no SOUTH AFRICAN MEDICAL JOURNAL. MARCH, 1894.

pa.tients wish it, discharge them from the Asylum as beingno longer a danger to the public. -

I look at this matter not only from a humane point ofview, but from a practical aspect, for I think it is not onlyunjust and quite unnecessary to keep such patients in theAsylum, but I am of opinion that, if they were discharged,every patient would be encouraged and cheered by hope,and every life would be brightened and perhaps renderedhappy by the prospect of recovery; and further, I think:the very fact of being able to hold out hope, though it bethe very slighest, to the poor nnfortunate lepers, willrender the segregation of the lepers and the working ofthe Act an easy and pleasant matter, for they will allcome to the Asylum to be cured, and will be happy, whereasnow they are without hope and miserable.

I take it that the chief object of the segregation of lepersis not to make prisoners of the patients, but to stamp outthe disease and to check its spread. If, therefore, the self­cured cases, being no long-er a danger to the public, aredischarged from the Asylum, the object of the A.ct will notbe defeated; the dangerous cases will still be kept in theAsylum, where they cannot endanger the lives of theunits in the outside world. Iris on ihe advice of medicalmen that laws affecting health and disease are made, andthe present Act was framed and passed in Parliamentbecause medical men thought the lives of. the healthynnits were in danger. When the Act was passed in 1884very little was 1..-nown of leprosy, and ignorance magnifiedits dangers. The veryname of It leper was almost shudderedat, and the poor patients were doomed to a perpetual exileon Robben Island.

Everything that can be done has been done and is stillbeing' done to make their lot a happy one. But, though Iam certain that many of the lepers, even if they weregrauted the privilege of leaving the Island, would soonreturn t<> their Island home, where they get comfort andattention, and where they are not shunned by mankind,yet their lot is a hard one and one most difficult to bear,and it behoves us as medical men and as fellow-citizens todo what we can to alleviate their sufferings.

If you are satisfied that these self-cured cases are nolonger capable of spreading the disease, then you mustagree with mu that they should be granted the option ofleaving the-asylum.

I find that there are of these self-cnred cases about 100iu the Asylum. Why keep these cases one J;lloment longerin the Asylum than is absolutely necessary?

In conclusion, I wish to draw your attention for- a fewmoments to that most unfortunate class of patients, thetubercular lepers. As I have before mentioned, thedisease in this form of leprosy runs its conrse in about eightyears. Nothing that bas yet been tried ha-s been able tocheck it in its onward course, to end in death, generallyfrom ulceration of the throat j but to this rule there are afew noted exceptions.

I find that a few of these tubercular U:ises bave livedmore than eight years after contracting the disease, andthat this protraction of the disease has been due to thepatients having been subjected to an intercurrent a.ttackof measles. Now, if the bacillus of measles has the powet·of checking the course of the disease, it is about the oulything that can do so, and it may be well worth 01].1' while~o cultiyate this friendly bacillus. Who knows but that inthe future it may be the power, which if rightly used willovercome the hitherto invincible leprosy ba-cillus ?

I am of opinion that leprosy will be cured, not_ by inter­nal remedies or by external application, but by theintroduction into the system of some bacillus inimical to thegrowth of the leprosy bacillus, and I believe such a baciHnsis to be found in measles:

Gentleman, before resuming my seat, I wish to statethat it wa-s my intention to illnstrate this paper -bymeans of a number of photographs of leprous patients;but, when it was decided that the members of theMedical Congress shonld do me the honour of visiting theinstitution under my charge, I tho~ght-the photographsunnecessary_ as I deemed it much more satisfactory foryou to be able to have an ocular demonstration of -thetruth of some of the points which 1 have very briefly an tvery imperfectly endeavoured tJ place before you thiamorning.

I thank you, gentlemen, for the patient he~ youhave accorded me, and I do hope the discnssion on mypaper will lead to good, not only for South Africa, butfor the g eat world of which this colony forms snch a.­small, but, I hope, not insignificant part.

----0---ON LEPERS AND LEPROSY;

By J. J. HOFFMA...1Il", M.B., C.:M:. (Paa--rl).

Read before the South African Medical COngIes8.

