. 
 
 At the present time the ambition for territorial expansion and the 
 desire for colonial possessions which have seized upon the dominant 
 nations of Europe have extended to this country, and the retention 
 of recent territorial acquisitions seems to have been accepted as a 
 settled policy for the future. The genius of modern civilization ap- 
 pears to be directed in the line of appropriating the territories of 
 the older countries, China, India, Africa, and partitioning them among 
 
602 MORROW — LEPROSY. 
 
 tlie younger and more aggressive nations. It must not be forgotten, 
 however, that, in ojjening wide the doors of communication and inter- 
 course with these older semi-civilized nations in which plagues and 
 pestilences have been domiciled for centuries, we are also brought 
 closely in contact with the diseases to which thej^ are subject. It is 
 probable that many of our soldiers who form the army of occupation 
 in Cuba, Porto Eico, and the Philippines will bring back leprosy as 
 a souvenir of their sojourn in these islands. The significance of pos- 
 sible danger to the health interests of modern civilized countries from 
 this source has been recognized, and schools for the studj- of tropi- 
 cal diseases have been established with the view of employ iug the 
 means and appliances of scientific medicine in their study, and utiliz- 
 ing the resources of modern sanitary science in their prevention and 
 cure. 
 
 In addition to the enlarged facilities for rapid communication and 
 intercourse between the peoples of different countries, the opening 
 up of trade and commerce, and the creation of new business and in- 
 dustrial enterj) rises, the commercial proximity thus established tends 
 to bring infected and non-infected races into closer and more inti- 
 mate relations. Our extensive maritime relations with other coun- 
 tries in which leprosy is endemic will enable leper subjects to find 
 ready transportation to our shores, and there is every reason to fear 
 that leprosy may eventually come to be one of our current maladies. 
 The only question is whether leprosy can survive the contact of civil- 
 ization; whether the better stamina of the people, the improved 
 hygiene public and i)rivate, and our modern methods of sanitary 
 supervision will be sufficiently strong to cope with the disease. 
 
 It is a fact worthj^ of consideration that the colonies of every 
 European country, with scarcely an exception, are infected with 
 leproSy, and the same may be said of the recent territorial acquisi- 
 tions of this country. The United States in annexing Hawaii has 
 incorporated a native population tainted with leprosy. In absorbing 
 Porto Rico, and in establishing a protectorate over Cuba, our people 
 have been brought into most intimate commercial and social relations 
 with the leprous inhabitants of these countries. In appropriating 
 the Philippine Islands we have become possessed of one of the most 
 important centres of leprosy in the far East, and which, from its 
 proximity to the "Cradle of Leprosy," in Kwang-Tung and Hong- 
 Kong, must be exposed to continued invasion of fresh increments of 
 infected material in the Chinese coolie lepers. It is probable also 
 that Japan will furnish a contingent of leprous immigrants from 
 among its overcrowded and non-productive population. The danger 
 will probably be not so much from the importation of native leper 
 
PEOPHYLAXIS. • 603 
 
 immigrants from these colonies, but from the exposure of our own 
 people, who will be attracted by considerations of trade or commerce, 
 to contact with the leper population. The lepers that have recruited 
 European countries in the present century have been almost without 
 exception sailors, soldiers, or official representatives of the administra- 
 tive departments who have sojourned for a longer or shorter period 
 in the leper colonies. In throwing wide open the portals of commu- 
 nication between our own and leprous countries we are virtually re- 
 leasing the diseases which had been secluded behind the closed doors 
 of caste and insular prejudice for ages. These facts have a most im- 
 portant bearing upon the prophylaxis of leprosy. 
 
 In the study of the prophylaxis of leprosy the teachings of the 
 observation and experience of other countries and other ages should 
 be utilized. First in point of antiquity, as well as of extensive experi- 
 mentation, may be considered the isolation or segregation of lepers. 
 In appreciating the value of this method and its adaj^tation to the 
 conditions of the leprosy problem as it presents itself at the jjresent 
 day, we may inquire into its utility as a prophylactic measure applied 
 to diseases in general and the practical results of its application to 
 leprosy in particular. 
 
 The separation of the sick from the well as a means of preventing 
 the spread of disease is based upon science and common sense, and 
 has been sanctioned by the results of experience in all ages. So far 
 as any sanitary procedure can be regarded as inspired, the separation 
 of the clean from the unclean may be considered a divinely appointed 
 measure for the prevention of disease. Leprosy enjoys the distinc- 
 tion of having been the first, and for many centuries the only, dis- 
 ease to which this cardinal principle of preventive medicine was ap- 
 plied. Indeed, sanitary science may be said to have had its origin in the 
 measures of isolation and segregation which were instituted in ancient 
 times for the control of leprosy. While the wisdom of this prophy- 
 lactic measure is under certain conditions unquestionable, the method 
 of its practical apjplication in earlier times cannot be commended. 
 
 Under the Mosaic law it was rigorously enforced with the strict- 
 ness with which punishment is meted out to crime, but with a lack 
 of discrimination and humanity which could be justified only by 
 the semi-civilized conditions of the age. Leprosy was regarded as a 
 mark of divine disfavor, a retribution for sin, and human approval 
 of divine judgment was shown by cruelty, oppression, and persecu- 
 tion. It is worthy of note that this traditional conception of the 
 moral etiology of leprosy still survives in certain Oriental countries. 
 In China, India, and Japan at the present day leprosy is accepted as 
 a punishment for sins committed by the individual or by his ances- 
 
604 MORROW — LEPROSY. 
 
 tors, and lepers visit shrines and lioly places in expatiation of these 
 fancied sins. At a later period in Jewish history the Divine Physi- 
 cian seems to have shown a special tenderness and consideration for 
 lepers, which markedly contrasts with the sentiment of hostility and 
 ostracism that characterized the spirit of the old Hebraic law. 
 
 For mau}^ centuries the severe and cruel measures formulated in 
 the Levitical code for the repression of leprosy were preserved and 
 l^erpetuated. In the Middle Ages, when Europe was overrun with 
 the plague of leprosy, the regulations for its repression exhibited the 
 same spirit of harshness and persecution as animated the Jewish law- 
 givers. The leper was separated from his family and friends, his 
 marriage was annulled, his civil rights were abrogated, and he was 
 pronounced legally dead, and incarcerated in a lazaretto until death 
 should release him. If we comi^are these projjhy lactic measures with 
 those of barbarous and uncivilized countries, we shall find that the 
 principal difference was in the greater sanctity in which human life 
 was held by the Jews and Christians. The aboriginal methods were 
 much more summary, but perhaps more merciful, in the swift ending 
 of the patient's suffering. In Africa, Sumatra, the Fiji Islands, and 
 many other uncivilized countries, the aborigines were in the habit 
 of privately killing lepers and burning their bodies. 
 
 If we contrast the ancient methods of dealing with leprosy with 
 those practised in modern times, it is evident that the tendency is 
 towards a more intelligent and humane treatment of lepers, although 
 the traditional spirit of intolerance, ostracism, and persecution still 
 survives in many countries. 
 
 The chaotic confusion of skin diseases has been cleared up, and, 
 thanks to our greater precision of diagnosis, it is exceptional for other 
 forms of disease to be confounded with leprosy. Again, under the 
 sanitary policy of many enlightened governments proscriptive meas- 
 ures are now enforced not only with a more intelligent discrimina- 
 tion, but also with more humanity. 
 
 So far as we know, leprosy was the only disease to which segrega- 
 tion was applied in earlier times. In modern times the principle has 
 been extended in its application to a large group of diseases which 
 come within the category of contagious or infections diseases. At 
 the same time there are certain other diseases of a recognized conta- 
 gious nature which do not come within the provisions of compulsory 
 notification and isolation; for example, varicella is not isolated, 
 although equally contagious with smallpox, because it is a mild dis- 
 ease and not a cause of death. 
 
 The isolation of venereal diseases is not regarded as feasible or 
 practicable, largely because they are private or secret, and the risk to 
 
PROPHYLAXIS. 605 
 
 others of contagion is chiefly clue to the voluntary exposure of the 
 healthy to contact with the diseased. Syphilis is perhaps an excep- 
 tion, although the cases of syphilis insontium are comparatively few. 
 In regard to these diseases, it is admitted that they may be severe in 
 their effects, both immediate and remote; they entail suffering and 
 may endanger life ; they have an important socio-economic relation to 
 the public health so far as their incapacitating effect upon wage-earn- 
 ers, army and navy invalidism, etc., is concerned, and also in their 
 undoubted influence as a factor in the depopulation of countries. The 
 individual liberty of these diseases is protected by their nature, their 
 secrecy, and furthermore, perhaps, by the failure of all measures hith- 
 erto proposed for their correction. 
 
 Tuberculosis, the modern Samson among diseases, which slays 
 its tens of thousands, while smallpox, measles, scarlatina, etc., slay 
 their hundreds or thousands, is recognized as a contagious and infec- 
 tious disease, yet modern sanitary science has not placed it under the 
 ban of notifiable diseases. This is because of its widespread preva- 
 lence, the impossibility of isolating and supporting the great -army 
 of consumptives, and the fear of infringing upon the rights of the 
 individual; again, because of its chronicity. Isolation contemplates 
 brevity, and finds its proper application in diseases which are of 
 short duration, and render the patient temporarily unable to care for 
 himself. But a consumptive may not be incapacitated for business ; 
 he may have years of usefulness and life before him. The disease 
 does not place him liors du combat in the battle of life. Indeed, he 
 may hope for a comparative or even complete cure. Sanitary science 
 cannot attack or apprehend him in these strongholds. The result is 
 that the sanitary supervision of tuberculosis is restricted to the disin- 
 fection or destruction so far as practicable of the sputa containing the 
 disease germs, the education of the patient as to the risk he carries 
 to others and the best means to avoid those risks, and the establish- 
 ment of sanatoria in favored regions for the cure or amelioration of 
 the disease. 
 
 In leprosy we have a disease which presents many analogies with 
 tuberculosis. As has already been said, there is no infectious disease 
 so mild in its initial manifestations as leprosy. There is no disease 
 of a necessarily fatal character which grants its victim so long a lease 
 of life ; even after characteristic evidences of the disease are manifest 
 the patient may live in comparative health for many years, with fac- 
 ulties unimpaired, and the capacity for usefulness and work practically 
 undiminished. This is especially true of anaesthetic cases. It may 
 be questioned whether it is just, humane, or necessary for the protec- 
 tion of society in countries where leprosy does not seriously menace 
 
606 MORROW — LEPROSY. 
 
 the public health to incarcerate such a person iu a lazaretto until 
 death releases him. 
 
 It will be seen that mere isolation of the sick by no means repre- 
 sents the highest wisdom of sanitary science or the perfection of sani- 
 tary methods. The diseases to which it is api:)licable are to be differ- 
 entiated, not only from the point of view of their gravity, but from 
 that of their prevalence and their tendency to propagate themselves, 
 and it is to be adapted to the peculiarities of each particular disease. 
 The science of modern preventive medicine takes into account, not 
 only the nature and contagiousness of a disease, but also the degree 
 of its contagioiis activity and the conditions under which this conta- 
 gion operates. The behavior of the disease as modified by these con- 
 ditions, and its epidemic, endemic, or sporadic character are to be 
 considered in determining the character of the sanitary measures to 
 be employed for its control. Each disease must be studied tn relation 
 to its environment, the character of the soil, and the conditions which 
 favor or lessen its tendency to spread. We do not apply, nor do we 
 deem" necessary, the same sanitary regulations for yellow fever iu New 
 York or the City of Mexico as for the same disease in Havana or 
 Vera Cruz, because the conditions which favor its si)read exist in the 
 two latter cities, but not iu the former. 
 
 Leprosy does not comport itself as a contagious disease under all 
 conditions of environment. Its contagious mode is a law unto itself. 
 It shows the most remarkable variations in its virulence and in its 
 development and decline. In some countries its contagious viru- 
 lence is manifest with all the characteristics of a violent epidemic. 
 In other countries its contagiousness is mild, scarcely manifest. It 
 is an error to suppose that in all countries where leprosy is intro- 
 duced it will necessarily spread, or that every leper will communicate 
 his disease to those with whom he comes in contact. It is equally 
 erroneous to conclude that we possess in segregation or isolation an 
 infallible or sure cure for the prevention of leprosy, or that these 
 measures employed in the most active, energetic, and vigorous man- 
 ner will infallibly cut short its epidemic violence. It may be claimed 
 that segregation constitutes the best means known to sanitary science 
 for the prevention of leprosy, but the indications for its employment 
 are to be differentiated and adapted according to the manifestations 
 of its contagious power in different countries and the degree of their 
 leprous contamination. 
 
 We may now inquire what has been the practical result of segre- 
 gation in certain countries where it has been applied. The success- 
 ful results of segregation are claimed to have been most brilliantly 
 illustrated in the extinction of the leprosy epidemic of the Middle 
 
PKOPHYLAXIS. 607 
 
 Ages, and in more recent times in the marked decline of the Norway 
 epidemic It may be observed that a great many intelligent and judi- 
 cious students of the history of leprosy insist that the cause of the 
 progressive diminution of the disease in the fourteenth and fifteenth 
 centuries and of its practical disappearance from Europe in the six- 
 teenth and seventeenth centuries was not due to the admittedly im- 
 perfect system of segregation then employed, but should rather be 
 ascribed to the improvement in the material hygienic and social con- 
 ditions of the people ; to the better food, better habitations, and the 
 increase in material prosperity. In the Middle Ages strict segrega- 
 tion, if we are to trust historical evidence, was never carried out. 
 
 Newman, in his prize essay on " The History of the Decline and 
 Final Extinction of Leprosy as an Endemic Disease in the British 
 Islands" (New Sydenham Society, 1895), believes that' probably the 
 famine (1315) and black death (1349) materially assisted in the exter- 
 mination of lepers in the fourteenth century. He believes that the 
 decline and final extinction of endemic leprosy was due not to segre- 
 gation, but to the general and extensive social improvement in the life 
 of the people and to a complete change in the poor and insufficient 
 diet, the agricultural advancement, improved sanitary and land drain- 
 age, etc. 
 
 Jonathan Hutchinson is also inclined to the belief that segrega- 
 tion exerted little influence in the decline of the mediaeval epidemic, 
 but that it took place by slow degrees pari passu with the advance of 
 agriculture and in social comfort. 
 
 As regards the decrease of leprosy in Norway, it may be said that 
 no effective system of isolation or segregation worthy the name has 
 ever been carried out in that country. Before 1885 the lepers, except 
 a limited number who were unable to provide for themselves, did not 
 enter the hospitals. Entrance into the leprosy hospitals was volun- 
 tary, not compulsory, and lepers were free to come and go. More- 
 over, leprosy had already begun to decrease before 1885, at which 
 date the leprosy law was enacted which made entrance into the hos- 
 pital compulsory for paupers who could not provide for their own 
 wants. "The leper, if he will live at home, must have his own 
 room, at least his own bed, his clothes must be washed separately, 
 he must have his own eating apparatus- — spoon, knife, fork, etc. If 
 he cannot or will not comply with this regime, he is obliged to enter 
 an asylum." 
 
 It is generally conceded that the leprosy laws of Hawaii are more 
 complete and rigorous and are enforced with more strictness and im- 
 partiality than in any country in the world. Segregation has been 
 practised for over a third of a century in these islands with a vigor 
 
608 MORROW — LEPROSY, 
 
 and severity whicli would not be possible among a people who were 
 jealous of their personal rights or individual liberty-. What has been 
 the result of this thirty-five years' crusade against leprosy? Is it on 
 the increase, or is it in process of extermination? Taking the rec- 
 ords of the leper settlement as a basis of comparison, there would 
 seem to be no favorable sign of its extinction. In the first twenty 
 years of its establishment 3,076 lepers, in the next ten years 2,049 
 were consigned to the leper settlement. This large relative increase 
 of admissions, it is claimed, may be due not to an actual increase in 
 the number of lepers in the islands, but to a more active and vigorous 
 method of segregation within the last ten years. In the first-men- 
 tioned period the number of lepers at the settlement ranged from two 
 hundred to eight hundred. In recent j'ears the number has varied 
 from one thousand to twelve hundred, and the annual consignment of 
 lepers shows little diminution in number from year to year. 
 
 Segregation must always be a defective measure from the very 
 nature of the disease, simply because all cases of leprosy cannot be 
 brought within the sphere of its oi^eration. No official dragnet can 
 ever be constructed which will gather up all the lepers in any countr}'. 
 The little fishes, the latent, incipient lepers will escape. Segrega- 
 tion, although incomplete, undoubtedly tends to limit the spread of 
 the disease by removing or rendering innocuous just so many sources 
 of contagion. 
 
 Experience teaches us that harsh measures of isolation and segre- 
 gation always defeat the object in view because their chief result is 
 the concealment of cases. Unless human nature changes, the more 
 rigorous and severe the measures adopted the greater will be the 
 incentive to evade and escape their operation, no matter how benefi- 
 cent their purpose. In South Africa the recent leprosy commission 
 came to the conclusion that the attempt to send all lepers to Robben 
 Island only led to many lepers being hidden throughout the country. 
 In the Berlin Leprosy Congress Alvarez of Honolulu declared his " op- 
 position to the adoption of rigorous or cruel measures against leprosy 
 in Hawaii, not only because they led to the concealment of cases, 
 and thus defeated the object for which they are designed, but because 
 we ought to adhere to principles of humanity and not treat the lepers 
 as if they were criminals." 
 
 Similar results from the operation of strict segregation laws have 
 been observed in all countries where an attempt has been made to 
 enforce them. 
 
 While allowing segregation to be the most effective measure known 
 to sanitary science for the prevention of leprosy, its application is not 
 universally practicable. In India segregation is not practicable be- 
 
PROPHYLAXIS. 609 
 
 cause of tlie number of lepers. Any government would stand appalled 
 and helpless before the task of segregating and supporting more than 
 one hundred thousand individuals. The same consideration applies 
 to leprosy in China and Japan. 
 
 Again, the social and political conditions in different countries 
 must be considered in applying measures vrhich infringe upon per- 
 sonal liberty. Serious difficulty -was met with in India recently in 
 endeavoring to induce the people to adopt simple sanitary precautions 
 against the plague, an acute and fatal disease. One may appreciate 
 the difficulties to be surmounted in instituting harsh measures against 
 a disease which has existed in piermanence among them from 'time 
 immemorial. 
 
 It must be remembered that in old countries where leprosy has 
 existed for centuries there are deep-rooted customs which seem al- 
 most as sacred as religious observances and which have all the force 
 of unwritten laws ; these customs cannot be eradicated without oppo- 
 sition or open revolt. It is not possible for anj- government by com- 
 pulsory laws to compel such people to have recourse to national estab- 
 lishments for isolation and treatment. 
 
 It was with a full knowledge of these facts that the Berlin Leprosy 
 Congress unanimously adopted the following resolutions as embracing 
 the views of the congress upon the best means to be employed for the 
 control and suppression of leprosy. 
 
 First, in such countries where leprosy is endemic, and in all coun- 
 tries where leprosy forms foci or has a great extension, isolation is 
 the best means of preventing the spread of the disease. 
 
 Second, the system of obligatory notification and surveillance and 
 isolation, as practised in Norway, should be recommended to all 
 nations with local self-government and a su:fficient number of physi- 
 cians. 
 
 Third, it should be left to the administrative authorities after con- 
 sultation with the medical authorities to take such measures as are 
 applicable to the special social conditions in each country. 
 
 These recommendations seem eminently wise and judicious and 
 coincide for the most part with the views expressed by the writer sev- 
 eral years ago. As regards "obligatory notification," it may be said 
 that the wisdom of a measure which renders it obligatory on the 
 part of physicians to report to the sanitary authorities every case of 
 leprosy coming under their observation is questionable in countries 
 when leprosy does not prevail to an alarming extent. In coun- 
 tries where segregation is compulsory, notification is, of course, 
 necessary to the effectiveness and success of the scheme. In this 
 country it might serve to locate a few cases of leprosy unknown to the 
 Vol. XVIII. —39 
 
610 MORROW— LEPROSY. 
 
 authorities, but unless they are empowered to isolate such cases they 
 could exercise over them only a sort of sanitary surveillance of doubt- 
 ful utility, and which, if oppressive, would result in the migration of 
 the leper to another locality. The action of the Philadelphia board 
 of health a few years ago in fining a physician for not reportiug two 
 cases of leprosy under his care was generally condemned by the med- 
 ical profession. 
 
 Another aspect of the question is worthy of consideration. In 
 countries where lepros\' is not endemic few jjhysicians have ever seen 
 a case. They are not familiar with the clinical features of the dis- 
 ease and are therefore uot competent to make a diagnosis. The ver- 
 dict of leprosy carries with it a grave responsibility, and should never 
 be pronounced, or at least accepted, as final unless confirmed by a 
 special board of competent experts. The consequences to the individ- 
 ual are of such a serious character that the same care and intelligent 
 skill should be exercised as contemplated in the law which provides 
 for a commission of lunacy to inquire into the mental soundness of an 
 individual. 
 
 One prophylactic measure which meets with universal acceptance 
 is the endeavor to confine leprosy in countries where it already exists 
 and prevent its extension in countries exempt or but slightly infected, 
 by the exclusion of all lejn-ous immigrants. As will be seen in another 
 section of this article, quarantine laws prohibiting the introduction of 
 leprous immigrants have been enacted by various governments, and 
 their strict enforcement guaranteed hj a heavy penalty of fine or im- 
 prisonment for violation of their provisions, but from the very nature 
 of the disease this measure is only partially effective. 
 
 As I wrote several years ago, " no system of quarantine has ever 
 been devised which will effectively prevent the importation of a dis- 
 ease so insidious in its development or so little manifest on ordinary 
 inspection as leprosy." 
 
 A thorough examination for signs of leprosy would necessitate the 
 stripping of the entire body, so that every portion of the cutaneous 
 surface might be subjected to inspection — a i)rocedure which for 
 many reasons is entirely impracticable. 
 
 Hansen says : " I have been given the names of many lepers in 
 America whom we did not know to be lepers when the}- left Norway. 
 A majority of them have got distinct eruptions after their arrival in 
 America. Even after the most scrupulous examination of these 
 people at the time of their departure from Norway we could not 
 have been able to diagnosticate their disease, and anj- prohibition 
 of the immigration of lepers will be for the same reason useless." 
 According to Bracken, " it would be far more probable to say that 
 
PROPHYLAXIS. 611 
 
 twenty-five of the fifty-one lepers had the disease before leaving 
 Europe." 
 
 That we are constantly importing leprosy is a recognized fact. 
 Quarantine protection could be made more effective by international 
 cooperation between governments in which not only the leper immi- 
 grant, but all immigrants coming from leprous families, should be 
 examined before they embark, and even if they show no signs of 
 the disease, they should be kept under surveillance for several years 
 after they arrive in the new country in order to watch for develop- 
 ments. The good effect of such a system is shown in the work- 
 ing of the international laws regulating the importation of Japanese 
 contract laborers into Hawaii. The Japanese laborers are examined 
 before leaving their own country and also upon their arrival in Hawaii. 
 During the period in which these laws have been in operation among 
 the twenty-eight thousand Japanese laborers who have been brought 
 to Hawaii only six cases of leprosy developed, and these were re- 
 turned to Japan. 
 
 At the jn'esent day there is a wide difference in opinion among 
 leprologists as well as sanitary authorities respecting the value, or 
 rather the necessity, of employing compulsory segregation for the sup- 
 pression of leprosy in this country and Europe. Some contend that 
 such radical measures constitute the only effective means at our com- 
 mand for the control of the disease, and they formulate the proposi- 
 tion that every leper, whenever and wherever found, should be at once 
 isolated from all contact with healthy individuals and that this com- 
 pulsory isolation should be enforced by government edict. It may 
 be said that a sanitary measure for the prevention of every disease is 
 like a panacea for the cure of all diseases : " what is good for all is 
 good for nothing." There is no doubt that an unreasoning enthusi- 
 asm often obscures the judgment and blinds the critical faculty, so 
 that one cannot intelligently decide as to the real value or efficiency 
 of a proposed measure. Just as in the curative treatment of disease 
 the indications vary according to the nature and course of the indi- 
 vidual disease, so sanitary and prophylactic measures must be adapted 
 to the character and the contagious mode of the particular disease. 
 They must be specialized or individualized. Under certain conditions 
 an expectant treatment, meeting the indications as they arise, is all 
 that is necessary. Under other conditions the treatment must be 
 energized. In other words, it must be symptomatic and adapted to 
 the peculiarities of the individual disease. 
 
 It is important, first of aU, to know the characteristics and course of 
 leprosy in a community or country in order to appreciate and measure 
 the prophylactic means which should be directed to its control. In 
 
612 MORROW— LEPROSY. 
 
 dealing with a disease so irregular and so variable in its contagious ac- 
 tivity, which seems to differ widely in different countries and in different 
 epochs under conditions which we can neither control nor comprehend, 
 it is evident that we cannot formulate regulations which are universalh- 
 applicable to all countries irrespective of the behavior of the disease, 
 its tendency to si:)read, and the degree of their leprous contamination. 
 
 In a country where leprosy is epidemic, as in the Sandwich Islands, 
 where there is great promiscuity in the habits of eating and drinking 
 and the mode of life is essentially communistic, where the natives are 
 too ignorant or indifferent to observe those precautions which science 
 has indicated as necessarj' to avoid contagion, and above all where the 
 disease manifests itself with intense virulence, strict segregation is a 
 necessary protective measure. But in this country, where tlie habits 
 of life are different, where persons are non-communistic in the mat- 
 ters of eating and drinking and sleeping, and where observation has 
 shown that the disease has a tendency to die out from natural causes 
 rather than to propagate itself, such harsh measures wotild be cruel 
 and inhuman, as they are unnecessary. It would be absurd to api)ly 
 the same repressive measures for the control of leprosy in England 
 and France as in their colonies in South Africa and New Caledonia, 
 where the natives are dirty and promiscuous in their habits, commu- 
 nistic in their modes of living, and who do not fear, but ignorantly 
 invite contagion. 
 
 From the above it is not to be inferred that the Avriter is an oppo- 
 nent of segregation ; on the contrary-, he believes that segregation is 
 the most effective measure that can be employed to limit the spread 
 of leprosj", and in some countries it is a necessary' measure ; but he does 
 not believe that it can ever result in the entire suppression of leprosy, 
 largely because of the nature of the disease and the impossibility of 
 making it thorough and complete. Upon this point may be quoted 
 the writer's views, expressed several years ago : " There can be no 
 doubt that if every leper on the face of the globe were removed 
 from all contact or communication wath the healthj- the disease 
 would become extinct with the death of the present leper popu- 
 lation. But isolation or segregation of lepiers in special communities 
 or hospitals, in order to be effective, must be thorough and complete. 
 In countries where the compulsory segregation of lepers has been 
 enacted by legislative authority its thorough enforcement has been 
 found to be impracticable. Even in the Hawaiian Islands, where the 
 energies of the Government have for years been directed to this end 
 with all possible vigor, it has failed to accomplish the object. Doubt- 
 less these measures have checked the disease, but the latter shows no 
 signs of extinction. 
 
PROPHYLAXIS. 613 
 
 " The causes of this failure are probably due largely- to the insid- 
 ious character of the disease. In every country where leprosy is en- 
 demic a large number of persons are infected months and years before 
 it is known to themselves or to others. Now unless leprosy is devoid 
 of contagious activity in the earlier stages segregation of this class is 
 absolutely essential to the effectiveness of the scheme. If such cases 
 are contagious, they are most dangerous since their intercourse with 
 family and friends is not restricted by the wholesome disgust which 
 the disease in the later stage always inspires. Again, manj- lepers 
 present in their face no visible sign of the disease, or they manage to 
 conceal all convicting Evidence for many years after it has developed. 
 Such persons must be active spreaders of the contagion. 
 
 " In this country, the compulsory segregation of lepers in lazaret- 
 tos, as has been recommended by some of our health authorities, can 
 scarcely be considered a necessary protective measure. Wherever 
 leprosy has been introduced, except in the moist, warm climate of our 
 Southern seaboard (Louisiana and Key West), it does not show an 
 alarming tendency to spread and develop new foci of infection. Pro- 
 fessional as well as public sentiment is ojjposed to the adoption of harsh 
 coercive measures to crush out an evil which does not seriously men- 
 ace the public health, but rather tends to die out from natural causes." 
 
 The endemic outbreak of leprosy in Louisiana, where the disease 
 had been quiescent and apparently extinct for a century or more, 
 shows conclusively that no measures for the control of leprosy can be 
 considered absolute or permanent. They must be modified and 
 adapted to changing conditions as they arise. Twenty -five years ago 
 the necessity of taking active measures for the suppression of leprosy 
 in that State would not have been considered urgent ; but the recent 
 statistics of leprosy in Louisiana show that the disease is spreading 
 and rapidly assuming alarming proportions. This is only another 
 illustration of the variability in the contagious activity of leprosy, 
 which manifests marked modifications in its virulence accordingly as 
 the conditions which influence its development and spread are pres- 
 ent or absent. In Louisiana an attempt has been made to prevent a 
 farther spread of the disease by the establishment of a leper asylum, 
 and while the advantages afforded by this institution have been ac- 
 cepted by a limited proportion of the leper population, the larger num- 
 ber of lepers is still at large. 
 
 In this country there is no possible protection against the spread 
 of leprosy by the enactment of laws for the segregation of lepers by 
 the different States. Segregation by single States is not practicable. 
 The result would be to drive lepers from States enforcing such prac- 
 tice to States where segregation was not practised. 
 
614 MORROW— LEPROSY. 
 
 Leprosy in the United States sliould be under the control of the 
 national Government. It in the opinion of our sanitary authorities 
 leprosy prevails in any State or section of this country to such an 
 extent as to prove a serious menace to the public health and demands 
 the segregation of the few for the pji'otection of the many, homes or 
 asylums with suitable hygienic surroundings should l)e provided for 
 the care and maintenance of lepers by the national Government. 
 Such asylums should he made comfortable and attractive and arranged 
 with special adaptation to the requirements and peculiar needs of their 
 inmates. In view of the chronicity of the disease, lepers should not 
 be condemned to confinement and inactivity, but should be j^rovided 
 with interests, meaus of employment, and recreation. As a large 
 proiDortiou of lepers are able to engage in some kind of industry, 
 3uch institutions might be made partly or wholly self-sustaining from 
 the jjroceeds of their industries. They might be conducted as colo- 
 nies, and provision shovild be made for giving occupation to those 
 able to work. 
 
 Many lepers would doubtless avail themselves of the advantages 
 of such an institution. There comes a time in the history of almost 
 every leper wlien he recognizes himself as an object of disgust and 
 pit}' to his family and friends, when he would be glad of an asylum 
 in which to end his miserable existence. Again, there are man}- 
 lepers who would gladly go to such a refuge as soon as the nature 
 of their disease is evident, for fear of spreading the contagion to their 
 families or friends. 
 
 An intelligent discrimination should be exercised in selecting cases 
 suitable for segregation. 
 
 Wliile we know nothing definitely of the modes of infection or the 
 conditions under which it takes place, we recognize Hansen's bacillus 
 as the active efficient cause of leprosy. Its degree of contagiousness 
 will depend upon the type of the disease and its stage of develop- 
 ment. In the pure type of anpesthetio leprosy the bacilli remain for 
 many years localized in the nerve tissues and are not found in the 
 cutaneous lesions. Sucli patients are probabl\^ exemiit from all pos- 
 sibilitj" of danger to others until at an advanced stage, wlien the tis- 
 sues break down and liberate the bacilli. In the writer's opinion 
 such cases bear much the same relation to the tubercular form, from 
 the point of view of contagion, as fibroid phthisis does to acute or 
 chronic pulmonary tuberculosis. 
 
 Lepers in good circumstances, able to provide themselves with 
 separate homes, and whose intercourse with the healthy could be 
 restricted under sanitary surveillance, should not be subject to segre- 
 gation. Observation shows that if a leper lives by himself, with sep- 
 
PROPHYLAXIS. 615 
 
 arate room, bed, board, etc., and does not come in intimate contact 
 with otliers, lie is practically innocuous so far as contagion is con- 
 cerned. In cases in wliicli sucli conditions cannot be complied with 
 the leper should be placed in a hospital or asylum specially provided 
 for this class of patients. 
 
 Wherever he may be placed, the leper himself, as well as his hab- 
 itation, should be kept scrupulously clean. In view of the fact that 
 contamination probably takes place chiefly from the nasal or buccal 
 excretions, these should be disinfected or destroyed with the game 
 care that would be exercised in cases of tuberculosis. In addition 
 strict antisei:itic and occlusive dressings should be ap[)lied to all open 
 sores or ulcerations. The garments of the leper should be separately 
 washed, and his clothes, linen, and ordinary objects of use should be 
 regularly disinfected from time to time. 
 
 Finally, if lepers are segregated they should receive expert med- 
 ical care. They should be treated energetically by all known means, 
 external or internal, sanctioned by experience. There is no doubt 
 that the lamentable failure of our therapeutic resources is due largely 
 to the conditions under which they have been aj^jjlied. The dominant 
 conviction forced upon lepers when placed in a lazaretto is that they 
 are shut up to die, and the utter hopelessness thus engendered ren- 
 ders all treatment a failui-e. Says a well-known writer: "When a 
 man affected with leprosy is taken from his home and friends, pro- 
 nounced unclean, immured in a lazaretto with many loathsome fel- 
 low-sufferers, and given to understand, as is usually the case, that 
 death is the only portal of escape open to him, the impression upon 
 his mind is such as to counteract the efl'ect of all remedies, and under 
 such circumstances nothing short of a miracle could be expected to 
 effect a cure of leprosy." 
 
 There is no doubt that if sanatoriums or colonies were instituted 
 for the reception of lepers, as in the case of tuberculosis, and pro- 
 vided with suitable means of treatment in the earliest stages, many 
 of the cases might be aborted or the fui'ther progress of the dis- 
 ease arrested. In view of the incompleteness of our knowledge of 
 leprosy and the necessity for the further study of the life history of 
 the bacillus and the conditions under which it is communicated, a 
 laboratory under the care of an expert physician should be estab- 
 lished in connection with every such asylum, for the study of the dis- 
 ease with the aid of modern technique and of the various instruments 
 of precision. 
 
616 MORROW — LEPROSY. 
 
 HISTORY. 
 
 Leprosy occupies r. peculiar positiou among diseases affecting the 
 human race. It is the most ancient, the most exclusively human, 
 and in the popular conception the most dreaded of all diseases. It 
 is a universal malady, affecting all races and occurring in all climates 
 and under all conditions of life. Although no race is immune, racial 
 peculiarities, climate, and the hygienic habits of civilization undoubt- 
 edly modify its spread. 
 
 Unlike the plagues and pestilences which formerlj' swept a,wa,j 
 entire populations and devastated countries and then disappeared for- 
 ever, leprosy has at certain periods of the world's history raged as a 
 veritable epidemic and then subsided and apparently disappeared, but 
 has never become extinct. It has preserved its individuality through 
 all the vicissitudes of time. It still survives and maintains its 
 supremacy- as the patriarch of diseases. 
 
 The origin of leprosy is lost in the night of time. There are cer- 
 tain special circumstances which have made the study of the early 
 history of leprosy one of peculiar difficulty. In endeavoring to trace 
 authentic records of leprosy in the earlier writings, we are confronted 
 with difficulties which arise from the lack of medical knowledge among 
 primeval peoples, their conseqiient defective description of disease, 
 and their inability to distinguish the morbid phenomena peculiar to 
 different diseases. It could hardh' be exj)ected in the undeveloped 
 state of medical science that Icprosj^ or any other disease would be 
 described with that accuracy and minuteness of detail which charac- 
 terizes the description of disease of the present day. We should 
 expect that only one or more prominent symptoms of the disease 
 which particularly impressed the observer would be mentioned. 
 
 Another difficulty arises from the doubt as to the exact meaning to 
 be given the terms emi:)lo3^ed by ancient writers in designating dis- 
 eases, and whether the words in different languages which have been 
 translated as leprosy actually referred to the same or to different dis- 
 eases. In the evolutionary changes to which all languages are sub- 
 ject the primary signification of certain terms is involved in obscurity, 
 and there has always been much diversit}^ of oi^iuion as to the iden- 
 tity of the Hebrew "tsaraath," the Greek "leuke," the Arabian "ba- 
 ras" with modern leprosy, but, irrespective of all these elements of 
 confusion, the fact remains that from the earliest attempts to record 
 the phenomena of disease there may be traced, through the succes- 
 sion of centuries, in the Greek, Arabian, and Roman writings, an 
 unbroken reference to a particular disease, which stands prominent!}" 
 
HISTORY. (;17 
 
 forth among other diseases, and which powerfully impressed the pop- 
 ular imagination by its severity, its hideous deformity, and its incur- 
 ability, and which we recognize as leprosy. It is equally certain that 
 many milder forms of disease, which present one or more symptoms 
 in common with this more formidable disease, were included in the 
 category of leprosy. This diagnostic error has been perpetuated 
 through mediaeval times and is still committed at the present day. 
 
 In the Middle Ages the diagnosis of leprosy was still in a state of 
 chaotic confusion, and in the leproseries were found numerous exam- 
 ples of almost every form of cutaneous disease. Even in countries 
 where leprosy is now endemic the result of the examination of sup- 
 posed cases of the disease by presumably skilled and competent phy- 
 sicians shows patients in whom the symptoms are suspicious but by 
 no means conclusive. 
 
 Although leprosy has existed in all periods of the world's history 
 and afforded abundant opportunities for its observation and study, it 
 is the reproach of medical science that, in some respects, it is to-day 
 the most mysterious and obscure of all diseases, especially in its 
 modes of communication, its variable virulence, and its faculty of 
 remaining latent for a long period and then reawakening into activity. 
 
 In explanation of this lack of definite knowledge of the disease it 
 may be said that for several centuries leprosy had practically dis- 
 appeared from Europe and other civilized countries where medical 
 'science was most cultivated and where the capacity of intelligently 
 studying and classifying diseases was most trained and developed. 
 During the seventeenth, eighteenth, and the first half of the nine- 
 teenth centuries leprosy had for the medical profession only a histori- 
 cal interest. When an important leprous centre was discovered in 
 Norway about fifty years ago, it was a revelation and a surprise, and 
 leprosy became invested with all the interest of a resurrected disease. 
 
 Prior to the appearance of the magisterial work of Daniellsen and 
 Boeck on leprosy, in 1848, the communications in regard to tbe dis- 
 ease were of a vague and incomplete character, possessing little scien- 
 tific value and not generally accessible. It may be said that the first 
 opportunity of studying the disease by the methods of modern sci- 
 ence was afforded by the Norwegian epidemic, which has been termed 
 the "academy of instruction," in leprosy. The epidemic gave a new 
 interest to the study of the disease by scientific men. Its survival or 
 reappearance in many civilized countries from which it was thought 
 to have definitely disappeared and its undoubted spread in many 
 countries previously exempt have awakened a general interest on the 
 part of the medical profession and stimulated the study of the sani- 
 tary measures best adapled to its suppression and control. 
 
618 MORROW — LEPROSY. 
 
 Leprosy in Various Countries. 
 
 Among the Jews. 
 
 Leprosy lias the distinction of being more frequently spoken of in 
 the Sacred Scriptures than any other disease. From the freciuencj- 
 with whicli it is mentioned and the prominence given to the measures 
 instituted by the great Hebrew lawgiver for its repression, it is evident 
 that leprosy overshadowed in importance all other diseases of that 
 period. From the Mosaic writings, the Talmud, and other historical 
 records we have evidence that leprosy was present during the entire 
 period of the early history of the Jews, and that the sanitary regula- 
 tions prescribed in Leviticus were framed chiefly for the control and 
 suppression of this formidable disease. 
 
 It is generally accepted that the Israelites contracted leprosy dur- 
 ing their sojourn in Egypt, where it had existed from time immemo- 
 rial, and that they carried the disease with them during their exodus 
 from Egypt, and that it has existed among them from that time to 
 the present day. At the time of Christ leprosy must have been com- 
 mon in Judea and Palestine, from the frequency with which lepers 
 are mentioned. All evidence jDoints to it being a commonly recog- 
 nized, if not a prevalent, disease. 
 
 The Mosaic account of leprosy forms no exception to the charac-" 
 terization previously made of the description of the disease bj^ other 
 ancient writers, viz., that it is exceedingly vague and indistinct and 
 that it was confounded with many skin diseases of a non-contagious 
 character. It must be remembered, however, that the medical knowl- 
 edge existing among the Jews at that period was not in advance of 
 that of other nations of the same grade of civilization. We should no 
 more expect that the Mosaic description of leprosy should conform to 
 the clinical description of the modern dermatological writer than that 
 the geological and astronomical teachings of the Bible would be ac- 
 cei)ted as correct by our modern scientists. 
 
 This confusion of dissimilar diseases under the same name and 
 the inability to distinguish between leprosy and affections of tlie skin 
 are so evident that they have led to a serious doubt on the part of 
 many authorities as to whether the leprosy of the Bible can be identi- 
 fied as the same disease that we now recognize under that name. It 
 is certain that the clinical features and course and especially the rapid 
 evolution of the diseases which were classed as leprosy in the Hebraic 
 records are entirely different from the evolutionary mode of leprosy 
 as we recognize it at the present time. 
 
LEPROSY IN VAEIOUS COUNTRIES. 619 
 
 Thus, for example, the Levitical code provided that successive 
 examinations of the suspected patient should be made at intervals of 
 seven days, thus enabling the priest to note the progress of the dis- 
 ease. Leprosy is so exceedingly slow in its evolution that a fortnight 
 would show absolutely no change in the character of the skin lesions. 
 The thirteenth chapter of Leviticus, in which is given a description 
 of the disease and the signs by which the priests recognized leprosy 
 and differentiated it from other diseases which were not leprous and 
 not contagious, has been analyzed at great length and in detail by 
 many writers on the history of leprosy. Much ingenuity has been 
 displayed in translating or interpreting the terms used by Moses to 
 conform to our modern conception of the clinical features and be- 
 havior of leprosy. 
 
 Kaposi asserts that the leprosj^ of the Bible is not -leprosy at all, 
 but merely pigment changes which we recognize to-day as vitiligo. 
 
 Dr. J. F. Schamberg has recently made a critical study of the 
 nature of the leprosy of the Bible with a view of determining whether 
 it is identical with modern leprosy. He concludes, first, that the 
 Biblical tsaraath comprises a number of diseases, chief among which 
 were vitiligo and psoriasis ; second, that there is no evidence in the 
 Biblical description to warrant the belief that leprosy existed among 
 the Jews at that period; and third, that the segregation of lepers 
 had its origin in the Biblical example of separating those afflicted 
 with tsaraath. 
 
 It is generally conceded that both vitiligo and jjsoriasis were 
 classed in the Levitical code with leprosy. For example, in verses 
 12 and 13 : " And if leprosy shall break out abroad in the skin, and 
 the leprosy covereth all the skin of him that hath the plague from his 
 head even to his feet, then the priest shall consider, and behold if the 
 leprosy hath covered all his flesh he shall pronounce him clean that 
 hath the plague. It hath all turned white and he is clean." This 
 description evidently does not refer to leprosy, but probably to vitil- 
 igo. In the opinion of Erasmus Wilson it refers to psoriasis. Again 
 in verses 7 and 8, " but if the scab increase in size and spread after he 
 hath been seen of the priest for his cleansing, he shall be seen of the 
 priest again, and if the priest see that the scab still spreadeth in the 
 skin, then the priest shall pronounce him unclean. It is leprosy." 
 The disease referred to in the above version, according to Dr. Scham- 
 berg, is psoriasis, while other commentators regard it as a form of 
 leprosy. 
 
 It is not possible for lack of space to enter into an analysis of the 
 arguments used pro and con as to the identity of the leprosy of the 
 Bible with modern leprosy. While it is certain that nothing corre- 
 
620 MORROW — LEPROSY. 
 
 spouding to the objective features of tubercular leprosy can be found 
 in the Mosaic descriptions, there is a general consensus of opinion 
 among authorities that the leprosy of the Bible is nerve leprosy, such 
 as is met with in India and in Palestine at the present day. 
 
 Many commentators believe that the affection of Job was tubercu- 
 lar leprosy. Certainly the description of the disease with which Job 
 was afflicted presented striking resemblances to this form of the dis- 
 ease. The fact that Job, Naaman, and others mentioned as being 
 stricken with leprosy were restored to health when suffering from a 
 disease recognized as incurable does not necessarily militate against 
 this view. In the Old-Testament Scriptures both good and evil Avere 
 attributed to divine agency, and it is not surprising that leprosy was 
 regarded as a manifestation of divine life and punishment for sin, and 
 the cure in any case was regarded as miraculous and the work of 
 divine intervention. 
 
 Egypt. 
 
 Egypt has been termed the cradle of leprosy. " There is a dis- 
 ease called elephantiasis, which has its rise on the Eiver Nile" (Lu- 
 cretius). Pliny the Elder, Galen, and other ancient writers refer to 
 Egypt as the home of the disease. There is abundant evidence that 
 it has existed in Egypt from a period of remote antiquity. Archaeol- 
 ogists have discovered in papyri found in the tombs of the Pharaohs 
 descriptions which relate to leprosy. In the Medical Papyrus of 
 Berlin there are frequent references to a dangerous and severe disease, 
 "uchetu," which, according to Professor Macalister, of Cambridge, 
 there is sufficient evidence to identify as leprosy. "If so, it seems to 
 have been very common, for both in this work and in the Papyrus 
 Ebers there are manj' prescriptions for it. The Papyrus Ebers was 
 transcribed in the fifteenth century before Christ, so that if uchetu 
 be the same as the Coptic ouseht which is used in the Pentateuch for 
 leprosy it would be evident that the disease prevailed then." 
 