During the present year _the public;) mind jn. thiscountry was greatly exercised by leprosy, a disease whichis more frequently found in South Africa than it oughtto be. As the general public look to the medical.profession for guidance in matters relating. to public andprivate health, and as the prominence into which thequestion of leprosy and the condition of our leperssprang within a very short time is already, in accOl,dancewith the law of reaction, giving place t<> apathy. andwant of interest, I deemed it proper to bring this matt.erbefore the members of this Medical Congress- in - orderthat the nature of the disease and the best wa.yof com­bating and uprooting it may be considered. At thesame time I must ask you to devote a considerableportion of your attention to devising the ·best· means ofdealing with those_ unfortunates who have alreadycont.racted the disease, of placing. them in the' bestposition to get cured of the evil, or, if that be impossible,of making what remains to them of life- as- bearable' astheir condition will permit.

I am not able to tell you anything new or startlingabout leprosy. Whatever I have to lay before you youwill already know as scientific men, and all the informa­tion which you wish for up to the present stand_p<>int. ofour knowledge of leprosy you will' find in many medicalworks far better and more ably set forth than I can -hopeto do. My aim is briefly to summarise the opinions. ofmany medical men of not-e upon certamaspects of thecase, and to draw some practical ~onclusions from themwhich may be useful to our legislators in dealing withthis matter.

There are three great 'questions which- I wish now' tolay before you, for the' consideration of which I must

SOUTH AJCRICA.- t MEDICAL JOURNAL.MA-RCH, 189*.

a-sk..your kind attention and your forbearance. Chiefamongst those questions, the one t{) wMch I would faindirect your thoughts first is the question of the transmissi­bility or non-transmissibility of leprosy.

I am well awa~'e of the fact that many medical menwhose authority carries great weight are of opinion thatleprosy is non-transmissible in the sense of non-con­tagious, and 1 have little reason to doubt that in thisgathering- of membe]"s of our profession the opinionswill be divided, and that both contagionists and non­contagionists will find sturdy and able defenders in ourranks.

After carefully sifting a mass of evidence for andagainst, I have come to the conclusion that, so far as Iam personally concerned, it is my duty modestly yetfirmly to assert that, in my opinion, leprosy is trans­missible in the sense of contagious.

According to Leloir, leprosy is "a chronic, parasiticdisease, characterised by the production of neoplasmsenclosing bacilli;" and I believe that, in accordance withour modern views of the origin of diseases, very fewmedical men will deny that bacilli in some fortn orother, and the effects of their presence, are the cause ofthe symptoms found in a disease. The acknowledgedpresence of a special bacillus, and the fact that leprosyis a disease which spreads, are in themselves alone indi­cations that there is a correlation between the germ andthe- disease, and, as in many other diseases in which aspecial bacillus has been discovered proofs have alreadybeen forthcoming that special germs may be cultivatedand ·transplanted, it is at least reasonable to supposethat in leprosy, also, germs peculiar to that disease maybe tra,nsplanted under conditions favourable to theirgrowth, and cause the symptoms of the disease.

Whe~her, however, the' bacillus lepra must be accom­panied by a streptococcus in order to become prolific andactive, as Dr. Impey suggests, or whether there is anintermediate stage through which the bacillus passes,or some as yet tmdiscovered host in which it undergoesfurther development, like the embryo tapeworm, beforeit can reproduce the disease, as Drs. Kaurin and Rakesuppose j whether it is eaten, and fish is the vehicle bymeans· of which it gains access to the human body, a-sAvicenna, Hutchinson, Hillis, Zambaco, Sandreczki, andWyn~ Cottle affirm j or whether it may be trans­planted by vaccination, as Sir Erasmus Wilson, Dr.Bakewell (Vaccinat{)r General of Trinidad), Dr. RogerChew of Calcutta, Dr. Edward A1'ning, Dr. ArmauerHansen, and others a-ssert, the fad remains that, in theopinion of many able men, leprosy can be transplanted intoand produce its characteristic symptoms in a previouslyhealthy constitution. In direct contradiction to a state­ment made by. one of our ablest and most esteemedmedical. men, who signs himself C. S. in a letter t{) theCape Times of Tuesday, August 8th, viz., that "at thepresent day its contagiousness is almost universallydenied by scientific medical men," I find in theSamtplung Klinischer V ortriige, by Richard von Volk­mann, a statement by A. von Bergmann, that the"number of contagionists is evidently increasing."

:211

(Die zahl del' kontagionisten nimmt sichtlich zu.) No.33, p. 4.

It struck me forcibly, while wading through a mass ofevidence for and against the contagiousness of leprosy,that many medical men who strongly combat the theoryof its contagiousness still admit that there is a suspicionlurking in their minds that after all the disease iscontagious under certain conditions. This suspicion,however slight, is sufficient to inyalidate many of theirarguments.