 " The Berlin Papyrus found in the necropolis at Memphis contains 
 many prescriptions for the cure of malignant leprosy, as well as many 
 other kinds of illness and fractures. It was discovered in a writing- 
 case of very ancient origin underneath the feet of the divine Anubis 
 in the town of Sokhem (the Letopolis of the Greeks and Eoraans) at 
 the time when the deceased Sapti was king (4166 B.C.)" (Thin). 
 
 Experts in the Assyrian and Babylonian hieroglyphics state that 
 stones discovered in the ruins of Babylon present inscriptions which 
 relate' to leprosy, and they carry imprecations against any one who 
 will dare to touch or displace them. 
 
leprosy in various countries. 621 
 
 India. 
 
 It is stated that leprosy has existed in India for at least three 
 thousand years. In the earlier times it was called "kushta." Many 
 centuries before Christ, the exact date unknown, Atreya refers to 
 seven varieties of kushta. There can be no doubt that leprosy was 
 common in India six hundred years before Christ (Susruta). Some 
 writers believe that it had its source in China and spread eastward ; 
 others believe that it came from India, and others again from Egypt. 
 
 China. 
 
 There are references in the earlier Chinese M'^ritings to a disease 
 which is thought to be leprosy, and there would seem to be no doubt 
 that the disease existed in China long before the Christian era. Ac- 
 cording to Thin, a writer of the earlier Han dynasty, two thousand 
 years ago, describes a disease which may refer either to leprosy or 
 syphilis. Dr. Monroe suggests that leprosy may have been introduced 
 into China from India, although he infers from the absence of distinct 
 evidence to the contrary in early Chinese writings that the disease 
 was less common in ancient times in China than it is now. 
 
 Greece. 
 
 It is not known at what precise date leprosy was introduced from 
 Asia into Greece. Hippocrates writes of leprosy, but it is evident 
 that he was acquainted with the disease only from descriptions. He 
 states that the leukai, "white diseases," spring from the most deadly 
 diseases, such as what is called the Phoenician disease, and this 
 Phoenician disease has been understood by those who accept that 
 reading to mean leprosy (Thin). 
 
 Aristotle, who wrote three hundred and forty-five years before 
 Christ, refers to the Phoenicia* disease as common in Phoenicia and 
 other Oriental parts, and calls it satyria, in which the countenance 
 seems to resemble that of an animal or a satyr. He compares the 
 term satyria with elephantiasis, a term used by Greek writers for true 
 leprosy. From his description he must have referred to tubercular 
 leprosy. Herodotus, writing four hundred and forty-six years before 
 Christ, was the first to use the word elephas for the animal, and he 
 only refers to it as existing in Ethiopia among other wild beasts. 
 
 It is probable that at that period leprosy found its way to the 
 coast of Asia Minor near Greece, probably to the latter. It is certain 
 that it was quite common in Greece in the last two centuries before 
 Christ. 
 
622 MOKROW — LEPROSY. 
 
 Aretseus, who wrote eighty-one ^ears after Christ, and also in 
 the second ceuturj^ says that elephantiasis is called satyriasis on 
 account of the supposed libidinous tendencies of the i:)atients, while 
 Galen states that the word has been used on account of the resem- 
 blance of the leper's face to that of a satyr. 
 
 It was called leoutiasis bj'' Archigenes, who wrote in 97, and leon- 
 tia by AretaBUS, on account of the supposed resemblance to the leonine 
 face produced by the thickened folds of skin on the forehead. 
 
 Aretajus, in the first century of our era, gave a clear and cor- 
 rect description of the clinical features of leprosy. Thin, from whose 
 work the following translation of Arets^eus is taken, says in compar- 
 ing the description of Aret?eus with the vague and imperfect allusions 
 in Hebrew, Sanskrit, and Egyptian literature : " We appreciate the 
 enormous intellectual advances which have been made by the genius 
 of the Greek race. " 
 
 "Formerly this affection was called leontiasis, on account of the 
 resemblance between the disease and the lion, produced by the 
 appearance of the raised part of the forehead, which I shall mention 
 later on; satyriasis, on account of the redness of the cheeks, as well 
 as of the insurmountable and shameless inclination; Herculean, 
 because there is no disease which is graver and more violent. Its 
 power is indeed formidable, for of all diseases it is the one which 
 possesses the most energy, 
 
 " Like the elephant, it is terrible and hideous from manj' ijoints 
 of view. It is irresistible, inasmuch as from the beginning it carries 
 in itself the cause of death ; that is to say, a chilling of the congenital 
 heat or a glacial cold like that of a rigorous winter, in which water is 
 transformed into snow or ice— altogether a horrible cause of sickness 
 and death indeed. 
 
 " At the beginning the disease is not characterized by anv distinc- 
 tive sign, the patient not being affected by any unusual symptom. 
 It does not show itself at first on the surface of the body, so that it 
 cannot be observed and remedied at the outset, but is concealed in 
 the bowels as in a subterranean abyss, and after having burned the 
 internal parts it kindles up a fresh inflammation on the external sur- 
 face, and most frequently the horrible fire visible manifests itself first 
 in the face, but sometimes, on the contrary, it begins on the elbow, 
 knee, and the joints, as well as on the feet and hands. Persons thus 
 attacked have no hope of cure, because the physician, bj'' carelessness 
 or ignorance of the true nature of the disease, does not apply his art 
 when the first symptoms appear. 
 
 " The patients are dull, taciturn, drowsy for a time, and suffer 
 from constipation, but all of these symptoms are not of themselves 
 
LEPROSY IN VAEIOUS COUNTRIES. 623 
 
 extraordinary, for tliey occur in people otherwise healthy. When 
 the disease has made progress, the breath becomes fetid on account 
 of the internal decomposition of the vital forces. The urine becomes 
 thick, white, frothy, like that of a beast of burden. The patients 
 digest without difficulty raw food, and do not appear to observe 
 whether the digestive functions are affected. The loss of digestion in 
 them is not noticed, for though in general they receive no benefit 
 from the food, digestion appears to be easy, as if the disease devoured 
 food for its own sustenance. 
 
 " Tumors arise one by the side of another, not continuous but 
 thick and unequal. Amongst the tumors there are fissures as in the 
 skin of the elephant. The veins are increased in volume, not by 
 abundance of blood, but by the thickness of the integuments. The 
 hairs for the most part die. They become scanty on the thighs, 
 calves of the legs, groin, and on the chin. The hair of the head 
 becomes thin, gra}^ and a rather pronounced baldness appears pre- 
 maturelj^ Soon the crown and chin are completely denuded of hair, 
 and if any remains, however little, it serves only to disfigure the 
 patient. The skin of the head is deeply wrinkled. More prominent 
 tumors appear on the face. They are sometimes white at the sum- 
 mit, but greenish at the base. The pulse is feeble, heavy, slow as if 
 moved with difficulty. 
 
 " The vessels in the temples and under the tongue are swollen. 
 The stomach is filled with bile. The tongue becomes unequal on 
 account of granular nodosities, and it is not surprising to see the 
 whole body covered with similar nodules. But if the disease develops 
 rapidly in internal parts and shows itself on the extremities, lichen- 
 ous eruptions develop which sometimes surround the chin in a circle. 
 The cheeks become red and swell a little. The eyes are dark and 
 copper-colored; the eyebrows prominent, thick, bare, and overhang- 
 ing. The space between them is contracted. The color is leaden 
 gray and blackish. The lower part of the frontal skin is drawn down- 
 wards and conceals the eyes, as in mad persons and lions. This is 
 why the affection is also called leonine. There are dark tumors on 
 the nose, which is pointed and prominent. The lips are thick, the 
 lower one being blue-back in color. The teeth are destitute of white- 
 ness and are blackish. The ears are red, but inclined to become 
 black, the apertures are apparently larger than usual, and at their 
 lower parts there are ulcers from which flows a very pruriginous 
 matter. There are also upon the whole body wrinkles, deep incisions 
 as well as furrows. This is why the disease bears also the name of 
 elephantiasis. 
 
 " The soles of the feet as far as the middle of the toes are cracked. 
 
624 MORROW— LEPROSY. 
 
 If the disease increases, the nodosities of the cheeks, chin, fingers, 
 and nose become ulcerated. These ulcers are fetid. They are incur- 
 able and appear in continous succession. Sometimes the limbs per- 
 ish before the individual, and at last there is seen to fall the nose, the 
 fingers and toes, feet, hands, and genital parts, for it is only after the 
 patient is dismembered that the disease causes death as a deliverance 
 from a horrible life and fearful sufferings. But this affection has the 
 same tenacity of life as the elephant. The taste is lost. Neither 
 eating nor drinking gives pleasure to the patient. 
 
 " In consequence of their sufferings they have an aversion to every- 
 thing. They abstain from food and have a strong inclination to sex- 
 ual ajjpetite. Languor is manifested. Weakness is i)articularly 
 revealed in every limb, and even the small members are a burden to 
 the sufferer. The body finds everything repugnant. It does not feel 
 satisfaction either in the bath or in abstinence from it, eating or fast- 
 ing, exercise or repose, for the malady is in enmity with everything. 
 Sleep is insignificant. Watching is worse on account of hallucina- 
 tions. The respiration is greatly disturbed. The i)atients often feel, 
 as it were, strangled with a cord. Some thus finish a remnant of 
 existence in sleeping, a sleep from which there is no rising until death 
 occurs. Such being their condition, who can avoid flying from them? 
 Who will not turn away from them, were it even his father, or son, 
 or own brother? There is also the fear that the disease may be com- 
 municated. Many for this reason remove their dearest ones to soli- 
 tude or to the mountains. Some preserve them from hunger for a 
 time, others not at all, desiring their death." 
 
 Arabia. 
 
 There is no authentic historical evidence of the existence of lep- 
 rosy in Arabia before the time of Mohammed, although from its 
 known prevalence in Egypt and Syria from the earliest times the close 
 communication between these countries and Arabia would render it 
 jn-obable that the disease was carried to Arabia at an early period. 
 Kaposi gives a long list of Moorish and Arabian writers who have 
 l^roduced treatises on leprosy, partly borrowing from the Greeks and 
 partly basing their descriptions upon their own observations of 
 the disease. 
 
 Italy and Continental Europe. 
 
 According to Aretaeus, it had in his time begun to spread into 
 Western Europe. The Romans ac(iuired leprosy after the Greeks. 
 Celsus, Galen, and Pliny thought that it was imported into Italy by 
 
LEPEOSY IN VAEIOUS COUNTRIES. 625 
 
 the troops of Pompey and tliat leprosy had gained Italy about one 
 century before Christ. Henceforth its spread was rapid over Europe. 
 We can trace it into France, Spain, Great Britain, Germany, Kussia, 
 and Scandinavia. We find it rising and declining at different periods 
 and in different parts of the world, moving gradually from east to 
 west and from south to north. While it is found prevalent in Egypt 
 and India in the early period of the world's history, in the beginning 
 of the Christian era it spread through Greece and Southern Europe 
 during the period ranging from the sixth to the seventh centuries, 
 reaching its culminating point during the crusade in the eleventh 
 and twelfth centuries, and began to decline from the fifteenth to the 
 seventeenth centuries. 
 
 The traditional idea that leprosy was introduced into Europe by 
 the crusaders is without foundation. It prevailed extensively in Wes- 
 tern Europe long before the crusades were instituted, although there 
 is no doubt that the movements of the crusaders to and fro afforded 
 effective means for the further spread of the disease. Certain writers 
 have attributed its introduction into Western and Eastern Europe 
 from Asia Minor to other agencies. Simpson suggests it may have 
 been brought by Roman armies or by numerous pilgrims who were 
 accustomed to flock to Jerusalem from various parts of Europe. Even 
 before the foreign armies left Britain in 418 numerous pilgrimages 
 had been made to Jerusalem. There were abundant opportunities 
 for contracting the disease in Jerusalem, where it had existed from 
 time immemorial. 
 
 Great Britain. 
 
 The early history of leprosy in Great Britain has been studied 
 with great care by Sir James Y. Simpson. He regarded it as prob- 
 able that leprosy was introduced into Great Britain by processions 
 of pilgrims to the Holy Land going and returning through Italy ; the 
 opportunity for contagion being afforded in both these countries. 
 The pilgrimages to the Holy Land were of frequent occurrence, and 
 the conditions of travel at that time necessitated the close con- 
 tact and intimate relations which favored the communication of dis- 
 ease. 
 
 Newman also has made an admirable study of the "History, 
 Decline, and Final Extinction of Leprosy as an Endemic Disease 
 in the British Islands." His researches prove that leper hospitals 
 existed in Ireland and that leprosy was prevalent in England long 
 before the first Englishmen engaged in the crusades. The disease 
 spread more or less rapidly through England, Wales, and Ireland, 
 although it always prevailed more extensively in certain localities 
 YoL/xyill.— 40 
 
620 MOREOW— LEPROSY. 
 
 than in others. It was very prevalent in the twelfth, thirteenth, and 
 fourteenth centuries, as shown hy the number of leper houses that 
 existed and by the ecclesiastical and legal regulations that were pro- 
 mulgated in respect to them. The disease was also common in the 
 fifteenth and sixteenth centuries, but had then begun to decline. 
 During the reign of Edward VI. (1547-1563) it was reported by a 
 commission that most of the lazar houses in England were empty. 
 
 It is not kno^n at what precise jieriod leprosy was first introduced 
 into Scotland, but the general impression is that it was a centur^^ or 
 two after its introduction into England. The earliest lazar house in 
 Scotland dated back to 1150. Numerous lazar houses were estab- 
 lished in various parts of the kingdom during the next two or three 
 centuries. The decline of leprosy in Scotland was noticed in 1652 by 
 an act for the diminishing of the houses at Edinburgh, but the dis- 
 ease still prevailed in the islands to the north of Scotland and in the 
 Shetland Islands. In 1742 a public thanksgiving was ordered for the 
 permanent disappearance of leprosy from the Shetland Islands. The 
 last leper of the Shetland Islands, it is stated, died in the Edinburgh 
 Infirmary in 1798. 
 
 The disease began to disappear in France and Italy at the end of 
 the sixteenth century, although leprosy centres were found on the 
 south Mediterranean coast in the seventeenth century. 
 
 In Norway there is a record of the establishment of a leprosy hos- 
 pital at Bergen in 1276, and the number of lepers was found to be 
 increasing in 1745. A leper hospital was established in Austria in 
 1301 and in Sweden in 1248. Evidence is abundant that leprosy was 
 present in Denmark. 
 
 Leper hospitals were also established in Iceland in the fifteenth 
 and sixteenth centuries. 
 
 North and South Ajierica. 
 
 In America the history of the introduction of leprosy and its spread 
 in the British provinces of North America, the United States, and 
 South America cannot be definitely traced. There are ho authentic 
 records of its existence in New Brunswick until 1815. It was intro- 
 duced into Louisiana by the Acadian refugees who were deported 
 from Nova Scotia. 
 
 In South America leprosy was introduced by the French, Spanish, 
 and Portuguese settlers, with an added increment of infected ma- 
 terial from Africa, the East Indies, and elsewhere. 
 
 Kubler, in his remarks upon the geography of leprosy, suggests 
 that there is some connection between leprosy in America and Africa, 
 
LEPEOSY IN VARIOUS COUNTRIES. 627 
 
 as the countries most occupied are on the side looking towards Africa. 
 A question of some importance in this connection is that of pre- 
 Cohimbian leprosy. Dr. Ashmead has made a very careful and elab- 
 orate study of pre-Columbian leprosy, in which he has examined col- 
 lections of the pottery found by the sides of mummies, the hands 
 and feet of mummies from Peru, from Chihuahua, North American 
 Indian remains, and from Mexico, and various other presumably pre- 
 historic remains from numerous other localities. In none of these 
 bones was there any evidence of leprosy. Nor were there any de- 
 formities depicted on the American pottery which could be identified 
 as characteristic of leprosy. 
 
 Within recent times leprosy has been widely disseminated in 
 the far East and in the islands of the Pacific chiefly, it is generally 
 held, by the Chinese. Cantlie declares that " the Chinaman taints 
 the world with leprosy," and he brings forward historical evidence 
 to prove that the spread of leprosy in the Malay peninsula, the 
 Dutch, Spanish, and Portuguese East Indies, and in Oceanica, as 
 well as the islands of Fiji, New Caledonia, Hawaii, and the western 
 coast of America, may be traced to Chinese coolie immigrants. " The 
 Chinamen are not only the probable introducers, but the chief vic- 
 tims. With the exception of Hawaii and New Caledonia, all over 
 Indo-China, Malaya, the Indian archipelago, and the Pacific it is the 
 Chinaman who is the dominant leper." 
 
 Whether these Bohemians of the Orient have carried leprosy with 
 them in their world-wide migrations, or whether they simply serve as 
 scapegoats, the opinion generally prevails that they have been the 
 chief contaminators of the world with leprosy in modern times. 
 
 The following chronological table, which gives the chief dates in 
 the history of leprosy which has been compiled from the most authen- 
 tic sources accessible, is taken from the prize essay, " The History 
 of the Decline and Final Extinction of Leprosy as an Epidemic Dis- 
 ease in the British Islands," by George Newman, 1895. The writer 
 has supplemented it with a few dates, while omitting many details 
 relating to the leper houses in Great Britain which are of less general 
 interest : 
 
 Chronological Table of Leprosy. 
 
 B.C. 
 
 3500. Leprosy in Egypt (Husapti?). ' 
 
 1320. The exodus. 
 
 1000-900. Celts in England.- 
 
 600-400. Leprosy common in Hindoostan (Susruta) and China. 
 
 460. Hippocrates described leprosy. 
 
 260. Manetho testified to presence of leprosy among the Jews (90,000). 
 
 200. Leprosy common in Greece, called elephantiasis (Kaposi). 
 
628 MOREOW — LEPROSY. 
 
 100. Leprosy known in Italy. 
 95. There is a disease called elephas which has its rise on the river Nile in the 
 
 middle of Egypt (Lucretius). 
 60. Leprosy first in Spain. 
 53. Celsus wrote on leprosy. 
 
 A.D. 
 
 81. Areta3us wrote on leprosy ; also in second century (?). 
 97. Archigenes wrote on leprosy also. 
 Second century. Leprosy became prevalent in Europe between the second and the 
 
 sixth centuries. 
 Fourth century. Theodoret mentions lazarettos for lepers. 
 360. Oribazius wrote on leprosy. 
 366. Order of St. Lazarus founded in Palestine. 
 Fifth century. Actius wrote on lepros3^ describing it as widespread. 
 433. First notice of leprosy in Ireland (Colgan's "Acta Sanctorum"). 
 500. Charaka wrote on leprosy. 
 
 Sixth century. Gregory of Tours speaks of lazarettos. 
 549. Council of Orleans leprosy decree. 
 
 .550. Pestilence of leprosy in Ireland ("Chronicon Scotorum "). 
 588. Council of Lyons leprosy decree. 
 Seventh century. Hospital St. John founded for lepers (Lake Constance). Leper 
 
 houses existed at Verdun, Metz, and Mastricht (Virchow). 
 603. St. Kentigern, of Glasgow, died: " mundabat leprosos. " 
 606. Increase of leprosy during a Roman invasion in the time of Heraclius (Lani- 
 
 gan, "Eccles. Hist."). 
 661-664. Leprosy in Brittany. 
 
 Rothar, King of Lombards, made laws to prevent the marriage of lepers. 
 Pestilence depopulated Britain and Ireland. 
 Eighth century. St. Boniface "mundabat leprosos. " Hospital St. Lazarus founded 
 at St. Gallen, Lake Constance, 720. St. Othmar founded leper houses 
 in Germany (died, 758). St. Nicholas of Corbie founded leper houses 
 in France. Isidore of Spain alludes to leprosy in Spain. 
 757. Pepin provided an act that leprosy should be sufficient cause for separation 
 
 or divorce (Parliament at Compiegne) . 
 789. Charlemagne re-enacted similar laws; also enforced sequestration. 
 
 868. Council of Worms leprosy decree. 
 
 869. Leper hospitals existed in Ireland. The hospital at Armagh burned by 
 
 Arlaf. 
 874. Iceland peopled from Norway. 
 Tenth century. Leprosy prevalent in Europe ; in England. Leper laws, Venedotian 
 and Dimetian codes. Law was passed in England making leprosy a 
 cause for divorce. 
 933. Truela, son of King Alfonso of Spain, dies of leprosy. 
 
 Leper houses had existed in Palestine for nearly a thousand years. 
 950. Hywel Dda, or Howell the Good (a Welsh king who died about 950), en- 
 acted a code of laws relative to leprosy ("Celtic General Repository," 
 vol. iii., 199). 
 958. Leprosy mortality excessive. Suffering and misery throughout Europe. 
 1007. Leprosy prevalent in Spain. In this century first leper hospitals and pest 
 
 houses were built. 
 1067. First leper hospital in Spain (Valencia) . 
 
LEPEOSY IN VAEIOUS COUNTRIES. 629 
 
 1075. Hugh D'Orivalle, Bishop of London, had leprosy. 
 
 1084. Several leper hospitals founded in England previous to first crusade. 
 
 Leper hospital founded at Canterbury by Lanfranc (Archbishop of Canter- 
 bury), who died 1089. 
 
 1095. First Crusade begun by Peter the Hermit. 
 
 1098. Return of the first Crusaders. Low condition of English agriculture, misery, 
 famine, and pestilence. 
 
 Twelfth century. It was a custom before this century to burn and otlierwise perse- 
 cute lepers in Europe. Henry H. in an edict sanctions it in England. 
 The writ " De Leproso Amovendo " in force at this period. The earliest 
 mention of leper houses in Scotland. Knights of St. Lazarus acquired 
 a footing in England (Stephen). Leprosy prevalent in Denmark 
 (Gislasen) . Third crusade under Richard I. Baldwin I. , King of 
 Jerusalem, became a leper and ten years later resigned his crown be- 
 cause of disablement (1184). Founding of numerous leper houses 
 in England and Scotland (first in Ireland, 1165). ,Over fifty leper 
 houses. 
 
 1179. Council of Lateran, famous leprosy decree. 
 
 1181. Pope Lucius III. 's leprous decree. 
 
 1190. Pope Clement III. 's leprous decree. 
 
 1192. Famine in England. Approximate time of appearance of leprosy in Iceland. 
 
 1200. Leprosy decree of Provincial Synod at Westminster ; Hubert, Archbishop of 
 Canterbury. Henry III. visited lepers every Holy Thursday. 
 
 Thirteenth century. Leprosy reached its zenith during this century (Liveing) (?). 
 Period of returning Crusaders. Louis Vni. 's code of French leper 
 laws. Two thousand leper hospitals in France. Equal number in 
 middle of fifteenth century (Heren). 
 
 1242. Leprosy canons of Scotch Church, separating lepers from society. 
 
 1248. Ferdinand III. founded leper hospital at SevUle. 
 
 1250. Leprosy existed in Japan. 
 
 1263. Norwegians invaded England, and in 1266 first mention of leper houses at 
 Bergen, Norway. 
 
 1269. Leprosy segregation of the canons of the Scotch Church. 
 
 1270. St. Louis of France on the last crusade. Many of his soldiers became leprous 
 
 (Joinville). 
 
 1283. Statutes of Society of Merchants ordered that lepers should not come into 
 the burgh. 
 
 1290. Council of Nogaro exempted lepers from the jurisdiction of secular justices, 
 prohibited their entrance into markets or towns, and insisted on their 
 wearing some distinguishing badge. 
 
 1296. Leprosy in Edinburgh. Fifty leper hospitals built in thirteenth century. 
 Leprosy prevalent, but probably declining. 
 A leprosy "visitation" in the west of England (Somerset, etc.). 
 
 Fourteenth century. Commencing decline of leprosy throughout Europe during 
 this century. Numerous leper houses built in England and Scotland. 
 Lepers getting scarce at various places. Leprosy visitation in west of 
 England. Regulations against lepers entering city of London. 
 
 1350. Lepers getting scarce at St. xllbans and Aylesbury. 
 
 1357. Black Death in Europe ; in England 1349. Laws passed in England protect- 
 ing fishers and for the supply of fresh fish instead of dried. Laws 
 passed against water pollution. 13S9, cleansing the streets. 
 
630 MORROW — LEPROSY. 
 
 1365. There were now. four leper houses at York, and they remained for just one 
 hundred years (Rol)ertson). 
 
 1375. Regulations against lepers entering the city of London; the taking of the 
 oath hy John Gardener. 
 
 1889. Renewal of persecution of lepers in France (Charles VI.). 
 
 1398. John of Gauut's will, bequeathing to London lepers. Henry IV. a leper 
 (according to Gascoigne) . 
 
 Fifteenth century. 1407. Great plague in London. Numerous leper houses pro- 
 vided in Switzerland and Spain. 
 
 1413. St. Mary Magdalene Hospital at Reading closed because no lepers forthcoming. 
 
 1414. Leper hospitals in England "for.tlie most part decayed, and the goods 
 
 thereof spent in other use" (2 Hy. V., c. i.). 
 
 1427. Scottish Parliament compelled to legislate for lepers (1427, c. 8, ii., 16). 
 
 1468. The leprosy certificate of the court physicians of Edward IV. 
 
 1470. A royal commission, appointed by Edward IV., reported marked decrease 
 of leprosy. 
 
 1485. Lepers still in London, and a number of legacies left to them ("Calendar of 
 Wills," vol. ii. ). Leprosy by no means rare in Lincolnshire. 
 
 Sixteentli centm-y. Leper hospitals still being founded in Netherlands and parts of 
 Germany and Spain. Final extinction of leprosy in Denmark (Gis- 
 lasen.) 
 
 1536-1540. Suppression of the monasteries and many of the existing leper houses ; 
 but the larger ones were spared by Edwwd VI. (c. 3), "to prevent the 
 contagion spreading." A royal commission (Edward VI.) reported 
 most of the leper hospitals in England empty, 1547. Leprosy was fre- 
 quent in Cornwall in the time of Elizabeth (Polwhele) . 
 
 1542. Leper hospital built on Canary Islands. 
 
 1555. Leprosy very prevalent in Iceland. 
 
 1574. Herbaldowne Hospital providing relief for more than thirty. Leper laws 
 made in Scotland ; repealed, 1579. 
 
 1582. Refoundation of Bodmin Hospital by Elizabeth. "A great company of 
 lazar people." Glasgow lepers allowed free access to burgh (Robert- 
 son) till 1593. 
 
 1585. Sherburn leper hospital, diverted from its original purpose (because no lepers 
 were forthcoming), became a general hospital. 
 
 1591. Five lepers consigned to hospital in Edinburgh. Lepers still at Aberdeen. 
 Apparent outbreak of leprosy in Scotland. 
 
 1593. Glasgow lepers banished from the burgh by Kirk Session. 
 
 1598. Heutzner, travelling through England, remarks on the frequency of leprosy. 
 Thirty-nine lepers in Bodmin Hospital in James I. 's reign, who were 
 largely patronized by the king. 
 
 Seventeenth century. Four le]ier hospitals built in Iceland, 1651. 
 
 1652. J'or "many years Ireland hath been almost quite freed" from leprosy (Boate). 
 
 1656. Leper hospital built in Madeira. 
 
 1657. An order made to dismantle the lazar house .at Greenside, Edinburgh. 
 
 1661. Leper house at Aberdeen razed to the ground. Leprosy was prevalent in the 
 Faroe and Shetland Islands. 
 
 1676. Leprosy very prevalent in the Faroe Islands, Shetland Islands, St. Kilda, 1684. 
 
 Eighteenth century. 1707. Smallpox epidemic in Ireland killed one-third of popu- 
 lation, including many lepers. Leprosy still in France (Upper 
 Auvergue, etc.), Belle Isle still used as leper refuge. 
 
METHODS OF DEALING WITH LEPEOSY IN ANCIENT TIMES. 631 
 
 1730. Leprosy prevalent in Ireland (Von Triol). 
 
 1749. Public thanksgiving in Shetland on account of disappearance of leprosy (fevf 
 
 cases still appear). 
 
 1753. Several lepers in St. Kilda. 
 
 1759. One hundred and fifty lepers in Norway (three hospitals). 
 
 1768. Two hundred and eiglity lepers in four Iceland hospitals (Petersen) . 
 
 1769. Captain Cook landed in ^ew Zealand. Leprosy present (?). 
 1775. Last endemic case of leprosy in Ireland at Waterford. 
 
 1778. "A leper is now a rare sight" (White of Selborne). 
 
 1787. Leprosy endemic in Auvergne. 
 
 1798. A man, John Burns, a Shetland leper, descended from a leprous family, ad- 
 mitted into the Edinburgh Infirmary. 
 
 Nineteenth century. Leprosy unknown as indigenous disease throughout the 
 British Islands. Since 1882 twenty cases of leprosy have been brought 
 before London Dermatological Societj^ probably none were indigenous. 
 
 1809. Supposed case of indigenous leprosy in Edinburgh ; another in the Shetlands 
 
 (Edmonston) . 
 
 1810. Leprosy endowment in Cornwall transferred to general infirmary because 
 
 there were no lepers needing assistance (Brown's " Cases in Chancery, " 
 166, n.). 
 
 1811. First leprosy hospital at Calcutta. 
 1815. Leprosy in New Brunswick. 
 
 1836. Many lepers still in Norway and Iceland. Some in Portugal, Spain, Italy, 
 Sicily, Crete, New Zealand, etc. Very prevalent in India, China, 
 Japan, and the West Indies. 
 
 1848. Leprosy introduced into Hawaiian Islands. 
 
 1850. Beginning of leprous endemic in Parcent, Spain. 
 
 1863. Leprosy still common in Iceland. 
 
 1866. Beginning of leprosy endemic in Louisiana. 
 
 1867. Royal College of Physicians Report declaring leprosy non-contagious. 
 
 1868. Leprosy introduced into New Caledonia 
 1874. Leprosy bacillus discovered by Hansen. 
 1885. Norway contained 1.377 lepers. 
 
 1889. Six hundred lepers at the Cape of Good Hope. 
 
 1890. Disease practically extinct in New Zealand ; 18,000 lepers in Colombia. 
 1892. Lepers in Spain, 1,200; Norway, 1,200; 600 to 700 elsewhere in Europe. 
 
 Lepers in India, 100,000; Japan, 150,000 (?). 
 1894. Iceland, 140; 1897, 200. 
 1897. Berlin Leprosy Congress. 
 
 Methods of Dealing with Leprosy in Ancient and 
 Modern Times. 
 
 Isolation of Lepers. 
 
 It is to be understood that a broad signification is given to the 
 term " isolation" in this connection : it will be used synonymously 
 with segregation or compulsory gathering together of lepers. 
 
632 MORROW— LEPROSY. 
 
 Complete isolation of lepers is practically impossible; even in 
 countries where leper hospitals and asylums have been established 
 strict isolation of the inmates does not exist. They come more or 
 less in contact with physicians, nurses, clergymen, attendants, and 
 purveyors of their food and other supplies, so that no leper commu- 
 nit}- can be absolutely shut off from the world. 
 
 In all ages and in almost all countries mankind has waged a 
 relentless warfare against the leper. Tlie belief in the contagiousness 
 of leprosy which was universally held from the earliest ages until 
 within recent times has led to an avoidance of contact' W' ith those af- 
 flicted with the disease, and in most countries there has been a general 
 tendency to ostracize or segregate tliem. All the severe proscriptive 
 measures formulated in the Levitical code and those practised in the 
 Middle Ages were based upon the belief that the leper is a source of 
 danger to those with whom he msiy come in contact. Even in 
 countries where segregation is not prescribed by legislative enact- 
 ments or enforced by governmental authority, public sentiment has 
 restricted association with lepers. 
 
 In India, China, and Japan, which are among the oldest leprosy 
 centres of the world, public opinion has decreed that those affected 
 should withdraw from the society of their fellows and dwell apart. 
 To this prevalent sentiment may be traced the origin of the leper vil- 
 lages and leper homes which form so distinctive a feature in many 
 Oriental countries, especially in China. 
 
 There is no doubt that the attitude of public sentiment towards 
 lepers is modified by race, religion, and civilization. Among certain 
 races — the negroes of South Africa, the Kanakas of New Caledonia 
 and of Hawaii — leprosy inspires neither disgust nor fear. 
 
 Dr. Eoss says of leprosy in South Africa : " It is a singular fact 
 that the people among whom leprosy is spreading have no fear of 
 contagion among themselves, nor do they abstain from embracing or 
 handling each other. The disease, so repellant to Europeans, seems 
 to have no repulsion to them. They bitterly resent being parted 
 from their kith and kin.' 
 
 In an article, published in 1889, embodying my observations of 
 leprosy in Hawaii, I wrote : " The Hawaiian, be it understood, has 
 not the wholesome horror of the disease entertained by his more 
 civilized brothers. He ignores its contagiousness, and neither dis- 
 gust nor fear leads him to shun his brother leper as a bearer of deadly 
 contagion. Leprosy carries with it no social ostracism and arouses 
 no instinct of self-preservation on the part of the patient's friends. 
 It is this total absence of fear, this ignorant contempt of its conta- 
 giousness combined with the promiscuous and intimate intercourse 
 
METHODS OF DEALING WITH LEPEOSY IN ANCIENT TIMES. 633 
 
 between the liealtliy and the diseased which accounts for the rapid 
 and unexampled spread of the disease in these islands." 
 
 Dr. Le Grand bears much the same testimony as to the attitude 
 of the natives of New Caledonia towards those affected with the 
 disease. 
 
 Among Mussulmans leprosy does not spread with the same rapidity 
 because it inspires a fear or terror which prompts every person to 
 avoid contact with a leper, except he happens to be a member of his 
 own family. 
 
 In the Isle of Mytelene, Zambaco Pacha declared that in a popu- 
 lation of several thousand Mussulmans there was not a single case of 
 leprosy, which he attributes to their wholesome horror of contact 
 with the disease. 
 
 The natural affection existing among members of the same family 
 has proven to be the most formidable obstacle to the segregation of 
 lepers. This sentiment of affection protests against the casting out 
 of a member of a family until the disease becomes so disfiguring as 
 to be r:pulsive, and this in connection with the opportunities of con- 
 tagion inseparable from family life, is probably the explanation of why 
 leprosy is so essentially a family disease. 
 
 It has been generally supposed that the Jews were the first to seg- 
 regate lepers. It is known, however, that the Persians had laws for 
 the extermination of leprosy before the time of Herodotus. This 
 author states (edition Feubrini, chapter 138): "If any citizen has^ 
 lepra or leuce, he may not enter into the city or mingle with the Per- 
 sians. Every stranger who is attacked is exiled from the citj'." 
 
 It is probable that segregation was practised in other countries 
 where leprosy prevailed. It has been suggested that Moses, in sepa- 
 rating lepers from the healthy and compelling them to dwell apart, 
 followed the custom he had seen practised in Egypt. In any case, 
 the policy of the segregation of lepers has been perpetuated with 
 varying degrees of severity and strictness from Mosaic times to the 
 present. 
 
 During the great epidemic of leprosy in Europe in the Mid- 
 dle Ages the practice of segreg^ation was prosecuted with the greatest 
 rigor. 
 
 Eeference will be found in the section on geographical distribution 
 of leprosy to the barbaric practice prevalent in many countries of the 
 putting to death of lepers or banishing them in the forests and deserts 
 to die of hunger and exposure. 
 
 In China, according to Cantlie, it has happened that when a case 
 of leprosy had declared itself the parents, after having drugged the 
 patient, burned him alive. 
 
684 M.ORROW— LEPROSY. 
 
 Segregation has been sanctioned by the experience of centuries as 
 the best prophyhxctie measure against the spread of lepros}'. 
 
 The Levitical code decreed that the leper shoukl be cast out of the 
 city and transported to a place called Beth Chofschitch, which means 
 "houses of impurity." Not only the leper, but his habitation, was 
 declared to be unclean. Jewish lepers under tlie penalty of eighty 
 stripes were forbidden to approach the mountains of the temple, yet 
 were not rigidly condemned to isolation, and in towns without walls 
 were even allowed to enter synagogues. They were required to make 
 themselves known at the first glance bj^ appearing in public with rent 
 garments, bare head, and covered beard, and if anj- one approached 
 inadvertently the lepers were to cry, " Unclean, unclean !" They were 
 interred in a separate burial ground (Thin). 
 
 We have little definite knowledge respecting the measures of deal- 
 ing with lepers before the invasion of Europe by the disease. Refer- 
 ence has already been made to the extent to which leprosy scourged 
 the population of Europe between the tenth and sixteenth centuries. 
 We know that during the period of this great epidemic the church 
 and State united their immense authority to secure the isolation of 
 the lepers. 
 
 According to Dr. G. Contenau, who has made a special study 
 of the proi)hylaxis of leprosy in the Middle iVges, the leproseries 
 in France were composed ordinarily of low buildings, without venti- 
 lation, enclosed by walls, with gardens, wells, chapel, and chaplain 
 in most of them. They were always designated by the name of a 
 patron saint. In France they were under the protection of St. 
 Lazar, of St. Marthe, or St. Madeleine. In Central Europe they 
 were und;^r the protection of St. Jaques. In the north and east of 
 Europe St. George was the patron saint, and in Poland St. Valentine 
 and St. Leonard. 
 
 " They were ordinarily situated near a cathedral without the walls 
 of a city. Thej- were built at the expense of the king or of the city 
 or often by charitable private means. They were supported often 
 by the crown almsbag, which was made up of receipts from the rich 
 lepers. The excess of these receipts was divided among the poor. 
 Often the leproseries had revenues in silver or in wine, barley, etc. 
 Although in the hospitals in the Middle Ages there were four or five 
 patients in the same bed, and oftentimes as many upon the roof, the 
 projiortion of the lepers was always restricted in these leproseries 
 on account of their immense number. When an individual was recog- 
 nized as lej^rous, his admission was gratuitous (by the grace of God). 
 If he was rich, he brought his house utensils and a sum varying from 
 ten to fifteen pounds sterling. The leprosery was ordinarily under 
 
METHODS OF DEALING WITH LEPEOSY IX ANCIENT TIMES. 635 
 
 the charge of a master or superior, assisted by leprous brothers and 
 sisters. Sometimes the chaplain was the chief, or instead a leper was 
 elected provost by the lepers. The ceremony of the entrances in a lep- 
 rosery was as follows : 
 
 " The priest with a cross went to search the leper, conducted him 
 personally to the church where he held mass, under the cloth of 
 the dead. At Amiens as a sign of renouncement of the world the 
 leper lay for a certain period in a grave. B}' his admission the leper 
 lost his civil rights. He could neither devise nor possess. His mar- 
 riage was annulled. If he had children of tender age, they were sep- 
 arated from him, to avoid contagion, but his wife might remain with 
 him if she wished. 
 
 " He received a gray calemot, a great coat, a claquet to warn persons 
 of his presence, a hood, and a sort of scarlet epaulet. 
 
 '' The lepers were compelled to wear a visible sign by which they 
 might be distinguished. No inmate of a leper hospital was allowed 
 to enter the town of Castres unless he had a white cloth around his 
 neck and a claquet, or rattle, with which to make a noise to warn 
 people of his approach. A high sack or a hood was also part of his 
 vestment. Not only the lepers, iDut those in charge of them, were 
 compelled to wear some dress of distinctive mark. 
 
 " The members of the grand Betra establishment of lepers were 
 compelled to wear on their dress a capital L of red cloth, one-half a 
 foot long, over the left breast, and this because they were in fre- 
 quent contact with lepers and might communicate the disease. 
 
 " Both male and female lepers took the name of brother and sister 
 and lived in community. They were compelled to receive communion, 
 hear mass, live purely and chastely ; their expulsion was the conse- 
 quence of grave infraction. The leproseries had then a religious 
 character; they were of a true monastic order by compulsion, it is 
 true, and not by volition. But it should not be forgotten that in the 
 Middle Ages the monastic state was regarded as enviable. 
 
 " The lepers had their subsistence assured. They had money for 
 their small expenses. They were not submitted to claustration. In 
 the regulations of the leproseries there were disciplinary measures ; 
 the most severe was expulsion. The leprosery was not then an 
 inferno, as in that case the expulsion would not have been considered 
 a chastisement. The best evidence of this is the considerable num- 
 ber of false lepers which it was necessary to evict." 
 
 Ambroise Pare has reported the history of an unfortunate tuber- 
 cular leper, whose ulcers were simply painted to insure his entrance. 
 This practice of simulation, almost incredible as it may appear, is by 
 no means extinct. In mv observations of leprosy in the Sandwich 
 
636 MORROW— LEPROSY. 
 
 Islands I found that occasionallj' natives from one motive or another, 
 sometimes to join their friends or familj', will endeavor to simulate 
 the disease in order to be sent to the leper settlement. With an 
 irritant they will produce discolorations of the skin which resemble 
 the port-wine discolorations characteristic of the beginning stage. 
 This is often most artisticall}' done, and the simulation is most de- 
 ceptive. 
 
 In consigning a leper to the leprosery an examination was made 
 by a jur\" consisting, at Laon, for example, of a doctor, a surgeon, 
 and an apothecary. 
 
 The signs of leprosy were divided into uuivocal and equivocal. 
 According to Chauliac and B. de Gordon, the uni vocal signs were 
 " roundness of the eyes, loss of the eyebrows, dilatation of the nostrils, 
 with narrowness of the summit, a raucous voice, alteration of the lips, 
 the fixed regard of the satyr (the beast of horrible aspect in which 
 are the said signs)." 
 
 The equivocal signs were " tuberosities of the flesh, the color of 
 morphcea, atrophy of the muscles, stupor and insensibility, creeping 
 of the flesh. The blood is black, granular, salt clings on the skin of 
 the leper, water adheres to it like oil." 
 
 Ambroise Pare thus describes the method of examination made by 
 a jury of surgeons, of which he was a member, to ascertain if X. was 
 a leper (1583). The repoii; is as follows: "In the first place, we 
 found the color of his visage blotched and pimpled and full of bluish 
 spots, then we plucked hairs from his beard and his eyebroAvs and 
 found that a small portion of flesh was attached to the root of the 
 hair. In the eyebrows and the lower part of the ears we found 
 small tubercles, the brow wrinkled, the expression fixed and immo- 
 bile, the reddish eyes flaring, the nostrils enlarged without and con- 
 tracted within, as if obstructed with small encrusted ulcers, the 
 tongue swollen and black, and above and beneath we found thin 
 small grains as one sees in measly pigs, the gums corroded, and the 
 teeth denuded, and the breath offensive, having a rough voice, speak- 
 ing through his uose. We also saw him naked and found tlie sur- 
 face of his flesh rough and unequal, like that of a thin-plucked fowl, 
 and in certain places many dartres. Besides we punctured pro- 
 foundly with a needle the tendon of the heel without his feeling 
 pain. By all these signs, unequivocal and equivocal, we declared 
 that X. is a confirmed leper." 
 
 So rapid was the increase of leprosy that in the time of Louis 
 VIII. there were in France two thousand leper houses, and the num- 
 ber in Europe, without counting those in Eussia and Sweden, was 
 nineteen thousand. 
 
METHODS OF DEALING WITH LEPEOSY IN ANCIENT TIMES. 637 
 
 In England, Scotland, and Ireland isolation was enforced and ren- 
 dered possible by the multiplication of lazarettos all over tlie country. 
 Tlie churcli regarded the leper dead, and performed the burial ser- 
 vice for him on the day he was separated from his fellow-creatures 
 and confined in the lazaretto. The priest went with the cross to the 
 house of the condemned leper, and consoled him for the incurable 
 plague with which God had stricken him, and then the condem ned was 
 conducted to the church, the usual burial hymn being sung on his 
 way thither. The parents, friends, and neighbors joined in the hide- 
 ous cortege which rendered the last honors to this living cadaver. 
 Upon reaching the church, he was clothed in a funeral pall, and while 
 placed before the altar between two trestles the mass for the dead 
 was celebrated over him. After this service he was again sprinkled 
 with holy water and led to the house or hospital des-tined for his 
 future home, where he was comj)elled upon entering to take the vows 
 of obedience, poverty, and chastity. A pair of clappers, a stick, 
 a cowl, and a gray habit were given to him. 
 
 Before leaving the leper the priest solemnly forbade him to 
 appear in public without his leper's gown to warn people who did 
 not know him to flee his company, or to enter inns, mills, churches, 
 and bakehouses. He was forbidden to enter any inn or habitation 
 other than the one in which he dwelt, and when he wished wine or meat 
 it was brought to him in the middle of the street, or to touch chil- 
 dren or to give them what he had touched, to wash his hands or 
 anything pertaining to him in the common fountains or streams, 
 or to drink from them except in a special cup, to touch in the market 
 the goods he wished to buy except with his stick, and in asking alms 
 he was always to sound his rattle ; he was forbidden to eat or drink 
 with any other than lepers, and especially to walk in narrow, paths 
 or to answer those who spoke to him in the roads or streets, lest he 
 should infect those whom he might meet by his pestilential breath 
 and with the infectious odor which came from his body. Before 
 leaving the leper forever to the seclusion of the lazar house the priest 
 terminated the separation from his fellow-creatures by throwing upon 
 the body of the leper a shovelful of earth in imitation of the closure 
 of the grave. 
 
 Upon the death of the leper his habitation was burned, and he 
 himself was buried with his face to the earth. In many places the 
 corpses of lepers were found in this posture. 
 
 Dr. Newman, in his prize essay on leprosy, refers to many 
 curious laws relating to the lepers in England and Scotland. He 
 characterizes them as curiously contrary and extravagant, some being 
 so mild and indefinite as to be useless, others so strict and severe as 
 
638 MORROW— LEPROSY. 
 
 to be cruel and impossible to keei), aud concludes that " strict segre- 
 gation as understood and practised uowada^'S never entered tiie minds 
 of those desiring to separate lepers from the health}-." 
 
 The religious duties forced upon inmates under the control of the 
 church were of the most monastical character. During Lent all the 
 brothers as well as sisters were obliged to receive discipline three 
 dsijs in the week. Disobedient members were punished at the dis- 
 cretion of their prior aud prioress by corporeal correction, aud 
 offenders who refused to submit to the usual discipline were reduced 
 to bread and water, and after the third offence they were liable to be 
 ejected. 
 