In the Report of the Leprosy Commission in India. Ifind the following statement (p. 259) :-" All modernauthorities are agreed that leprosy is an infective disease,i.e., one caused by a microbe, the bacillus leprre, whichobtains access to the body from without, and subsequentlymultiplies within the organism, calling forth the charac­teristic lesions."

Here we have a distinct, unequivocal statementthat a microbe is introduced from ,vithout and multi­ples within the system. On the strength of this state­ment one would reasonably suppose that contact witha leper must of necessity greatly increase the danger ofcontracting the disease. A leper is the breeding groundof the germs; those germs are abundantly thrown off bythe leper, and the surroundings of the leper are impreg­nated by them; whether, therefore, we must eat, orinhale, or in some unforeseen way inoculate some of thevirus containing germs, it is clear that in immediateneighbourhood of a leper there is a greater chance to getthe disease that in surroundings from which all lepers areexcluded.

According to Flugge the diffusion of leprosy by con­tagion is exceedingly rare, and can only take place underspecial and predisposing favomable conditions; in otherwords, Flugge admits that leprosy is contagious, buttones down the statement by stating that it is exceed­ingly rare. Hansen, Leloir, and Virchow all admit thatleprosy is contagious.

Again, in the Report ofthe Leprosy Commissionalreadymentioned I find the following statement (p. 265) :­"Though they (the Commission) consider leprosy aninfective disease, caused by a specific bacillus, and more­over also a contagious disease, they are of opinionthat there is not sufficient evidence that leprosy ismaintained or diffiused by contagion." Here, also, wehave a definite statement, all the more valuable becauseeverywhere in that Report there is to be found a tendencyto minimize the dangers which may result from thecontagiousness of leprosy, and to lay stress upon the factthat it is an infective disease.

Again, according to Flugge," The natural mode oftransmission of an infective disease depends on thefaculty pathogenic germs possess of leaving the body ofthe diseased in the full pos~ssion of their power ofsetting up an infection. If, however, the pathogenicgerm reproduced in the body of the diseased personnever leave the latter, or only do so without the powerof causing subsequent infection, the infective diseasecaused· by such germs is non-contagions." But oothFlugge and the Leprosy Commission admit that leprosy

/MARCH, 1894-.

is contagious, therefore the germs are able to leave thebody of the diseased person with the power of causingsubsequent infection. In the same Report I find a veryinstructive paragraph on p. 2"71. At Almora an oppor­tunity occurred of examining the paths and banks inAsylum Compound, on which the lepers were in the habitof walking and sitting. One hundred cover-glasses wereprepared from earth taken from these sites, and only tenleprosy bacilli were found in the whole number ofspecimens. Hence one may with some reason concludethat leprosy bacilli do leave the body of a leper, and thatbacilli, until proof to the contrary is given, may proveto be a source of contagion.

As to the percentage of people who contract leprosyby contagion, the Commission, after cutting down thefigures as much as possible, put it down at from five toseven per cent.-a sufficiently high rate to prove thatleprosy is a contagious disease.

Rut the question now presents itself whether leprosyis also transmissible in the sense of hereditary. Uponthis pnint, also, there is great difference of opinion amongmedical men. Danielssen, Boeck, Vandyke Carter,Lewis CUliningham, "' irchow, all amnit an hereditarypredisposition to the disease. There appears to be aconsiderable analogy between the bacillus leprm and thebacillus of tuberculosis, and it is not unreasonable to sup­pose that, since tuberculosis is admitted to be hereditaryas a predisposition, leprosy also is a disease which isheraditary in the same sense. By those who oppose thistheory much stress is laid upon the assertion that a casewas never seen of a child leprous at the time of birth.This would prove that no case of congenital leprosy isas yet authenticated, but it cannot invalidate the theoryof an hereditary predisposition.