 No inmate was allowed to transgress the bounds or to attempt to 
 go beyond the walls of the hospital without his close cape, or to stand 
 or walk by any king's road before or after service. By a decree of 
 the Archbishop of Canterbury (1200) lepers, when forming a large 
 colon 3% were entitled to have their own church and graveyard, but in 
 many places this special church and graveyard were quite impossible 
 through lack of funds and lack of lepers. In many places arrange- 
 ments were made by which the lepers were enabled to take some 
 share in the church services by means of the leper window or squint 
 window or hagioscope. There were generally openings or apertures 
 in the wall or narrow, oblong slits through which the elevation of the 
 Host at the high altar and other ceremonies might be viewed with- 
 out the lepers themselves being seen by the congregation. Certain 
 churches also had a st(jue slab let into the sill of the window and so 
 placed that a leper could receive the sacrament without actual con- 
 tact with the administrator. 
 
 By the laws of England lepers were classed with idiots, mendi- 
 cants, outlaws, etc., as incapable of being heirs. 
 
 In both Britain and Normandy lepers were expelled from society, 
 and had no power to alienate their effects or dispose of them to any 
 one. They were regarded as dead. 
 
 It would appear that the means provided for the sustenance of 
 the lepers were not of a very abundant character. The lepers were 
 allowed to go where they chose and beg what they could or reside in 
 any leper hospital to which they could get admittance. 
 
 A regulation in support of the hospitals all over the land states 
 that tainted beef is to be sent to the leper house in the neighborhood, 
 and if there was not one, then it was to be destroyed. Then again, 
 when a wild beast was found wounded or dead in the forest it was to 
 be sent to the nearest leper hospital. 
 
 Many hospitals were supported by voluntary or compulsory con- 
 tributions of a certain toll ujjon everything carried to the markets. 
 
METHODS OF DEALING WITH LEPROSY IN ANCIENT TIMES. 639 
 
 Other establishments were financed bv means of fairs in which 
 the chief articles for sale were wool, meal, hops, hardware, etc. , and 
 on one day horses. The business transacted was very extensive. 
 
 In the hospital at Edinbm-gh it seems that the lepers were kept in 
 the home, and between dawn and sundown the lepers took turn in 
 sitting at the gate asking alms, which were put in their cups. The 
 allowance was only four shillings a week for each inmate. 
 
 At the hospital in the city of Glasgow the inmates were allowed to 
 go out of the hospital, drawing attention by means of their clapper, 
 and asking alms. 
 
 The number of leper houses in England, Scotland, and Ireland 
 was over two hundred. " The number of these lazar houses, however 
 great, was insufficient to accommodate more than a small proportion 
 of those suffering from the disease." 
 
 In a majority of these leper houses, if a man was married, the wife 
 was allowed to go with him. As early as 789, Charlemagne promul- 
 gated laws forbidding the marriage of lepers. A similar law was 
 passed in Great Britain hj the Welsh king, Hywel Dda, who died in 
 950, and there are acts of Parliament which forbid cohabitation if 
 either wife or husband is a leper, the leper in these circumstances 
 being considered as dead. 
 
 In 1757 leprosy was declared to be a valid cause for divorce in 
 France. In 1776 a law was passed in Iceland to prevent lepers from 
 marrying. 
 
 As early as 1488 there was an edict ordering all lepers to leave 
 Paris. 
 
 In England in the fourteenth century, according to Simpson, a 
 leprous woman with a child was buried alive, and in 1746 lepers were 
 driven from London. 
 
 The harsh measures used in Europe for the suppression of leprosy 
 have always been regarded as an illustration of the value of segrega- 
 tion. Strict segregation, if we are to trust to historical evidence, 
 was, however, never carried out, as the inmates of most of the leper 
 homes were not strictly confined, but were allowed to leave the hos- 
 pitals and beg in the street, and thus mingle with their feUow- 
 beings. 
 
 Nevertheless leprosy decreased in a most remarkable manner. 
 In the thirteenth century the disease reached its zenith in Europe. 
 In the fourteenth century it had commenced to decline throughout 
 Europe, and by the end of the sixteenth century it had practically 
 disappeared. 
 
 Dr. Newman is inclined to attribute the decline and final extinction 
 of endemic leprosy in England and Scotland, not to segregation, but 
 
640 MORROW — LErROSY. 
 
 to the tendencj' of leprosy to die out und6r the more favorable hy- 
 gienic conditions, good food, and improved sanitation. 
 
 It is stated that formerly in China more drastic measures were 
 used for the suppression of leprosy than now prevail. 
 
 Dr. B. Taylor, of Fuh Ning Fuh Chow, in China, states that, 
 while there are lepers in the vicinity, there are none in the town it- 
 self, and that in a small village a mile from the city a village hospital 
 still exists, but there are no lepers in it. Concerning this assertion 
 Dr. Taylor has been told that a mandarin, about sixty years ago, desir- 
 ous of stamping out leprosy, having invited all the lepers to a feast in 
 the hospital, surrounded it with soldiers and then set it on lire. 
 
 Richard, in his history of Tonquin, states that leprosy is so com- 
 mon in Tonquin that there are pieces of land assigned where those 
 attacked by it must reside. Thej' are shut out from society, and it is 
 even lawful to kill them if they enter cities or towns. 
 
 In Damascus the fear of detection is stated to have compelled 
 lepers either to live in communities in huts outside of the village or 
 to seek refuge in leper houses in the city. 
 
 In comparatively' recent times a leper house has been discovered in 
 Bagdad surrounded by a thick wall, with a little room in which all 
 the lepers ^vere compelled to retire. 
 
 In Rhodes they are said to have been banished, destroyed, or sent 
 to some uninhabited island to subsist as best they could. 
 
 In Finland lepers were at one time isolated in houses built on 
 islands in the lake, and on the death of the leper the house and all 
 its furniture were burned. Similar leper huts were found by Savory 
 in Caudia, and Boeck discovered them in the island of Siera. 
 
 In Europe the leper houses were abandoned because of the grad- 
 ual decrease and final extinction of the disease, but it is worthy of 
 note that in other countries leper houses and hospitals have fallen 
 into disuse or been abolished from indifference on the part of author- 
 ities or from a lack of confidence in their utility. For example, in 
 Iceland towards the middle of the sixteenth century four leper houses 
 were erected in four quarters of the island. In 1848 the leper hos- 
 pitals were abolished. It is worthy of note, however, that during the 
 past year (1898) a leper hospital has been built at Reikiavik. 
 
 In various portions of China, in Java, as well as in North and 
 South America, lazarettos which were formerly used for the isolation 
 of lepers have fallen into disuse. The San Lazaro Hospital, which 
 was founded in Mexico by Cortez, the conqueror, was abolished about 
 thirty -five or forty years ago, although there has been no sensible 
 decrease observed in the disease. 
 
 The decline of the epidemic of leprosy in Norway is cited as an 
 
METHODS OF DEALING WITH LEPROSY IN MODERN TIMES. 641 
 
 evidence of the value of segregation. Since the establishment of the 
 leper hospitals 3,400 lepers have been admitted, while during the 
 same period 5,053 new cases have appeared. The total number of 
 known lepers in 1856 was 2,870, and in 1896 only 688. In 1885 a law 
 was passed making the segregation of lepers compulsory, but it is 
 understood that if a leper is able to provide himself with a separate 
 bed, cooking and eating utensils, and have his clothes separately 
 washed, he is not compelled to enter the leper hospital. 
 
 In Norway isolation is by no means absolute. The doors and 
 gates of the hospital are not kept locked, and the inmates may some- 
 times be met in the neighboring roads, those who have no ulcerations 
 being allowed to go out. They are kept in on market days. At 
 Trondhjem and other places they are permitted to enter houses and 
 churches or come in contact with other people. 
 
 In the island of Cyprus the effect of isolation is seen in the fact 
 that previous to 1878 there were 150 lepers in the island, 120 of whom 
 have been placed in the leper island ; of these 57 have died and 63 
 remain. At the end of ten years there were not more than 30 lepers 
 outside of the hospital, the whole number in the island not exceeding 
 100, showing a decrease of one-third during this comparatively short 
 period (Thin). 
 
 In 1896 the British Government passed a bill to provide for the 
 segregation of pauper lepers and the control of lepers following cer- 
 tain callings which extended to the whole of British India. 
 
 It is worthy of note that no person is termed a leper unless he is 
 suffering from a variety of leprosy in which the process of ulceration 
 has commenced, and the provision of the act extends only to a leper 
 who has in a public place solicited alms or exposed or exhibited any 
 sores, wounds, bodily injuries, or deformities with the object of excit- 
 ing charity or obtaining alms. Such person may be sent to a leper 
 asylum, where he shall be detained until discharged by order of the 
 board. 
 
 The leper is prohibited from pursuing any of the following call- 
 ings : (a) Practice as a medical practitioner, work as a barber, wash- 
 woman, water-carrier, baker, tailor, haberdasher, or domestic servant; 
 (b) selling any food, drink, or drug for human consumption; (c) bath- 
 ing at a stream or drinking at any drinking-fountain, well, tank, or 
 reservoir; (d) riding in any public conveyance. 
 
 Violation of any of these acts is punishable by a fine not exceed- 
 ing fifty rupees. 
 
 In the Straits Settlements a leper may be removed upon an order 
 from the senior magistrate to the nearest detention ward or other 
 building authorized for the reception of lepers. 
 Vol. XVIII.— 41 
 
642 MORROW— LEPROSY. 
 
 A further act in 1897, entitled a warrant to amend the law relating 
 to lepers, prohibits the leper from following any of the callings men- 
 tioned above. 
 
 Vagrant lepers may be sent to the leper asjdum and detained until 
 released by order of the Government. 
 
 A further p>rovisiou of the same act makes it lawful for the com- 
 missioner to undertake the registration and visitation of lepers within 
 the municipal limits. The landing of lepers is prohibited, and the 
 master of a vessel from which such a leper is lauded i.s lial^le to a fine 
 not to exceed 8500. Lepers uulawfullj^ landed ma}- be sent to the 
 leper asylum or returned to the jjlace whence they came. 
 
 In the Cape of Good Hoi)e an act was passed in 1884 to " check 
 the spread of the disease known as lepros}'." 
 
 Any person suffering from " infectious" lei)rosy shall, after exam- 
 ination by the district surgeon and by another duly qualified medical 
 I^ractitioner, be removed to a hospital for lepers, therein to be con- 
 fined according to the provisions of the law. This was amended in 
 1890, and infectioiis leprosy was defined as " leprosy in an advanced 
 and grievous stage, whether embraced in the loss of auj^ member of 
 the body or any other mark of the disease." A distinction was made 
 between such cases of lepros}' as are advanced and likely to be of 
 immediate danger to other persons and such cases as are less ad- 
 vanced, and separate provisions were made for dealing with cases of 
 the one kind and the other. Indian immigrants and certain others 
 afilicted with leprosy were to be sent back to their own country. 
 Male and f -male lepers were to be entirely separated from each other 
 while in the hospital. No communication or intercourse could be 
 allowed between the persons confined in a hospital or location for 
 lepers and j^ersons not confined tlierein Except the attendants of the 
 hosjntals, although the leper had the pri%'ilege of seeing his friends 
 and legal advisers at reasonable times. 
 
 The leprosy law was amended in 1894, permitting any person oi 
 persons belonging to the family or relatives of the person about to be 
 committed in the leper location to go with the leper, provided that 
 in case of minors accompanying such leper the consent of the guar- 
 dian or parent may be taken on behalf of such minors. 
 
 In 1892 a law was passed for the extermination and repression of 
 the disease of leprosy in British Bechuanaland, which ju'ovides for 
 the report of cases, the power of removal to the asylums, the creation 
 of separate male and female asylums, and the power of removal to the 
 asylum at the Cape of Good Hope. 
 
 In the Seychelles vagrant and pauper lepers may be removed to 
 the lei)er asylum. It is lawful, however, to grant the apj)lication of 
 
JMETHODS OF DEALING WITH LEPEOSY IN MODERN TIMES. 643 
 
 any next of kiu or friend that such lejDer be delivered to such next of 
 kin or friend and entrusted to his keeping. 
 
 The laws applying to Queensland, New South Wales, and other 
 Australian settlements are practically the same. In addition the lep- 
 rosy act of New South Wales (1890) provides for the obligatory notifica- 
 tion of cases of leprosy ; for the detention and isolation of lepers, the 
 estabKshment of lazarettos, and other purposes. In Queensland the 
 leprosy act of 1892 .provides that when any case of leprosy or sup- 
 posed leprosy is not rei:iorted by the medical jn-actitioner under 
 whose observation it comes, he shall be liable to a fine not exceed- 
 ing £100. 
 
 In Jamaica there was a leper asylum law passed in 1896 which 
 provides for the arrest of lepers wandering about begging and their 
 consignment to the leper asylums. If the leper can furnish security 
 for his proper maintenance and provide treatment, he may be dis- 
 charged from the asj'lum. 
 
 The laws in regard to the employment of 4)ersons affected with 
 leprosy are as follows : That he shall not be employed in the prepa- 
 ration or sale of any article which concerns the food, drink, or the 
 clothing of the public in general, and shall not follow the occufjation of 
 a barber, washer of clothes, cigar and cigarette maker, tobacco manu- 
 facturer, or school teacher. Such person or the person who employs 
 him shall be liable to a fine not exceeding £5, and in default of 
 payment, to imprisonment with or without hard labor for a period 
 not exceeding three months. 
 
 In the Leper Act for Barbadoes in 1890 there is provision made 
 for the voluntary entrance into the leper asylum of any one suffering 
 from the disease, and the compulsory entrance of those who seek 
 alms or support or who are without any visible means of subsist- 
 ence. 
 
 In the Islands of St. Christopher, Nevis, Antigua, Trinidad, and 
 Tobago, the provisions of the different acts affecting leprosy are about 
 the same. Lepers have the privilege of entering the leper asylums, 
 and there is compulsory segregation of mendicant, pauper, and 
 obnoxious lepers. 
 
 In British Guiana essentially the same provisions are made. 
 Leper vagrants who are found wandering abroad begging alms, seek- 
 ing pecuniary support, or exposing their leprous sores in any public 
 road may be conveyed to the leper asylum. Lepers may be dis- 
 charged on security being given for their treatment in private. 
 
 In Cuba and Porto Eico there are hospitals for the care of lepers, 
 but entrance is not compulsory. 
 
 In the Island ' of Malta, the laws for checking the spread of 
 
644 MORROW — LEPROSY. 
 
 leprosy are to the effect that any person found, upon the examina- 
 tion of the medical board, composed of five physicians, three of 
 whom shall be in the service of the Government, to be suffering from 
 leprosy shall be removed to the asylum for lepers, to be there de- 
 tained during the whole period of the disease. It is provided, how- 
 ever, that anj" person detained in the asylum may leave the asylum 
 for the purpose of fixing his residence abroad. 
 
 In the island of Cyprus the leper laws of 1891 make various pro- 
 visions for the isolation of all persons who are found upon ex- 
 amination of three qualified medical practitioners to be suffering 
 from the disease of leprosy, in the leper asylum. Lepers may build 
 separate dwellings for their own use within the precincts of the asy- 
 lum grounds. There is a penalty of £5 for not giving information of 
 the existence of lepers. 
 
 It will be seen from the section on " Geographical Distribution" 
 that leprosy is very extensively distributed in almost all the French 
 colonies. In New Caledonia it has been j^ropagated with an almost 
 incredible rapidity. The insurrection of 1878 contributed to dissem- 
 inate the disease. In French Guiana leprosy " propagates itself with 
 such rapidity that one-tenth of the population is infected." Ac- 
 cording to Jeanselme, Tunis, Senegal, the coast of Guinea, and the 
 French Congo are all contaminated, but there are no accurate docu- 
 ments giving reliable statistics. 
 
 While numerous lejiroseries have been established in various parts 
 of these colonies, strict isolation or segregation is nowhere practised. 
 A decree of the French Government in 1840 decided that the situation 
 demands the segregation of every free person who is attacked. A 
 new decree was promulgated in 1841. It provides that " there will be 
 admitted to the leprosery at I'Acarouuay all persons diseased with 
 leprosy who may make the demand, and that there will be sent there 
 all those who, being recognized as attacked with leprosy, have no 
 means of taking care of themselves." Persons in good circumstances 
 who wish to be treated at home at their own expense may be isolated 
 at a distance of two kilometres at least from Cayenne and one kilo- 
 metre from villages. Unfortunately the provisions of the laws for the 
 control of lei)ros3" in the French colonies have never been strictly 
 enforced. 
 
 In 1893 there was promulgated for New Caledonia a decree almost 
 identical with that of French Guiana. These are the only French 
 colonies where there has been established any regulation of leprosy. 
 
 The United States. — In this country the Government has taken no 
 active measures respecting the prevention of leprosy bej-ond quaran- 
 tine regulations with a view of preventing the immigration of persons 
 
METHODS OF DEALING WITH LEPROSY IN MODERN TIMES. 645 
 
 affected witli the disease. These regulations promulgated by the 
 Treasury Department through the United States Marine-Hospital ser- 
 vice in 1894 provide "that vessels arriving at quarantine with lep- 
 rosy on board shall not be granted pratique until the leper, with his 
 or her baggage, has been removed from the vessel to the quarantine 
 station. No case of leprosy will be landed. If the leper is an alien 
 and a member of the crew, and the vessel is from a foreign port, said 
 leper shall be detained at quarantine at the vessel's expense until 
 taken aboard by the same vessel when outward bound." 
 
 Many years ago the people of California recognized the danger of 
 the introduction of leprosy on the Pacific coast through Chinese immi- 
 gration. Section 2,952 of the Penal Code provides: "It shall not 
 be lawful for lepers or for persons affected with leprosy or elephan- 
 tiasis to live in ordinary intercourse with the population of this State. 
 But all persons shall be compelled to inhabit such lazarettos or leper 
 quarters as may be assigned to them by the Board of Supervisors by 
 the city or county in which they may be domiciled or settled. And 
 the Board of Supervisors are vested with power and are required to 
 • make all necessary provision for the separation, detention, or care of 
 lepers or persons affected with leprosy or elephantiasis settled or 
 domiciled in their respective cities or counties." 
 
 Section 2,955 provides for the inspection of all persons arriving in 
 California from foreign ports by the Commissioner of Immigration. 
 Those found to be lepers are to be taken in charge by him and placed 
 in a suitable lazaretto, and there detained separate from the general 
 population so long as they shall elect to remain in the State, or until 
 they shall have recovered, bat they are allowed to return whence 
 they came. The master or consignee of the vessel bringing lepers 
 is liable to a penalty of $1,000 for failing or refusing to comply with 
 the law. 
 
 Additional laws were passed in 1883, forbidding the landing of 
 lepers from any ship, their transfer to another vessel, or their har- 
 boring by any person outside the lazaretto. 
 
 While there is ample legislation in California for the segregation 
 of lepers, the health authorities in many towns are exceedingly lax 
 about enforcing the laws. 
 
 In Oregon the health officers for the different ports are required 
 to board all vessels arriving by sea ancl to examine passengers and 
 crews for leprosy, but there is no provision for the detention and care 
 of lepers. 
 
 Louisiana is the only State in the Union which has provided a 
 home or asylum especially for lepers. In 1892 there was passed by 
 the legislature " an act to prevent the spread of leprosy and provide 
 
646 MOREOW — LEPROSY. 
 
 treatment for the same and for isolation of persons afflicted with said 
 disease and j)enaltie8 for non-compliance with the provisions of this 
 act." This act was supplemented by one in 1894 which ordered that 
 "all persons afflicted or suifering with said disease of leprosy shall 
 be confined in an institiition isolated and used for the treatment of 
 said disease." Notification of all cases of leprosy was required under 
 penalty of fine or imi)risonment. Pursuant to the provisions of this 
 act a home was established (1895) in Iberville Parish, about eighty 
 miles from New Orleans. During the first year of its existence 
 thirty-one lepers were transported to the home, twenty -three of whom 
 were born in Louisiana. Since then a few additional cases have been 
 admitted, but, owing to the apathy of the profession and the public, 
 the provisions of the above acts have not been successfully carried 
 out. 
 
 In Massachusetts the boards of health are empowered to isolate and 
 provide necessary attention to persons afflicted with le])rosy or other 
 sicknesses dangerous to the public health. 
 
 The Board of Health of New York has, under the general provision 
 of the chapter relating to diseases which in the opinion of the board 
 shall be dangerous to the public health, the power to isolate leprosy. 
 Several years ago the New York Board of Health began to take official 
 cognizance of leprosy in this city. All lepers coming within their 
 jurisdiction were isolated on North Brother Island. At first they 
 were quartered in a tent on the island as far removed as possible from 
 the other buildings. Later a cabin-like structure was erected for 
 their confinement, from which they were transferred and quarantined 
 in one of the disused buildings for contagious diseases. In 1897 the 
 few lepers in confinement on North Brother Island were allowed to 
 esca])e, and since then there has been no official action on the part of 
 the Board of Health in reference to lepers in this city. 
 
 Many other of the individual States have made laws afi'ecting the 
 control of lepers within their respective Ix rders, and the national 
 Government exercises no jurisdiction over them. 
 
 There was passed Jauuary 24tli, 1898, by the Congress of the United 
 States, an act for the investigation of leprosy, which provides that the 
 Su[)ervising Surgeon General of the Marine-Hospital service, under the 
 direction of the Secretary of the Treasury, shall ai)point a commission 
 of medical officers of the Marine-Hospital service to investigate the 
 origin and prevalence of leprosy in the United States and to decide 
 upon what legislation is necessary for the prevention and the spread of 
 this disease. So far as can be ascertained" no active ste])S have been 
 taken to carry the ])rovisions of this act into effect. 
 
 Haioaii. — In 1863 the health authorities became alarmed at the 
 
GEOGEAPHICAL DISTEIBUTION. 647 
 
 rapid spread of leprosy in the Hawaiian Islands, and in 1865 the legis- 
 lative assembly passed an act to prevent the spread of leprosy, wliicli 
 provided for the gathering together of all the lepers of the kingdom, 
 with a view to their isolation and treatment. The execution of this act 
 was entrusted to the ♦Hawaiian Board of Health. A portion of land 
 was set apart on the island of Molokai for the seclusion of the lepers, 
 and a hospital for the reception and examination of the lepers was 
 established at Kaliki, near Honolulu. 
 
 The method adopted by the sanitary authorities in dealing with 
 leprosy is as follow^s : The authorities are empowered to bring all 
 suspected lepers to the hospital for examination. The examination 
 takes place under the supervision of the board of three physicians, who 
 are selected for their especial fitness for this task. Those suspected of 
 leprosy are kept under surveillance until either the suspicious symj)- 
 toms have disappeared or unmistakable signs of leprosy are manifest. 
 The pronounced lepers are kept secluded and forwarded to the leper 
 settlement to remain there until they die. 
 
 Nearly all the lepers sent to the Molokai settlement have passed 
 through the receiving station. In the earlier times some occasionally 
 were sent there direct from other islands. 
 