Congenital tubercubsis is as little authenticated ascongenital leprosy, yet the weight of evidence in the caseof tuberculosis is greatly, in favoUl'o£ its heredity. Asin tuberculosis, many years may pass by before the diseasemanifests itself in a constitution in which there is ahereditary tendency, so also in leprosy a long period oflatency may be reasonably supposed; and as intuberculosisit is not all the offspring of tuberculous parents who,as a rule, show symptoms of the disease, so in leprosy itis not necessary that all the offspring should of necessitymallifest the symptoms of leprosy. We cannot consist­ently deny a predisposition to disease, and it is notalways the person who is most exposed to and mostin contact ,vith disease who is of necessity most ready tocatch the disease. Even the same person is not at alltimes equally ready to take a disease; certain conditionsare required which are often obscure and difficult, if notimpossible, to be traced in order that a disease may finda footing in the system. According to the Report of theLeprosy Commission true family histories of leprosy couldbe obtained in only 5 or 6 per cent. of the cases; but, as themethod of investigation was admittedly incomplete, morereliable information may considerably alter the resultsobtained. A great deal of weight is attached by many toHans'en's statement that" of about 160 lepers who haveimmigrated into th~ t4ree states-Wisconsin, Iowa, and

Minnesota-thirteen are alive, whom I have seen myself,and perhaps three~or four more. All the others a.redead. Of all the descendants of these lepers not asingle one has become leprous." But what does thisprove absolutely and conclusively? Certainly not thefact that an hereditary predisposition may and does notexist in the offspring of leprous parents. It may meanno more and no less than this-that 160 lepronsNorwegians have been taken away from surroundingswhich favour the development of latent germs, and havebeen pla<:ed in surroundings and under conditions whichare decidedly antagonistic to the development of thosegerms. Such results are obtained in the case ofindividuals in whom tuberculosis is an inherent pre­disposition; why should we deny the operation of thesame law in the case of tuberculosis? It is a law whichmedic-al men endeavour to enforce in the war whichthey are constantly, incessantly, wag:ng against disease,that the sufferer should be placed under the. mostfavourable conditions to throw off the disease. Surelyheredity is not infinite, unlimited, and illimitable.

The general tenor of the lines upon which I havehitherto argued win make it clear to you that, in myopinion, leprosy is contagious and- also hereditary. -Ishall now endeavour to lay before you a few practicalpoints bearing more especially upon the duties of ourlegislators with regard to the disease under consideration.

Since telluric, atmospheric, hygienic, and social condi­tions to some ext-ent modify diseases, and since theinterest taken in the study of leprosy is of very recentdate amongst us, and there are many points still to beelucidat-ed or confirmed, it appears to me that our Govern­ment is fully justified to appoint a Commission of medical·men to investigate and report upon leprosy in its variousaspects as observed in this country. Th~ facilities whichJllen like Dr. Impey and some others have to investigatethe disease may enable them to confirm or to invalidatethe results obtained by learned Commissions elsewhere. _Discussion and comparison mnst ultimately lead to greaterclearness of comprehension 9f the nature of the disease,and to the adoption of true and scientific methods tothoroughly eradicate the evil.

The co-operation of all medical men in South A£ricaought to be invited, in so far as it is practicable, and Ihave no reason to doubt that a ready response tq such aninvitation will be made by most practitioners in thiscountry. In this manner much useful information andmany useful suggestions might be obtained, and thelabours of the Commission greatly aided.

With regard to the condition and treatment of thoselmfortUl'lates who have contra.cted the disease it appears tome that a radical change ought to be made. Holding, as Ido, that leprosy is both contagious and hereditary, it

_follows as a logical sequence that in my opinioJ:!. !>egre­gation is a necessity, although it be a painful one. It isnot fair to point to syphilis and tuberculosis, and henceto argue that, since segregation is not enforced in thosediseases, it ought not to be enforced, in leprosy. If .thatwhich is proper is not dOI;le in certain cases, no validargument can-he drawn that it ought llOtto be done in

MARCH, 1894. SOUTH AFRICAN ·MEDICAL JO RN AL.

analogous cases. Surely we segregate in the case ofsmall-pox, why not in leprosy? Justice is due to thosestricken by disease, but is not less due to those who arehealthy. And the risk of trausmission ought to beminimised to its utmost if we desire to act justly towardsthe sound. But not all lepers are leprous to the samedegree, aud it appears t-o me to be an injustice to themildly or the incipient leprous to herd them togetherwith those in whom the disease manifests itself in all itsvirulence and loathsomeness.

A place of probation, therefore, is absolutely required,and ought t<> be provided for. Some station on the main­land, a fertile spot well supplied with water, amidhealthy and agreeable smroundin",O'S is surely a betterlocality than a desert island. Many of our lepers comefrom rural districts. To .such gardening, the rearing offlowers, fruit, vegetables, would prove a healthy and anagreeable pastime, and may serve to economise theexpense of their enforced detention, while it improvedtheir chances of an ultimate cure. The climatic condi­tions of their present abode may in themselves prove tobe, after careful investigation, adverse to their: generalhealth. Upon this point I cannot speak with authority.I make the suggestion, which mayor may not findfavour with those who are in a better position to judgethan I am.