 Since the establishment of the leper settlements over six thousand 
 lepers have been received. 
 
 Geographical Distribution. 
 
 Asia. 
 
 India. — India has always been regarded as one of the chief and 
 oldest centres of leprosy. It is exceedingly difficult to ascertain 
 whether leprosy is on the increase or decrease, as in many districts 
 there are no reliable data upon which to base an accurate estimate as 
 to the prevalence of the disease. Vague and widely differing esti- 
 mates have been given. According to the investigations of the com- 
 missioners of the national leprosy fund, who were sent to India to 
 investigate and report upon leprosy, there were over one hundred 
 thousand lepers in India. Little has been done in the way of legis- 
 lation or in the systematic management of lepers; probably not two 
 per cent, receive proper care. A leper asylum known as the Matoonga 
 Hospital has been recently established near Bombay, with accom- 
 modations for three hundred inmates, entrance into which is volun- 
 tary. There are a number of other hospitals in which lepers may 
 receive care and attention. 
 
 The census of 1891 gives 114,239 lepers in India, a proportion of 
 0.5 per thousand. There is in the presidency of Bengal 0.51 per 
 
648 MORROW — LEPROSY. 
 
 thousand; in Madras, 0.37 per thousand; in Bombay, 0.47 per thou- 
 sand; in Lower Burmah, 0.63; in Upper Burmah, 1.18 per thousand; 
 in Mj'sore and Coorg, 0.16 per thousand. In single districts, Bam- 
 koora and Berhoom and Bengal, there are 3.63 to 3.52 per thousand. 
 The island of Ceylon has about two thousand lepers — 1.10 per thou- 
 sand. 
 
 In certain regions leprosy is much more prevalent than in others. 
 Dr. Van Dyke Carter found that from one-third to one-half of all the 
 districts are affected with leprosy in variable proportions ; in some 
 the ratio was two lepers in one thousand inhabitants, and as high as 
 one in two or three hundred people, or one in eighty, or even one in 
 fifty existed in certain parts. 
 
 The opinion of the Leprosy Investigation Committee was to the 
 effect that the available data point strongly to a decrease in the dis- 
 ease and that leprosy does not prevail in India to such an extent as to 
 constitute a general or universal danger. 
 
 China. — Although China is one of the oldest and most prolific hot- 
 beds of leprosy in Asia, it is impossible to obtain accurate statis- 
 tics of the prevalence of the disease. The traditional policy of the 
 Chinese, observed in their exclusiveness and their disposition to 
 thwart outside investigation into their customs, habits, and manners 
 of living ; the enormous extent of their territory, much of it unex- 
 plored or unknown to modern civilization ; and the teeming population 
 (one-fifth of the human race), constitute conditions which preclude 
 the possibility of obtaining accurate information. The general state- 
 ment that leprosy prevails throughout the whole empire of China 
 would seem to be contradicted by recent investigations. 
 
 Cantlie, in his prize essay on "Leprosy in China, Indo-China, 
 Malaya, the Archipelago, and Oceanica" (New Sydenham Society, 
 1897), says that not one-third of the territory of China is under the 
 ban of leprosy. It is certain that leprosy does not prevail in the 
 north of China to anything like the extent it prevails in the south- 
 eastern parts. In endeavoring to arrive at the precise facts, based 
 upon the most reliable data, it is necessar\' to comjjare the notes of 
 various observers and carefully sift the evidence. For exami)le, the 
 statement was quoted in a prize essay of the national leprosy fund, 
 by Dr. George Newman, that " at Tientsin there are two large asylums 
 for wretches who are taken with lepros}', located on the outside of 
 the cit}-; two or three hundred lepers live at each of these asylums." 
 Dr. Cantlie's investigations show that there are no leper hospitals at 
 Tientsin. 
 
 Likewise it was stated by von Bergmann that Hanoi, the capital of 
 Tonquin (one hundred thousand inhabitants), in ludo-China, was so 
 
GEOGEAPHICAL DISTRIBUTION. 649 
 
 infected by leprosy fcliat one-lialf of the inhabitants were lepers. The 
 truth is that in the leper village not far from Hanoi one-half of the 
 four hundred inhabitants were lepers. 
 
 In the province of Shantung there are a few lepers in almost 
 every village, more in the interior than on the coast. In Hupeh 
 and Szechuen leprosy is more or less prevalent. In the province of 
 Fokien it is a veritable scourge. 
 
 The province of Kwantung is called by Cantlie the cradle of 
 leprosy. In Kwantung there is a leper village near every large 
 town in the province. There were formerly two leper asylums near 
 Canton, one with seven or eight hundred inhabitants, the other over 
 a thousand. At present there is but one leper village one and one- 
 half miles outside of Canton with six hundred and fifty inhabitants. 
 In addition to the lepers in this village several hundred dwell in the 
 river on boats. In the district and port of Swatow, situated at the 
 mouth of the Han Eiver, which serv,es as a place of embarkation for 
 the enormous coolie trade of the densely populated regions of this pro- 
 vince, leprosy prevails extensively. In this district there are villages 
 called leper settlements, but there is no segregation, and lepers are 
 allowed to move about freely. 
 
 In Macau, a Portuguese settlement in Kwantung province, lepers 
 are segregated on an almost inaccessible island, and the character of 
 the coast acts as a natural barrier against leper deserters. They are 
 not sent here until the disease is quite far advanced. 
 
 During Dr. Cantlie's visit there were in the leper island forty 
 males and twenty-nine females. The proportion of Portuguese of the 
 entire population affected with the disease would be about one per 
 thousand. 
 
 The island of Hainan has a large proportion of lepers among its 
 Chinese population. The aborigines are exempt. 
 
 In the island of Hong-Kong leprosy is more or less prevalent. In 
 two and one-half years one hundred and twenty-five lepers presented 
 themselves for treatment at the Alice Memorial Hospital. Before 
 the annexation of the island by the British leper families and com- 
 munities lived in huts on the hiUs about the town and maintained 
 themselves by begging or otherwise. Since the British occupation, 
 whenever a leper is suspected, the police arrest him, and if he should 
 prove leprous he is sent away to the mainland. It is worthy of note, 
 Jiowever, that a minimum calculation shows that in seven years, from 
 1880 to 1886, at least six or seven hundred lepers dwelt in the island 
 of Hong-Kong unknown to the Government. 
 
 In the island of Formosa many of the Chinese population are 
 lepers, but the Japanese are exempt. In the peninsula of Korea 
 
660 MORROW— LErEOSY. 
 
 leprosy is most prevalent iu the south and dies away to the north. 
 All the cases met with iu the north are importations. 
 
 Dr. Cantlie says: "Leprosy in the far East is centred iu the 
 sontheastern provinces of China. The coolie emigrants come chiefly 
 from Kwautung and Fokien ; three-quarters of the coolif emigrants 
 from China are from these i^ro^-inces, and the spread of leprosy in 
 the Malay peninsula, iu the Dutch, Spanish, and Portuguese East 
 Indies, and in Oceanica, has been in all cases coincident and concur- 
 rent with the immigration and residence of coolies from these prov- 
 inces. In no instance over this vast area has any native acquired 
 leprosy except where Chinese coolies have settled." 
 
 The natives ascribe leprosy to the Chinese immigrants, and the 
 name used shows the belief in the Chinese origin of the disease. 
 There is no native name for the disease in the alioriginal languages, 
 except in Malay. 
 
 The Chinese recognize thirty-two kinds of leprosy ; the two prin- 
 cipal forms, which they term "moist" and "dry," corresponding to 
 the tubercular and anaesthetic types. The causes assigned for leprosy 
 are almost innumerable. They believe in the hereditary transmission 
 of leprosy, but believe that the disease does not go beyond the third 
 generation. They attach a great importance to sexual intercourse iu 
 the spread of leprosy. In most ])rovinces they think that the efHuvia 
 from the patient are sufficient to transmit the disease. When a leper 
 quits his seat, another person will not hesitate to occupy it, but be- 
 fore the newcomer sits down he will fan the place where the leper sat 
 as precaution against infection. The Chinese in some provinces 
 believe that leprosy is caused by a microscopic animal which flies 
 unseen. A person is stated to have been beaten with a stick smeared 
 with blood from a leper, and to have died subsequently from lei:)rosy. 
 The urine tainted with leprosy is stated to have been the means of in- 
 fecting healthy persons. Compulsory segregation is practised only 
 by the Portuguese in Macau. 
 
 The methods used by the Chinese for the segregation of their 
 lepers is by the establishment of asylums or settlements termed leper 
 villages. Each asylum is under the control of a head man, who must 
 reside at the institution and who is nominall}^ or really a leper who 
 manages the general affairs of the asylum, reporting from time to 
 time to the district authority the condition of the establishment, ad- 
 missions, deaths, etc. A small stipend is allotted to the lepers by 
 the Government, which they supplement by begging in the streets, 
 and thus eke out the means of a miserable existence. When a deper 
 dies, his corpse is burned, as fire is supposed to destroy the insects 
 which cause the disease. The leper villages are not isolation estab- 
 
GEOGEAPHICAL DISTRIBUTION. 651 
 
 lisliments, but merely refuges where lepers may dwell. Tlie majority 
 are beggars who daily go forth to obtain alms. They are met with 
 in shops and streets, on the river, everywhere. These dwellers in 
 the leper villages mix with the crowd, handle the food exhibited for 
 sale, and pay the cash they carry in their leprous hands. Nobody 
 refuses to buy from a leprous huckster, and provisions are bought 
 fearlessly in the store of a leper (Ashmead). Cantlie says: "The 
 leper village they dwell in serves merely as a hotbed of infection, and 
 the disease will remain endemic so long as these nests of infection are 
 maintained." 
 
 Cochin. China. — Leprosy also extensively prevails in Indo-China, 
 in Siam, Annam, Gamboge, and in Tonquin. At the gates of Saigon 
 at Tinghe there is, according to M. Jeanselme, a leprosery containing 
 from two hundred to two hundred and fifty i:)atients. At Tonquin lep- 
 rosy is rare in the mountainous regions which are but little inhabited. 
 The leprous village of Hanoi is situated in a depression. It is 
 isolated by a high dike, pools, and impenetrable bamboo thickets. 
 Half of its four hundred inhabitants are lepers. There is a smaller 
 leper village in the city of Hanoi, and tlie leper mendicants freely 
 traverse the streets of the capital. The disease is quite widely spread 
 among the Annamites. Segregation is extensively practised. Lepers 
 are not isolated in the villages, but live in separate localities from one 
 another and take part in ordinary labor as if they were not diseased. 
 In certain regions, however, they are segregated very vigorously. 
 They are compelled to keep away from frequented roads and to follow 
 special paths. 
 
 Malay Peninsula. — In Singapore, which is the headquarters of the 
 British Government of the Straits, there is a large and well-ax)pointed 
 leper hospital. The inmates are chiefly Chinese, but a number of 
 ■ Malays, a few Portuguese, and occasionally some other European are 
 met with among them. There is also a large leper asylum in Penang. 
 Most of the cases are imported from other countries, principally 
 China. Another leper hospital is at Johore. In all these hospitals 
 the Chinese form the largest number of the patients. 
 
 In Perak leprosy is widespread, both Malays and Chinese being 
 extensively affected. None of the Japanese are known to be lepers. 
 
 In Muar leprosy is uncommon. Chinese suffer mostly, Malays 
 rarely. 
 
 Butch East India.— In Malaysia leprosy has its principal seat 
 in the islands of Java, Sumatra, and the island of Borneo, although 
 other portions of the Dutch East Indies are infected. 
 
 Broes van Dort, as also Cantlie, insists that the propagation of 
 the disease is especially due to the immigration of the Chinese. 
 
652 MOBROW— LEPROSY. 
 
 Tliere are in Central Java 30 to 38 patients ; in Western Java, 42 ; in 
 Eastern Java, 2,703; upon the east coast of Sumatra about 1,000; 
 and upon the west coast, 156. In the island of Java tlie disease has 
 taken on dangerous proportions. Up to 1865 there were fourteen 
 hospitals. In 1886 there were six voluntary asylums for lepers. 
 The inmates are principally Chinese, who are everywhere the chief 
 sufferers. The few Europeans when attacked have returned to Hol- 
 land. Since the introduction of European civilization leprosy is said 
 to have increased, as formerly the Javanese killed their lepers or 
 exposed them so that they should perish from lack of nourishment. 
 The Malucca Islands and the Islands of Amunta and Tarnacte are also 
 infected. 
 
 The Philippine Islands. — There are no data of a definite character 
 accessible as to the prevalence of lei:)rosy in the Philippine Islands. 
 There are leper hospitals near Manila. One hospital in Luzon has 
 one hundred and fifty beds. The general impression is that the cases 
 which were the origin of local epidemics of leprosy in Valencia and 
 Alicante, Spain, were imported from the Philippines. 
 
 Japan. — We have no knowledge of the origin of leprosy in Japan. 
 The general impression is that it has existed in this country for cen- 
 turies, at least six hundred years before the Christian era, and that the 
 disease was formerly more severe in its ravages than it is now. Ac- 
 cording to the latest official communication, based ujoon the investiga- 
 tions of the Sanitary Bureau of the Home Office, there were in Japan 
 (in September, 1897) 23,647 lepers distributed through the empire. 
 Leprosy is more prevalent on the coast than in the mountainous 
 regions of Japan. There is no attempt at government control of lep- 
 rosy, and leprosy asylums or hospitals have never existed. In many 
 instances the families themselves have a separate room for the leper 
 member. People regard the disease as hereditary and do not marry 
 members of a leprous family. The lepers intermarry among them- 
 selves. 
 
 Australia. — There is no official record of leprosy in any part of the 
 Australian continent prior to 1885. Dr. Ashburton Thompson, in his 
 contribution to the " History of Leprosy in Australia" (London, 1897), 
 gives a chronological summary of all cases of leprosy in Australia 
 which had been recorded. They amounted to 70 in New South Wales, 
 45 in Victoria, 48 in Queensland, 2 in Western Australia, and 19 in 
 the Northern Territories. Of the New South Wales cases, 34 occurred 
 among the whites. The large majority of the lepers in Australia have 
 been Chinese and Kanakas (South Sea Islanders). The Chinese, 
 however, are at present the most numerous. 
 
 There is no record of leprosy among the aborigines in any ex- 
 
GEOGEAPHICAL DISTRIBUTION. 65'6 
 
 plored part of the continent before the known advent of emigrants with 
 recognized leprosy ; but that they are susceptible to the disease has 
 been proven by the breaking out of leprosy among them since 1892. 
 Dr. Thompson's table shows a general increase of recorded cases sub- 
 sequent to 1877. It also shows a marked increase of cases subsequent 
 to legislation for the control of leprosy in these colonies. For exam- 
 ple, in thirty-one years before compulsory notification was established 
 there were in certain districts seventy-two cases.; in four years after 
 compulsory notification sixty-three cases were recorded. He thinks 
 that there is probably no such increase as would appear from these 
 tables. The proportionately larger number which have been recorded 
 within the last feAV years is due to the greater attention which is given 
 the disease. The most stringent laws extant against leprosy have 
 been enacted in Australia. 
 
 In JVeiv Zealand many cases have been discovered among the 
 Maoris; both Chinamen and whites have also been affected. The 
 disease is said to be declining. 
 
 In the Samoan Islands leprosy has been introduced within recent 
 years, but its spread has been comparatively restricted. 
 
 In the Fiji Islands one per cent, of the inhabitants are lepers. 
 Of twenty -one cases reported by Dr. Corney, eleven were in Indians; 
 the others were in natives of other islands, Solomon, Tonga Islands, 
 but there were no cases among the Europeans. The increase of lep- 
 rosy in the Fiji Islands of late years has been attributed to the abo- 
 lition of the practice of privately killing affected persons, which was 
 in vogue before the British rule. 
 
 New Caledonia is one of the most important and extensive of the 
 modern centres of leprosy. The disease is said to have been brought 
 in by the Chinese, although its introduction may possibly have 
 been through other sources. A Chinaman in 1866 or 1868 had been 
 received by a tribe of Kanakas with whom he had lived for several 
 years. His body and extremities were covered with hideous sores. 
 Within ten years, according to the missionaries, several analogous 
 cases wore observed among the natives who had been previously ex- 
 empt from the disease. In 1880 five New Hebrides islanders were 
 found to be suffering from the disease, and in 1883 numerous lepers 
 were found on the north coast of tlie island. 
 
 After the insurrection of 1878 and the dispersion of the tribe the 
 malady was propagated with astonishing rapidity through the entire 
 colony. It is estimated that at least four thousand Kanakas have 
 been affected with leprosy in New Caledonia. In 1886 ten foreigners 
 had contracted the disease ; three years later forty-six had been at- 
 tacked ; and this estimate Dr. Grail says is much below the actual 
 
654 MORROW— LEPROSY. 
 
 number. There are three leproseries provided for the patients, but 
 there is no strict isolation. The lepers of this archipelago were segre- 
 gated at the leproseries of the Marquisas Islands, which contain about 
 four hundred lepers. 
 
 Northern and Central A'iia. — Little is known of leprosy in Central 
 Asia. From Northern China it extends up to Kamschatka and up 
 the land of the Jakats. It is slightly prevalent in Siberia and also 
 prevails among the Kouts. Smirnow stated that in the province of 
 Vilinisk there were in 1891 seventy-seven lepers in a population of 
 about seventy thousand. 
 
 In Persia and in Turkestan little is known of the facts in regard to 
 lejiros}', except that it ]jrevails more or less extensively' in certain 
 provinces. According to Munsch, the proportion is about one per 
 thousand and in some districts one per hundred among the inhabitants 
 of Turkestan. 
 
 In Asiatic Turkej' the disease exists in Syria, Arabia, Asia 
 Minor. In Asia Minor, according to von During, the proportion of 
 lepers is about one per thousand of the inhabitants. 
 
 Leprosy prevails in all Palestine. The principal centres are at 
 Jerusalem, Pvamleh, and Naplouse, near Jerusalem. The leprosery 
 of Byr About Jesus Hilfe contains about thirty-four patients. 
 Another small hospital has six or eight inmates. The total number 
 of lepers in Jerusalem is said to be forty to fifty. The Araljs are 
 the principal sufi'erers, the Christians and Jews being comparatively 
 exempt. The patients rarely enter the asylum in the earlier stage of 
 the disease, but remain with their family and friends until they become 
 helpless. 
 
 Africa. 
 
 Egypt has always been regarded as one of the oldest centres of 
 leprosy. The oflBcial census which was made by Engel gives as the 
 result a total of 2,204 lepers in 1893. This number is evidently 
 very much below the exact figure. The disease is encountered prin- 
 cipally in the delta and in the Upper Nile regions. The present 
 Khalifa, according to the press reports, is suffering from leprosy, con- 
 tracted by taking the wife of an emir who died of leprosy. It is met 
 with in Abyssinia, in Darfur, and along the east coast line of Africa. 
 
 It is found in Madagascar, Mauritius, Isle of Pieuuion, Santa 
 Maria, and in the Seychelles, In the island of Eeunion there is 
 a leproserj' in which the number of patients varies between seventy 
 and one hundred. 
 
 In JIadagascar, according to Davidson, the disease has extended 
 since the old laws of isolation were abolished. 
 
GEOGRAPHICAL DISTRIBUTION. 655 
 
 In German East Africa leprosy prevails less upon tlie coast than 
 in the neighborhood of the Great Lakes, where it is quite extensive, 
 and in certain islands of the Victoria Nyanza. Here the Government 
 established a leprosery (Metento), where, in 1895* 18 casqs had been 
 admitted. In South Africa leprosy for the past fifty years has shown 
 a marked increase (Impey). 
 
 Gaj^e Colony. — According to the most authentic records, leprosy 
 existed among the earliest races which inhabited this continent. In 
 South Africa, according to tradition, leprosy has always existed 
 among the Bushmen. On account of the custom of the natives of 
 abandoning their sick or driving them in the forests to die of hunger, 
 the disease was liept in rejjression. 
 
 According to Dr. Isaacs, the Bantas, including the Kaffir tribes, 
 with whom the earlier settlers came in contact in 1750, occujjied a 
 large part of the African continent. Leprosy was a disease well 
 known to them and had existed as far back as their traditions went. 
 They likewise had the custom of putting out of the way their sick and 
 helpless. 
 
 The earliest ofiicial records of leprosy occur in the year 1756, dur- 
 ing the Dutch rule. Early in the present century, in the year 1817, 
 the first asylum for lepers was established by European missionaries 
 at Hemel en Arde. Four hundred patients were admitted from 1817 to 
 1846. Later another asylum was established at Graf-Einet. In 
 1846 the two asylums were closed, and the lepers transferred to Eob- 
 ben Island. In 1889 a compulsory segregation act was put in force, 
 owing to the notable increase in leprosy. The total number of lepers 
 admitted to Eobben Island from 1846 to 1897 was 1,948. There are 
 in Cape Colony at the present time 812 lepers ; in Basutoland, 250 
 lepers ; in Griqualand East and in the Transkeian district, 650 cases ; 
 in Bechuanaland, 10 cases ; in Natal, 200 lepers ; in the Orange Free 
 State, 150 cases ; in the Transvaal Eepublic, 105 cases. 
 
 German Southwest Africa is up to the present time believed to be 
 free from leprosy. The disease is encountered in the Congo State, 
 but not extensively. Most of the cases are met with in the lower 
 Congo. It is unknown to the Kamerun; the estuary of the Niger 
 seems to be also free from the disease, but it is found on the Gold 
 Coast, Sierra Leone in Senegambia, and in the Canary Islands.. 
 Stamford, in TJie Journal of Tropical Medicine (No. 31), reports 15 
 cases of leprosy in the Canary Islands. Dr. Goldsmith estimates 
 that in Madeira there are about 70 cases, or six to 10,000 inhabitants. 
 There has been a 'sensible decrease in the disease in the past thirty 
 years. Tonkin has never observed leprosy in the coast between Sierra 
 Leone and Old Calabar. Lepers are found in vast numbers upon the 
 
656 MORROW— LEPROSY. 
 
 Upper Niger and along the Benin River. Leprosy also prevails 
 quite extensively in Maroc. 
 
 Algeria. — Gemy and Raynaud report having observed 58 cases 
 of leprosy in Algerki. Of these about 40 were in Algiers ; the others 
 lived at Constantiue and other places. This number of cases rei)orted 
 is, in their opinion, very much below the actual number. The Span- 
 iards brought the disease from Alicante and Valencia, in which region 
 there exists a considerable leprosy centre. Some of the patients were 
 afflicted with the disease at the time of their arrival in Algiers. In a 
 great number it was manifest only after a residence of from three to 
 twenty years. 
 
 Among the number there were 8 Jews, which represents a propor- 
 tion of 1 per 1,000, as there are 8,000 Jews in Algeria. 
 
 Europe. 
 
 The countries of Central EurojDe have for the most part been free 
 from leprosy since the decline and extinction of the great epidemic in 
 the sixteenth and seventeenth centuries. Within the past two cen- 
 turies onh^ occasional cases have been met with here and there, and in 
 these for the most part the patients have contracted the disease in for- 
 eign countries where leprosy is endemic. 
 