The object which I had in view in bringing thismatter before you will be clear to you, I trust :-Thethorough investigation of the disease under considerationin all its phases j the search after the best methods tocombat and to stamp out the evil j the amelioration ofthe condition of those who are suffering from a fearfulmala.dy; and the complete protection of the uncontami­nated from the possible results of contagion or ofhereditary transmission-these. are the goal of myaspirations, and, if my efforts may prove to have beenhelpful in promoting anyone of these aims, I shallconsider myself amply repaid for whatever time andtrouble I have spent upon the subject.

----0----ON LEPROSY;

By A. J. J. BIESMAN SrnoNs, M.D.Read before the South .African Medical Congress.

Mr. President and Gentlemen,-With your permissionI shall give an outline of the history of Leprosy in thiscolony, and add a few remarks on the Report of the LeperCommission in India.

The archives of the colony do not contain much informa­tion about this loathsome disease. The first cases ofleprosy officially reported were communicated to theGovernor of the Colony, Ryk Tulbagh, and the PoliticalCouncil, hy the LaJ?ddrost and Heemraden of Stellenbosch,

. on the 10th of May 1756.The report is as follows :-"To the Governor Ryk Tulbagh and the Political

.Council." We, the undersigned, have observed that some persons

in seme households in the country show such outward

signs as to cause us to dread that possibly they mightbe affected with leprosy, and therefore we have consideredit our duty, in consequence of the g)'eat dauger to whichthe contagiousness of the disease, if allowed imperceptiblyto grow, would expose the inhabitants of this land, toorder the surgeons practising in the country, W ynandLouw and William Ferdinand Hoyer, most carefully toexamine such per-sons as arc suspected to be infected withthis loathsome disease, so ~hat, if any of them may befound to be infected, they may be able to report to yout'Honour and Honourable Councillors. But, a-s the surgeonsmentioned have notified to us that, for weighty reasons,they scruple to make this inspection, we have taken theliberty t.c inform you of these matters, with the humblerequest that you may be pleased to appoint one or morecapable surgeons to act with them, so that the examina.tion be more satisfactory."

Then follows the Report of the Snrgeons, dated July20th, 1756:-

"1st. In the family of the farmer,JohuM--,of French­hoek, we found the said J. M. affected in the worst form.He stated to have had the disease for 18 years. Hisfamily consists of his Wife, four daughters, and two sons,all apparently healthy, with the exception of the eldestdaughter, who had taken the greatest share in nursingher father, and shows at present indubitable symptoms ofthe disease."

"2nd. In the family of the farmer, James M--, ofWagonmaker's Vlei, J ..1'1., who has had the disease for9 years, is so bad that the extremities of his fingers andtoes are mortified. His wife, four sons, and three daughtersdo not show any symptoms of leprosy. But, as it hasappeared to us that the two J. Ms., after having becomediseased, became the fathers of many children by theirwives, we would respectfully suggest that a careful eyeshould from time to timc be kept on those children, sothat if any sign of the disease should show on them, stepsmight be taken in time."

Nen we find another report of Landdrost and Haem­raden of Stellenbosch, dated Augnst 24th, 1756;-

" We have the honour most obediently to report that inour opinion, the surest method would be to entirely separatefrom interconrse with healthy people the persons provedto be leprous. But, as there is some difficulty in thiscourse with regard to the hithert-o healthy members ofthose families, we would suggest for the present, to recom­mend the families affected with leprosy to know their ownduty in this matter, and to refrain from such intercourseby which others might become infected; further, byaffixing notices, to inform all the inhabitants in whatfamilies the disease has to a certainty hitherto been dis­covered; also, that, a-s from time to time it has beenobserved that many of the inhabitants do not think muchof the disease, and have even less notions of its dangerousand contaO'ious chara<:ter, to warn them that everyoneshonld mo~t carefully beware of those families, so as toavoid exposing themselves to the dreadful results which itwould afterwards be useless to regret."

Mter this comes the Resolution Qf the Council:­" Approved of the suggestions of the L. and H. of Stellen­boscb, adding, that, as by the adoption of those measuresthe two families would be plunged into extreme poverty,they should provide for the maintenance of thoseunfortunates ."

In the above-mentioned times the Statutes of the