 Great Britain. — As a result of a careful and painstaking investiga- 
 tion Dr. Phineas Abraham, of London, reported to the Berlin Lep- 
 rosy Congress that the total number of cases of leprosy of which he 
 could find records in England, Scotland, and Ireland was 56, 14 of 
 which were personal cases. He had reason to believe that there were 
 about 20 more under the observation of medical men, who for various 
 reasons were unable to furnish notes of their cases. Estimating a 
 margin of about 20 unrecognized cases, he concludes that the num- 
 ber of cases of lei:»ros3' occurring during the last ten years in Great 
 Britain and Ireland does not exceed 96, or certainly not more than 
 100. He concludes that there is no reason to believe that there 
 are more lepers in the United Kingdom now than for many years 
 past. 
 
 Jonathan Hutchinson, who sees more cases of rare diseases than 
 an}^ other man in London, says that " cases of leprosy are fewer now 
 than formerly." All of the cases above mentioned contracted the dis- 
 ease in India and in countries where leprosy is endemic. The only 
 cases recorded in this century in which the disease must have been 
 communicated in England are the cases of Dr. Hawtre^' Benson and 
 Dr. Liveing, and a case published in Guy's Hospital Reports for 
 1868. From time to time supposed cases have been reported which 
 
GEOGKAPHICAL DISTEIBUTION. 657 
 
 upon investigation proved to have been examples of erroneous 
 diagnosis. 
 
 Holland, Belgium, Denmark, Sivitzerland, Germany, and Austria 
 are practically leprosy free. In Holland tliere are 30 cases (Broes van 
 Dort); in Belgium there are 4 cases (Bayet) ; in Denmark there are 
 from 1 to 3 cases (Ehlers); in Switzerland there are 2 cases (Jadas- 
 sohn) ; in Germany there are 33 cases (Blascho). 
 
 In Germany there has been noted within the past few years quite 
 an epidemic around Memel, a village near the Kussian frontier, sup- 
 posed to have been brought in from the province of Cracow, in Rus- 
 sian Poland. The epidemic which began in 1873 has attacked 32 
 persons ; of these 16 were imported and 16 acquired in the locality 
 in which the patients live. Nineteen of the lepers have died. The 
 Memel epidemic is regarded by leprologists as affording an admir- 
 able opportunity for studying the direct contagiousness of leprosy — 
 brother to sister, daughter to mother, mistress to servant, servant to 
 mistress, etc. 
 
 ' In Austria-Hungary the disease is sporadic in Bosnia and Herze- 
 govina. The official report states there are 133 lepers, which number 
 is, according to the reporter, vastly below the actual number. 
 
 In Montenegro about 1,000 to 2,000 of the inhabitants have the 
 disease. Almost the entire Isle of the Vulcrans is infected. 
 
 In Servia and Bulgaria there are only a few cases reported (104 
 tubercular and 29 anaesthetic cases), but the indications are that the 
 disease is quite prevalent. 
 
 Boumania. — Drs. Petrini and Kalindero reported to the Leprosy 
 Congress the existence of 208 lepers in Boumania. The first record 
 of its existence was in 1874. It has markedly increased since the 
 Eusso-Eoumania-Turkish War in 1877. The greatest number of 
 lepers are found along the roads followed by the Eussian army or in 
 the neighborhood of those roads. 
 
 Constantinople. — Von During reports that he has personally ob- 
 served 258 lepers and estimates the entire number in the city at be- 
 tween 500 and 600. Zambaco Pacha estimates that there are 4,000 
 lepers in the Ottoman Empire. In Constantinople the Jews are the 
 principal sufferers. The Mussulmans are rarely attacked, their 
 immunity being attributed to their mode of living. 
 
 Greece.— Bexgmsinii estimates the number of lepers upon the Gre- 
 cian continent at about 400. Zambaco Pacha gives a similar esti- 
 mate. During the war Greece received a large number of lepers from 
 Crete, augmenting the number. The statistics of leprosy in Greece 
 presented to the Berlin Leprosy Congress differ somewhat. Eosolimos 
 estimates there are 99 lepers ; Mitaftsis estimates there are 119 lepers. 
 Vol. XVIII.— 43 
 
658 MORROW— LEPllOSY. 
 
 Samos aud other islands of the J^^^^eaii Sea are also infected. Ehlers 
 found 15 i:)atients in the peninsula of Pelion in 1897. He remarks 
 that when one searches for lepers one always finds more than are uj^on 
 the official lists. 
 
 Maud of Crete. — According to Zambaco, Crete itself contains 
 from 2,000 to 3,000 lepers. There are no reliable data to show when 
 leprosj^ was introduced into the island. Dr. Smart in 1851-52 gave 
 the number of cases in the leper villages as 625. There is no leper 
 hospital on the island, nor are the patients subjected to any govern- 
 ment or municipal control. The fear of contagion alone compels a 
 semi-separation of the lepers in the three leper villages situated just 
 outside the three principal towns. In 1891 Dr. Bilioti estimated the 
 number at 320 out of a total population of 300,000, the number of 
 males far exceeding that of the females. 
 
 Itahj. — There are no definite statistics as to the number of lepers 
 in Italy, although Pellizari states that the number is large. Ferrari 
 reported several years ago 152 cases in Sicily . Mazza has observed 20 
 cases in Sardinia. Breda has seen 24 cases at Commachio. SmMl 
 foci of the disease are known to exist in various parts of Italy. The 
 ancient leprosery of San Eemo, which is regarded as the last remnant 
 of the ancient leproseries in Europe during the Middle Ages, always 
 contains a few lepers. Giovaunini has observed at Turin since 1890 
 13 Piedmontese lepers. Pellizari states that these figures all fall 
 below the actual number. 
 
 Lepers are found along the entire Kiviera, both the French and 
 the Italian Eiviera. Jaja reports 18 cases in Apulia. Amicis reports 
 15 leprous families in the vicinity of Naples. The disease is scattered 
 in small foci throughout almost the entire country. There are also 
 lepers in tlie islands of Elba, Malta, aud Gozzo. 
 
 Portugal. — Leprosy prevails extensively in this peninsula. Fal- 
 cao collected statistics of 468 lepers, but this number is far below the 
 actual number. He estimates that the actual number of lepers in 
 Portugal is not less than 1,000. Small foci of the disease are 
 scattered here aud there ; the most infected centre is Lisbon. There 
 are special hospitals for lepers at Lisbon and at Cordova, but there 
 is no attempt at isolation. These hospitals contain a small number 
 of inmates, who are free to enter or leave as they wish. Falcao has 
 since collected reports of 772 cases. 
 
 Spain. — M. Olivade estimates that there are from 1,000 to 1,500 
 lepers in Spain, 500 of whom have come under his personal observa- 
 tion. The disease prevails most extensively in Galicia, Asturia, and 
 Andalusia, Granada aud Catalonia. There is a leprosery at Granada 
 and another at Seville, the latter containing 40 patients. Poucet has 
 
GEOGEAPHICAL DISTEIBUTION. 659 
 
 recounted the list of lepers and tlie origin and spread of the disease 
 in 1850 in the village of Parcent, and Zuriaga gives details of cases 
 which he has observed to the number of 66. There were known to 
 be in 1888 in the province of Valencia 69 lepers, and in 1893, 120, 
 
 France. — There are leprosy foci at Brest, Bordeaux, Marseilles, 
 and Toulon. On the Mediterranean coast along the French Kiviera 
 small foci of the disease are found, and sporadic cases in Brittanj'. 
 There are, according to Hallopeau, constantly from 160 to 200 lepers 
 in Paris, aU of whom have been infected in foreign countries. It is 
 worthy of note that so far as known none of these patients has pro- 
 pagated the malady. 
 
 As-regards leprosy in Iceland, opinions differ whether the disease 
 was of ancient origin, brought by the Norwegians in settling the island 
 in 874, or whether it was brought from Norway about the end of the 
 thirteenth century with the return of the crusaders. Towards the 
 middle of the sixteenth century leprosy had obtained such a foothold 
 as to attract public attention, and four hospitals were erected in four 
 quarters of the island. The smallpox epidemic of 1707 destroyed 
 more than one-third of the population and with them the greater part 
 of the leper families. In 1848 the leprosy hospitals were abolished. 
 In 1889 Ehlers personally examined 102 cases ; besides there were 42 
 patients living at too great a distance to be accessible ; making a total 
 of 144 cases. Ehlers in his second voyage to the island, in 1895, 
 unearthed 13 more cases, making a total of 157. In 1898 he knew 
 of 181 cases, and thought that the number exceeded 200. Becently 
 (1898) a new leprosy hospital of twenty beds has been established in 
 Iceland, and a system of obligatory notification and modified isolation 
 has been instituted. 
 
 In Finland there are known to be 67 lepers. In 1807 the disease 
 had increased to such an extent that it was determined to isolate the 
 sufferers in order to x^revent any further spread. A building was 
 erected at the end of a small island in Lake Kitajarvi, and the lex^ers 
 were removed thereto. In 1845 the hospital system was abandoned. 
 
 In Sweden there are known to be from 70 to 75 patients, of 
 whom 30 are isolated; 36 live in the province of Hels^gland and 15 
 in Dalarne. 
 
 The most important centre of leprosy in Europe in modern times 
 is in Norway. Three leproseries have been established in Norway — 
 the Lungegaards Hospital in Bergen in 1857; two others in 1861, one 
 in Molde, and the other in Throndhjem. In a period between 1857 
 and 1895 there were admitted to these hospitals 3,400 lepers, while 
 during the same period 5,053 new cases of leprosy appeared. 
 
 The total number of known lepers at the close of 1856 was 2,870; 
 
360 
 
 MORROW — LEPROSY. 
 
 at the end of 1895, 688. The followiug table gives at a glance evi- 
 dence of the remarkable decrease in leprosy in the last forty years : 
 
 
 New 
 cases. 
 
 Results. 
 
 
 Year. 
 
 1 
 Died. 
 
 Transferred 
 
 to 
 leproseries. 
 
 Cured. 
 
 Emi- 
 grated. 
 
 Total. 
 
 liviDg 
 at home. 
 
 1856 
 
 1.157 
 
 1,027 
 
 979 
 
 703 
 
 116 
 
 110 
 
 105 
 
 86 
 
 75 
 
 62 
 
 72 
 
 90 
 
 62 
 
 74 
 
 53 
 
 53 
 
 41 
 
 42 
 
 49 
 
 23 
 
 35 
 
 17 
 
 14 
 
 14 
 
 '668 
 549 
 498 
 456 
 88 
 78 
 61 
 69 
 66 
 75 
 52 
 53 
 76 
 77 
 64 
 37 
 43 
 34 
 57 
 45 
 
 4o 
 26 
 26 
 
 '585 
 732 
 573 
 434 
 79 
 92 
 61 
 70 
 96 
 61 
 37 
 63 
 50 
 63 
 73 
 50 
 52 
 54 
 49 
 45 
 25 
 24 
 15 
 17 
 
 i 
 
 9 
 9 
 
 8 
 1 
 1 
 6 
 3 
 2 
 2 
 1 
 5 
 5 
 17 
 9 
 
 I 
 
 7 
 5 
 4 
 5 
 6 
 4 
 5 
 
 30 
 45 
 47 
 66 
 
 a 
 
 7 
 8 
 
 10 
 7 
 8 
 7 
 5 
 2 
 3 
 9 
 3 
 1 
 
 12 
 2 
 2 
 2 
 1 
 3 
 1 
 
 1.290 
 
 1.335 
 
 1.127 
 
 964 
 
 174 
 
 178 
 
 136 
 
 152 
 
 171 
 
 146 
 
 97 
 
 126 
 
 133 
 
 160 
 
 155 
 
 91 
 
 100 
 
 107 
 
 113 
 
 96 
 
 68 
 
 76 
 
 48 
 
 49 
 
 2.598 
 
 1856-60 
 
 1861-65 
 
 1866-70 
 
 1871-75 
 
 1876 
 
 2.221 
 1.913 
 1.765 
 1.504 
 1,446 
 
 1877 
 
 1.378 
 
 1878 
 
 1,347 
 
 1379 
 
 1.281 
 
 1880 
 
 1,185 
 
 1881 
 
 1,101 
 
 1882 
 
 1,076 
 
 1883 
 
 1,040 
 
 1884 
 
 969 
 
 1885 
 
 883' 
 
 1886 
 
 781 
 
 1887 
 
 743 
 
 1888 
 
 684 
 
 1889 
 
 619 
 
 1890 
 
 555 
 
 1891 
 
 482 
 
 1892 
 
 449 
 
 1893 
 
 390 
 
 1894 
 
 356 
 
 1895 
 
 321 
 
 
 
 Total 
 
 5,053 
 
 3,279 
 
 3.400 
 
 126 
 
 287 
 
 7,092 
 
 
 It is known that 287 of the lepers emigrated from Norway, and 
 of these about 170 went to North America. It is probable that the 
 statistics of leper immigrants here given by Hansen are very much 
 below the reality. Hansen believes that the only possible explana- 
 tion of the remarkable decrease in Norway is that the segregation 
 of so many lepers has prevented them from infecting their fellow- 
 beings. He further believes that the most effective remedy to prevent 
 the spread of laprosy is the isolation of as many as possible and pre- 
 venting them from infecting others. 
 
 Bussia. — Alarmed by the obvious increase of leprosy in Russia, 
 the Russian Government ordered in 1895 a general census of leprosy 
 in its dominions. Twelve hundred and ninety-nine cases were re- 
 ported, and upon examination of these 1,200 were declared lepers. 
 In 1889 it was calculated that there were from 1,500 to 2,000 cases 
 in Russia, and that the number was increasing. In 1877 Dr. Walsh 
 found 378 lepers in the Baltic province, 3 cases at Moscow and at St. 
 
GEOGRAPHICAL DISTEIBUTION. 661 
 
 Petersburg. In South Kussia, tlie Volga districts, tlie Crimea, the 
 Don Cossack territory, and in Turkestan Professor Munch collected 
 information of 373 cases. He believes that the Crimea serves as the 
 starting-point for leprosy in Southern Kussia, and particularly in the 
 Don Cossack territory. Crimea was colonized in the thirteenth and 
 fourteenth centuries by the Genoese, who brought leprosy with them. 
 In some settlements the number of lepers is from 1 to 300, to 1 
 to 1,000 of the population. Such centres of leprosy have interven- 
 ing healthy settlements or they are in communication with each other 
 and then occupy a considerable extent of territory with several nests 
 of the disease. 
 
 South America. 
 
 The western coast of South America is practically free from lep- 
 rosy. Middendorf during twenty-five years' practice in Peru saw 
 only three patients — two Chinese and one European. 
 
 Upon the north coast the disease is frequent in Venezuela and in 
 Guiana. In Surinam alone there are from five hundred to two thou- 
 sand lepers. 
 
 Leprosy also prevails in Curagoa, St. Martin, and St. Eustatius. 
 
 Leprosy was probaby imported into Brazil in 1644 by the Portu- 
 guese. In the year 1697 there were so many lepers in Brazil that a 
 special hospital was asked for in which the lepers might be treated. 
 During the last two centuries it has spread throughout the country. 
 There are special leper hospitals at Pernambuco, San Paulo, and Eio 
 de Janeiro, although residence is not compulsory and no obligatory 
 notification of the disease is imposed upon physicians. The entire 
 coast of Brazil is affected. The last census has given the number as 
 five thousand, which, according to Lutz, does not indicate one-half of 
 the real number. 
 
 In Uruguay, Canabal reports that there are only twenty-seven 
 lepers. 
 
 The disease exists likewise in the Argentine Repuhlic. Since 1892 
 there has been noted a progressive increase in the number of lepers 
 admitted into the hospital for infectious diseases at Buenos Ayres. 
 Gache declares that the disease is frequent and increasing in the inte- 
 rior of the country. 
 
 British Guiana. — Leprosy was introduced into British Guiana by 
 blacks from Africa. In 1831 the government report showed a total 
 of 431 lepers. In 1841 there were 65 lepers. A general leper asylum 
 was opened at Mahieia in 1858. During twenty years from 1858 to 
 1878 there were admitted into the hospital 1,120 patients, 879 males 
 and 223 females. The present population of British Guiana is 278,- 
 
662 MORKOW— LEPROSY. 
 
 000, and tlie ratio of lepers is estimated to be 1 in 4,276. According 
 to another estimate tliere are more than 1,000 lepers in this country. 
 
 French Gidaiia. — lu this country, according to Laure, one-tenth 
 of the population is infected. The disease was imported by the 
 blacks from South Africa. The native Indians are absolutely exempt. 
 At Cayenne the number of lepers is between 100 and 120. 
 
 Colombia. — The first authentic case of leprosy in Colombia was 
 that of one of the Spanish governors who died in Bogota in 1646. 
 Leprosy was unknown among the Indians previous to that period. 
 The disease extended slowly during the next two hundred years, but 
 in the last two or three decades the increase has been very rapid. 
 Nearly all districts where leprosy was previously unknown have been 
 invaded, and now nearly every locality in Colombia is more or less 
 infected. The number of lepers in Colombia is not positively known. 
 The number ioxij years ago was estimated at 400 ; at present it has 
 increased to 27,000. A still later estimate gives the number at not 
 less than 30,000. In the three hospitals provided for the reception 
 of lepers there were in 1896 only 841 patients. 
 
 The West Indies. 
 
 Jamaica. — The consensus of opinion is that leprosy was brought 
 to the West Indies by negroes imported as slaves from the west coast 
 of Africa. The first ofiicial recognition of the disease was in 1865. 
 In 1891 there were 85 inmates of the leper home in Kingston. The 
 number of lepers at the date of the last report of Dr. Donovan, was 
 450, or 1 in 1,555 of the total population. Donovan thinks that many 
 have not been recognized. 
 
 Trinidad. — The government census returns show that in 1871 
 there were 102 lepers, 93 per 1,000; in 1881 there were 149 lepers, 97 
 per 1,000; in 1891 there were 225 lepers, 112 per 1,000. These re- 
 turns are not accurate, as the census ordinance made no provision 
 for obtaining information concerning lepers outside the leper asy- 
 lums. 
 
 There was no accurate census of lepers in Trinidad until 1889, 
 although the number was variously estimated from 480 to 860. The 
 census of the island in 1889 showed there were 348 lepers, 210 of 
 whom were in the asylum ; 43.56 per cent, were coolies who had the 
 disease when they arrived from India, and about 38 per cent, were 
 natives of the colony. In December, 1896, there were 218 inmates of 
 the asylum. The disease appears to be on the increase. 
 
 Leeivard Islands. — The census of 1891 gives the total number of 
 lepers at 172. 
 
GEOGRAPHICAL DISTRIBUTION. 663 
 
 In St. Cliristopher or St. Kitts the number has increased from 72 
 in 1872 to 120 in 1890. 
 
 In the island of Antigua there were, in 1891, 45 cases, 34 being 
 in the asylum. 
 
 In both islands the percentage of lepers to the total population 
 has doubled in the last twenty years. 
 
 French Antilles. — Leprosy is extensively spread in the French 
 Antilles. At Guadeloupe and Martinique there is 1 leper to every 
 600 inhabitants. According to M. Brassac, the number of leper 
 inmates of the leproseries of the two colonies on the island of Desi- 
 rade is 100. 
 
 In the Danish Antilles there are at least 22 at St. Thomas. Santa 
 Cruz possesses a small asylum for lepers, but entrance is not compul- 
 sory; they go and come as they please. Their present number is 
 82, 36 men and 46 women. 
 
 In Ciiba and Porio Eico the disease prevails extensively. There 
 are usually about 80 lepers in the San Lazaro Hosx)ital of Havana. 
 There are other hospitals in Santa Clara and Puerto Principe. Con- 
 finement in none of these hospitals was, under Spanish rule, com- 
 pulsory, nor was the isolation of the inmates complete, as they were 
 always allowed to go out during certain hours without any restric- 
 tions on their movements. Under American rule the sanitary author- 
 ities of Havana have ordered the sequestration of all lepers in the 
 city, and the same regulations have been ordered at Santiago. The 
 total number in Cuba has been estimated at from 300 to 500, which 
 is probabh" below the reality. 
 
 In Porto Eico there are numerous lepers, but there are no statistics 
 showing the actual number. 
 
 Barhadoes. — The increase of leprosy in the island of Barbadoes is 
 shown by the census of 1871, 96; 1881, 108; 1891, 156. The ratio of 
 the increase of leprosy to the increase in population in the last ten 
 years has been from 57 to 80 per 1,000. There were 114 cases in the 
 lazaretto at the last report. 
 
 St. Vincent.— The census returns of 1891 give 62 lepers, an increase 
 of only 5 since 1881. In the asylum there were, in 1894, 23 cases, as 
 against 19 in 1887. 
 
 Santa Lucia.— The census of 1891 gives 32 lepers. In Grenada 
 in 1891 there were 21 cases according to the census ; in the census of 
 1881 there were only 3 cases. 
 
 CEISfTEAIi AjMERICA. 
 
 There are no authentic statistics of leprosy in the States of Cen- 
 tral America. Numbers of lepers may be seen in Panama, and the 
 
664 MORROW — LEPROSY. 
 
 disease is also prevalent iu Costa Rica, Nicaragua, Honduras, Salva- 
 dor, and Guatemala. In the latter country attempts have been re- 
 cently made to secure segregation of the infected. 
 
 Mexico. 
 
 There is every reason to believe that leprosy was introduced into 
 Mexico by the Spanish, as Cortez established a lei:>er hospital in the 
 city of Mexico, and there is no record of the existence of leprosy be- 
 fore the arrival of the Spanish conquerors. The states of Michacan 
 and Sinaloa are the main centres of leprosy. The states of Guanajuto 
 and Jalisco and tlie adjacent districts of the adjoining states and the 
 state of Guerrora iu the north are all infected with lejDrosy. 
 
 Orvaiianos states that there are about 30 lepers in the leper 
 ward of the Juarez Hospital. The San Pablo serves the purpose of a 
 general hospital and a hospital for typhus fever and other infectious 
 diseases and also as a leprosj' hospital. In my visit to the hosjjital 
 in 1889 I found 11 cases of leprosy, almost all of them of the 
 anaesthetic type. No attempt at segregation of the lepers is made by 
 the authorities. Many lepers may be seen in the streets of the city, 
 and their entrance to the hospital is voluntary rather than compul- 
 sory. The special leper hospital was abolished about thirty-five years 
 ago. Statistics fail to show whether the disease has been on the in- 
 crease or not since the discontinuance of any attempt to isolate lepers, 
 but many Mexican physicians assert that the disease is gradually 
 decreasing. 
 
 North America. 
 
 Owing to the geographical continuity of the British provinces of 
 North America with the United States and the intimate intercourse 
 between the inhabitants of the two contiguous regions, the history of 
 the introduction and spread of leprosy in the United States and Can- 
 ada may be considered together. 
 
 New Brunswick. — Little is known as to the origin and spread in 
 New Brunswick. Since 1815 it has existed continuoush^ among the 
 French settlements near the Bay of Chaleurs in the Gulf of St. Law- 
 rence. Leprosy first appeared in Tracadie, situated on the bank of 
 the Gulf of St. Lawrence, at the mouth of Miramichi Eiver. It was 
 said to have been introduced by the French emigrants from St. Malo, 
 in Normandy. It was not until a number of people had taken the 
 disease that public attention was drawn to it, and a lazaretto on Chel- 
 dro Island, in the Miramichi Eiver, was established in 1844. In 1849 
 the present hospital at Tracadie was constructed to take its place. 
 Altogether alwut 150 cases have been admitted since the foundation 
 
GEOGRAPHICAL DISTRIBUTION. 665 
 
 of the hospital. At present there are 23 inmates. The laws are not 
 sufficiently stringent to compel the imprisonment of lepers at large, 
 and there has been no notable increase in the j'early number of 
 inmates in a long period. 
 
 Cape Breton. — A small outbreak of leprosy was discovered in 1892 
 upon the Island of Cape Breton. There were then 11 cases observed 
 in individuals living in close contact. This number has since de- 
 creased to 6 or 7 cases. 
 
 British Columbia. — About ten years ago the existence of leprosy 
 was observed among the Chinese residents of the British Pacific 
 coast. In 1894 Dr. Graham, of Toronto, reported 7 cases, 6 of which 
 were in Chinamen and 1 in a vv'hite man. The patients were kept in 
 quarantine on an island near the City of Victoria. 
 
 The United States. 
 
 The heterogeneous character of the population of the United 
 States, embracing representatives of so many of the nationalities 
 of the old world, renders it probable that leprosy has been intro- 
 duced into this country through many sources. France, Spain, 
 Portugal, Norway and Sweden, Africa, and China, as well as Mexico 
 and South America, have doubtless furnished contingents. The fact 
 that the disease shows no tendency to an alarming spread, except 
 on our Southern seaboard, notwithstanding the supply of infectious 
 material from such diverse and numerous sources, but rather shows 
 a tendency to die out with the death of the imported lepers, would 
 seem to indicate that the soil of this country is not favorable to the 
 geripination and growth of leprosy. 
 
 The importation of leprosy in the United States may be traced to 
 several distinct sources. 
 
 1. It was introduced into the Atlantic coast cities and the coun- 
 tries along the Atlantic seaboard from the West Indies, and probably 
 Africa through the importation of slaves and intercourse through 
 travel and commerce with the neighboring West India islands. 
 
 2. By leprous immigrants from Norway and Sweden into the 
 Scandinavian colonies of Minnesota, Wisconsin, Iowa, and Dakota. 
 
 3. By the Acadian refugees from the British provinces of New 
 Brunswick into Louisiana. 
 
 4. By lepers from Mexico into Texas and States bordering the 
 Gulf of Mexico and the Eio Grande. 
 
 5. By Chinese immigrants into San Francisco and elsewhere on 
 the Pacific coast. 
 
 6. By Hawaiian lepers in California, Utah, and other parts of the 
 country. 
 
666 MORROW— LEPROSY. 
 
 In Boston, New York, and Pliiladelpliia, and other large cities 
 there has always been a variable number of cases of leprosy, made 
 up from foreigners of the various countries where leprosy is endemic 
 and of American sailors, soldiers, and civilians who have visited or 
 resided in foreign leprous countries. 
 
 In New Scandinavia, embracing certain regions in the Northwest- 
 ern States of Minnesota, Iowa, and Wisconsin, whose population is 
 estimated to be over one million, made up largely of immigrants from 
 Norway and Sweden, have been observed a certain numlier of lepers. 
 Dr. James C. White, in his report to the Berlin Leprosy Congress, 
 1897, estimates that there were 168 leper immigrants who either had the 
 disease when they left home or in whom it developed after they came 
 to this country ; of these, about 30 still survive. Investigations which 
 have been recently made would seem to indicate that the number of 
 Scandinavian lepers exceeds the figures which have been heretofore 
 given. It is probable that the number is augmented by the arrival 
 of new cases from time to time among the Norwegian immigrants. 
 
 Dr. Bracken says we have knowledge of 51 lepers who have re- 
 sided in Minnesota, of whom 17 died during 1890 ; 34 have been added 
 to the records since 1890, 29 from Norway and 5 from Sweden. The 
 statistics of 168 known lepers above referred to could not have in- 
 cluded more than 17 of this number of 51. 
 
 Dr. Bracken thinks that there must be at i:)re8ent a total of about 
 20 lepers in Minnesota, although Northwestern physicians, who 
 should be qualified to judge, estimate that there are at least 50. He 
 estimates that there are 60 lepers in the States of Wisconsin, Iowa, 
 North and South Dakota, and 128 in other parts of the United States, 
 making a total of 160 Scandinavian lepers in the United States at the 
 present time. Another estimate places the number at 104. 
 
 Utah. — In 1889 I called attention to the fact that among the ac- 
 cessions to the Mormon population of Salt Lake City there has been 
 a certain number of lepers among the Hawaiian converts. 
 
 Calif or ma.—HhQ Chinese population of our Western States is 
 quite large — 25,000 in San Francisco alone. There had been up to 
 1894, as estimated, 196 cases of the disease detected in the State, 
 most of which have been reshipped to China from time to time. 
 At present there are 26 cases of the disease known to exist in Cali- 
 fornia ; a number are confined in the pest house in San Francisco. 
 Among the inmates of the pest house there have been quite a number 
 of Hawaiian lepers, who h.ave come to this country either for treat- 
 ment or to escape the rigorous laws of sequestration which exist there. 
 Oregon. — In this State a number of cases have been observed, prin- 
 cipally among the Chinese residents. 
 
GEOGEAPHICAL DISTRIBUTION. 667 
 
 South Carolina. — Turning novs' our attention to the Atlantic sea- 
 board, we find that a limited focus of the disease was reported bv Dr. 
 Geddings as occurring in South Carolina, near Charleston, between 
 1847 and 1882. Sixteen cases have been observed during that period; 
 according to the latest reports four of these patients still survive. 
 
 Florida.— The proximity of Florida to the infected West India 
 islands renders the importation of the disease extremelj^ easy. Dur- 
 ing the last ten years the number of lepers in Florida has been 
 variously estimated as from 6 to 100. 
 
 Texas. — I have had personal reports of three cases of leprosy in 
 Galveston and a number in San Antonio. Most of these originated 
 in Mexico or in Louisiana. 
 
 Ohio. — Two cases have been reported as occurring near New Lex- 
 ington, Ohio. The opinion of medical men who have seen them is 
 divided as to whether or not they are true cases of leprosy. 
 
 Louisiana. — The most important centre of leprosy in the North 
 American continent is in Louisiana. Leprosy was introduced into 
 this State by the Acadian refugees who were expelled from their 
 homes in 1758 and who settled in Lafourche and the Tesche Eiver 
 districts, and it is also claimed that it was introduced into New 
 Orleans from Martinique. It increased to such an extent that a hos- 
 pital was founded in New Orleans in 1785. The disease gradually 
 diminished, and the hospital decayed, and was finallv abandoned in 
 1807. 
 
 No definite history of prevalent leprosy can be found until 1866, 
 although that leprosy still existed during this period is evident from 
 the records of the admission from time to time of cases in the 
 Charity Hospital of New Orleans. The attention of the health 
 authorities was not attracted to its increase until 1866, when it ap- 
 peared in Yermilion Parish, in a woman whose father came from 
 Southern France. She died in 1870, and subsequently four children 
 and a nejjhew became lepers. From this centre the disease has spread 
 through several other districts in the State and infects both native- 
 born citizens and the alien population. Dr. Jones collected a total of 
 37 cases from 1877 to 1880. In 1889 Dr. Solomon reported 6 cases 
 in New Orleans. In 1883 Dr. Blanc reported 42 cases ; in 1892 he re- 
 ported 41 additional cases— 83 altogether. 
 
 In 1894 Dr. Dyer reported 25 cases, and since then has reported 91, 
 a total of 116. Most of the cases in New Orleans originated, according 
 to Dr. Dyer, in the district near where the old leper hospital was 
 situated. A lepers' home was established in IlDerville Parish in 1895. 
 Dr. Dyer's statistics embrace 277 cases— 7 from 1800 to 1878; 270 
 cases from 1878 to the present day. Dr. Dyer reports that 171 pa- 
 
668 MORROW— LEPROSY. 
 
 tients were born in Louisiana, 8 elsewhere in the United States, and 
 39 were born in Europe. There was no instance of heredity and no pa- 
 tients who died under five or six years. One hundred and thirty-one 
 patients are supposed or known to be living at the present time. The 
 regulations for the compulsory isolation of lepers in Louisiana are 
 not stringently enforced. No well-sustained measures for the control 
 of the disease have been adopted. New cases are continually crop- 
 ping up. At the moment of this present writing two new cases have 
 just been discovered in St. John's Parish, both natives of the parish. 
 Contagion has been traced to their association many years ago with 
 an old leper who has since died of the disease, and in whose cabin 
 they were frequent visitors. 
 
 Hyde, in his report to the Congress of American Physicians and 
 Surgeons (1894) upon the " Distribution of Leprosy in North Amer- 
 ica," says : " It may thus be approximately determined that the cases 
 of leprosy heretofore recognized in the United States have been dis- 
 tributed as follows : In Arkansas, 3 ; in California, 158 ; in Dakota, 
 2 ; in Florida, 6 ; in Georgia, 1 ; in Idaho, 2 ; in Illinois, 13 ; in In- 
 diana, 2 ; in Iowa, 20 ; in Louisiana, 83 ; in Maryland, 4 ; in Massa- 
 chusetts, 5 ; in Minnesota, 120 ; in Missouri, 2 ; in Mississippi, 2 ; 
 in New York, 100; in New Jersey, 1; in Oregon, 3; in Pennsyl- 
 vania, 6; in Utah, 3; in Wisconsin, 20— a total of 560." It is evi- 
 dent, however, from later reports that the number of lepers in this 
 country is largely in excess of his figures. 
 
 Haivaii. 
 
 The position of the Hawaiian Islands and their maritime com- 
 munication with so many countries where leprosy is endemic render 
 possible the introduction of the disease from numerous sources. 
 The history of leprosy in the Hawaiian Islands is somewhat vague. 
 The understanding among the natives is that it was introduced by 
 the Chinese, and it is always called by them the Chinese disease, 
 " mai paka." The first case came to notice about 1848. The disease 
 was known to be gradually spreading from 1855 to 1863, but the at- 
 tention of the health authorities was not awakened to the alarming 
 prevalence of the disease in the islands until 1863 when an act " to 
 prevent the spread of leprosy," which provided for the gathering 
 together of all the lepers of the kingdom, with a view to their isola- 
 tion and treatment, was passed. In 1865 a hospital for the inspec- 
 tion and examination of lepers was built at Kalihi. In November, 
 1864, a portion of the island of Molokai was purchased by the Gov- 
 ernment. Within the first three months 174 lepers were sent to the 
 
GEOGRAPHICAL DISTRIBUTION. 
 
 669 
 
 settlement. Since its establisliment more than 6,000 lepers have been 
 consigned to the settlement. The number of admissions from year to 
 year varies according to the vigor displayed by the successive health 
 boards in carrying out the provisions of law for the detection, arrest, 
 and isolation of the lepers. In certain years, 1873, 1883, 1888, there 
 was a notable increase in the number of lepers sent to the island, the 
 number of 579 being sent in the latter year alone. 
 
 . The following table which has been carefully compiled from the 
 reports of the Hawaiian Board of Health shows the number of admis- 
 sions, the mortalitj^ and the number on the books at the end of each 
 year from the establishment of the settlement to January 1st, 1898. 
 
 Year. 
 
 . o 
 •a .2 
 
 s 
 
 XD 
 
 IS 1 o 
 
 « 8 
 
 
 Year. 
 
 10 
 
 s 
 
 •-A 
 1 ' 
 
 P 
 
 1.5 
 
 
 1864* 
 
 141 
 
 26 
 
 10 
 
 105 
 
 1888 
 
 71 
 
 131 
 
 6 
 
 649 
 
 1867 
 
 70 
 
 25 
 
 7 
 
 143 
 
 1883 
 
 801 
 
 150 
 
 15 
 
 785 
 
 1868 
 
 115 
 
 28 
 
 2 
 
 338 
 
 1884 
 
 108 
 
 168 
 
 8 
 
 717 
 
 1869 
 
 126 
 
 59 
 
 11 
 
 384 
 
 1885 
 
 103 
 
 143 
 
 36 
 
 655 
 
 1870 
 
 57 
 
 58 
 
 4 
 
 379 
 
 1886 
 
 43 
 
 100 
 
 8 
 
 590 
 
 1871 
 
 183 
 
 51 
 
 9 
 
 403 
 
 1887. ....... 
 
 330 
 
 108 
 
 4 
 
 698 
 
 1873 
 
 105 
 
 64 
 
 4 
 
 439 
 
 1888 
 
 579 
 
 312 
 
 28 
 
 1,085 
 
 1873 
 
 487 
 
 156 
 
 31 
 
 749 
 
 1889 
 
 308 
 
 149 
 
 7 
 
 1,187 
 
 1874 
 
 91 
 
 161 
 
 8 
 
 671 
 
 1890 
 
 303 
 
 158 
 
 18 
 
 1,313 
 
 1875 
 
 213 
 
 163 
 
 14 
 
 706 
 
 1891 
 
 143 
 
 313 
 
 2 
 
 1,143 
 
 1876 
 
 96 
 
 123 
 
 8 
 
 677 
 
 1893 
 
 109 
 
 137 
 
 19 
 
 1,095 
 
 1877 
 
 168 
 
 139 
 
 1 
 
 710 
 
 1893 
 
 311 
 
 151 
 
 
 1,155 
 
 1878 
 
 239 
 
 147 
 
 
 803 
 
 1894 
 
 138 
 
 155 
 
 3 
 
 1,134 
 
 1879 
 
 135 
 
 209 
 
 1 
 
 717 
 
 1895 
 
 106 
 
 138 
 
 15 
 
 1,087 
 
 1880 
 
 51 
 
 153 
 
 10 
 
 606 
 
 1896 
 
 146 
 
 116 
 
 2 
 
 1,115 
 
 1881 
 
 233 
 
 133 
 
 
 706 
 
 1897 
 
 134 
 
 139 
 
 
 1,100 
 
 * Settlement opened. 
 
 It will be seen from the above table that in the first twenty years 
 of its establishment, to January 1st, 1866, there were 3,036 lepers ad- 
 mitted ; in the next ten years, 2,049. In the first-mentioned period the 
 number of lepers was from 200 to 800, the average being about 500. In 
 recent years the number has varied from 1,000 to 1,200. This large 
 excess is explained by the health authorities by the fact that they are 
 now sent there at early stages of the disease. The average death rate 
 of the lepers has been reduced from 20 to 25 per cent, to 13 to 15 
 per cent. Leprosy is by no means confined to the native i)opulation. 
 In the first twenty years of the leper settlement, among the 3,036 ad- 
 missions there were 22 Chinamen and 16 whites, about 1 per cent. 
 With the past ten years the number of foreigners has averaged from 
 3 to 5 per cent. 
 
 The Chinese furnish the largest contingent of the foreign popu- 
 
670 MORROW— LEPROSY. 
 
 lation of the settlement. Among the nationalities represented are 
 Americans, British, Germans, Portuguese, Spanish, Russians, ne- 
 groes. South Sea Islanders, etc. It has always been the policy of 
 the board to return to their own countries when possible the Chi- 
 nese and Jaj)anese laborers who become lepers. More than 100 cases 
 of leprosy have occurred among the white population which are 
 not included among the statistics of the leper settlement. Man}- for- 
 eigners learn the nature of their disease from their own physicians 
 and voluntarily return to this country or Euroi^e for treatment. The 
 endemic of leprosy in Hawaii has afforded an excellent opportunity 
 of studying the disease by competent medical men, enabling them to 
 trace its origin and the influences of heredit}^ contagion, racial and 
 other characteristics, food, climate, modes of life, etc., in favoring 
 its spread. 
 
 In studying the geographical distribiition of leprosy an attempt 
 has been made to give the statistics of the disease in various countries, 
 which have been compiled from the most reliable data accessible, and 
 also the indications which point to an increase or decrease of the dis- 
 ease. It is to be understood, however, that these statistics are apt to 
 be misleading, as indicating a number which falls far below the 
 reality. 
 
 As regards the actual percentage of lepers in various countries, 
 it is for obvious reasons an unknown and unknowable quantity. Any 
 one familiar with the natural history of leprosy must recognize that 
 it is impossible to compute the number of lepers in any country by 
 the methods ordinarily used for the detection and registration of dis- 
 ease; only advanced cases are recognized by inspection. In every 
 country where leprosy is endemic a large number of persons are in- 
 fected months and years before it is known to themselves or to others. 
 The disease exists in a latent state, but it is none the less leprosy. 
 
 Many of the above statistics are based upon the number of lepers 
 in the hospitals or asylums provided by the government or health 
 authorities. Only a small proportion of the leper community, and 
 those probably paupers or advanced cases, enter these institutions. 
 In many' countries official cognizance is not taken of leprosy until the 
 patients reach an advanced stage of the disease. In the government 
 enactments for the control and suppression of leprosy in the various 
 British colonies, the ordinance relating to leprosy thus defines the 
 disease : " A leper means any person suffering from any variety of 
 leprosy, in whom the in'ocess of ulceration has commenced." Again, 
 "the term ' infectious lepros}-,' is to be interpreted as meaning one 
 who has leprosy in an advanced and grievous stage." Only pauper 
 
GEOGEAPHICAL DISTRIBUTION. 671 
 
 lepers, unable to provide for themselves, come under governmental 
 supervision. It is evident that in all these countries a large propor- 
 tion of lepers, unless the disease is advanced and presumably infec- 
 tious, do not come within the category of cases subject to segregation 
 in hospitals or asylums. 
 
 The leper settlements are not a popular institution in any country, 
 and a leper is not apt to jiresent himself when he knows that his con- 
 finement is virtually a lifelong imi)risonment. As a consequence, in 
 countries where a strict policy of segregation is adopted lepers use 
 every possible precaution to conceal all incriminating evidence of the 
 disease, and when concealment is no longer possible they are often 
 secreted and cared for by their relatives and friends. Again, the 
 very severity of the measures necessitated by a rigorous policy of 
 segregation is indirectly a cause of its partial failure. - The severity 
 of the banishment stimulates all the inventive resources of the patient 
 to elude arrest. It is a matter of general knowledge that in Hawaii, 
 where segregation is rigorously enforced, lepers hide themselves or 
 are secreted by their friends, or they flee to the mountains and forests 
 for concealment. 
 
 Another source of error arises from the difficulties which attend 
 the diagnosis of the disease and applies with special emphasis to 
 most countries where leprosy prevails to the greatest extent. In 
 countries such as Europe and the United States and in the modern 
 leprosy centres of Norway and Hawaii it would appear practicable to 
 give facts and figures with approximative certainty and also to arrive 
 at conclusions respecting the progressive, stationary, or retrogressive 
 character of the disease which have a definite scientific value. This 
 is obviously not the case in semi-civilized and Oriental countries, 
 which are not under skilled medical surveillance. In many Oriental 
 countries, such as Northern China, Japan, Thibet, the hill countries 
 of India, and also Africa, we are compelled to rely largely upon the 
 testimony or reports of native doctors, travellers, missionaries, and 
 others who are unfamiliar with the characteristics of leprosy and who 
 in most instances would be unable to recognize the disease when they 
 saw it. 
 
 According to Dr. Murata, of the Investigation Bureau of Conta- 
 gious Diseases (Tokio) , quoted by Ashmead, the statistics of the Jap- 
 anese Health Department give the total number of lepers in Japan at 
 23,660, but in Dr. Murata's opinion this figure could be doubled or 
 trebled without exaggeration. 
 
 The inability to diagnose leprosy applies to many medical men, 
 who may come in contact with the disease without knowing it, espe- 
 cially the anaesthetic form. Even in countries advanced in civiliza- 
 
672 MORROW — LEPROSY. 
 
 tion it is practically impossible to get accurate figures. Leprosy is 
 uot recognized on ordinary inspection except when the disease is 
 advanced in its evolution and more or less disfiguring. There are 
 many cases which are suspicious and not well defined, so that even 
 skilled leprologists may hesitate or find it impossible to pronounce a 
 positive diagnosis. 
 
 Norway- and Hawaii have been instanced as countries in which it 
 would .seem possible to arrive at an ai)j)roximately correct estimate of 
 the number of cases of leprosy, since they are directly under skilled 
 sanitary supervision. 
 
 In Norwaj^ the official count of the number of lepers in 1856 was 
 given as 2,221. It has since transpired that the actual number at 
 that date, verified b3' the deaths taken from the Bureau of Yital Sta- 
 tistics, was nearly one thousand more than was calculated. 
 
 Again, the statistics of leprosy in Hawaii are also to a certain 
 extent misleading, although the method adopted by the sanitarj^ au- 
 thorities is systematic and well organized. There are about twenty 
 government physicians established in the different districts of the 
 various islands, one of whose important duties is to report all sus- 
 pected cases of leprosy, and the police officers are empowered to 
 bring every suspected leper to the Kalahi reception hospital for ex- 
 amination, and all i)ersons who are pronounced lepers are forwarded 
 by the next boat to the leper settlement to remain there until they die. 
 The number consigned each year depends upon the more or less vig- 
 orous policy of the Board of Health and the activity of the agents 
 of the board in identifying and ajiprehendiug the lepers. 
 
 In the report of the Hawaiian Board of Health (1890), we read 
 (page 13) : " According to the best information obtainable there are at 
 the date of this rejKjrt about one hundred persons supposed to be 
 affected by the disease still at large who have not been before the 
 examining board," and yet the statistics of the leper settlement dur- 
 ing the next eight j-ears shows that there were twelve hundred lepers 
 sent to the leper settlement, or within the first five years seven hun- 
 dred and ninety-three admissions. Now leprosy does not develop 
 tVemhlee; it may preserve its incognito for five or ten jears, or even 
 longer, before its identity is declared. It is probable that most of 
 these twelve hundred persons sent to the settlement and manj- more 
 not apprehended were lepers on March 31st, 1890, when the Board 
 of Health reports that there were only about one hundred lejoers at 
 large. 
 
 One element to be considered in the calculation of the number of 
 lepers is the vast number of cases of incipient, latent, or undeveloped 
 leprosy existing in all countries where leprosy is endemic. These 
 
BIBLIOGRAPHY. 673 
 
 cases may not be detected in the earlier stages, but they are none the 
 less leprosy, and as the disease develops into a recognizable form 
 they furnish recruits to the ranks of the leper population. 
 
 From these and other facts we must conclude that all statistics of 
 leprosy in different countries are inexact, as they indicate a much 
 lower number than actually exists. In the writer's opinion the figures 
 should be doubled or trebled in order to arrive at the actual number 
 of cases. In the same way the number of cases of leprosy in different 
 cities, such as New York, Boston, Philadelphia, is largely underesti- 
 mated. The writer has personally seen over fifty cases of leprosy in 
 New York, without taking into account the number coming under the 
 observation of other specialists. 
 
 Bibliography. 
 
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