Vol. 64, No. 25. Whole No. 1728.

Original Articles.

LEPROSY IN HAWAII.

BY JAMES T. WAYSON, M.D.,
HONOLULU, T. H.

LEPROSY is defined as an endemic, chronic, constitutional disease analogous to syphilis, caused by the Bacillus lepræ, and varying in its morbid manifestations, depending upon the tissues of the body affected, such as the skin, the nerves, the mucous surfaces, the lymphatic ganglia, and certain viscera. It occurs in three forms, the tuberculated, nontuberculated or anæsthetic, and the mixed tuberculated.

"The microscope is the supreme agent of the final diagnosis of leprosy. No patient should be committed to a segregated colony without a bacteriological demonstration of the disease. Of clinical symptoms, maculæ, chiefly leucodermic spots, are found in 89 per cent. of all cases. The lepra nodule, found in 74 per cent., is the one chief distinguishing lesion of skin leprosy. Thinning or complete loss of eyebrows and lashes is present in 63 per cent. Atrophic changes in hands and forearms with retraction and contraction of fingers and enlarged ulnar nerve in 32 per cent., a leading feature of nerve leprosy. The plantar ulcer found in 26 per cent., usually on the ball of the foot. Absorption of phalanges in 16 per cent., with occasional spontaneous amputation. Elephantiasis of hands and feet in 16 per cent. Facial paralysis in 11 per cent. The entire body should be carefully tested for anæsthetic areas. Some of the above symptoms can be found in some slight degree at least in every leprous subject” (J. T. McDonald).

At the present time it is firmly believed that the Bacillus lepræ, discovered by Hansen, is the cause of leprosy, but its method of entering the human body is absolutely unknown, whether by the skin, with or without abrasions; the mucous membranes; inoculations by insects; inhalations; or by articles of diet, such as salted or dried fish-the latter a theory of Jonathan Hutchinson of London, who believes the lepra bacilli are in such food. However, it is well known in Hawaii that people become leprous who have never made salted or dried fish a part of their diet.

Personally, I believe that a syphilized people are more susceptible to the disease than even the offspring of lepers; also, that there is but a slight predisposition among the children of leprous parents, and that the disease is in no way hereditary. Touching upon the point of the heredity of the disease, a striking peculiarity is to be noted, and that is, that while brothers, sisters, and cousins may be lepers their parents are aliens to the disease. According to the latest authorities it is unknown whether the Bacillus lepræ has spores, but I believe it has, and that it is by the spores the disease is spread. The spores are thrown off the body of a leper and become lodged either in the integument

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or mucous membranes of a predisposed healthy person, where they remain inactive for many years, or become very active within a short time, developing into full-grown bacilli, and soon manifesting their presence by the usual lesions of leprosy.

Father Damien de Veuster said that when near lepers, as at confession, or in their cabins before coming to the Leper Settlement, he felt on each occasion a peculiar sensation in the face, a sort of itching or burning, and that he felt the same here at the Settlement, during the first two or three years.

The first lesions of leprosy are surely local, as there is undoubted evidence of aborted cases, especially in the purely anæsthetic form. The activity of the spores is due to their passage through the air before entering the human body (otherwise direct inoculation would be possible-an experiment which has often been tried, but has never been successful), and is also dependent upon the predisposition of the human body-which is probably caused by certain foods, syphilis, and climate, which so modify the tissues that the otherwise healthy person becomes a suitable soil for the growth of the bacillus.

I believe the length of life of the lepra bacilli is so short that it accounts for the inability of experimenters to cultivate it, and that the danger of infection is wholly due to the activity of the spores. Also, that it will be necessary before a cure is obtained, to find some drug that will act solely upon the spores (having a selective action upon the skin and mucous membranes of the diseased person), destroy them, and at the same time overcome the condition of the system upon which the spores seem to thrive. If a cure is obtained it will certainly stop the spread of the disease by eradicating the source of infection.

No specific remedy is known. General tonic treatment and hot baths with hygienic surroundings aid in checking the disease.

The Kausatsu Springs of Japan are reported to check materially the advance of the disease, and I have received personal letters from lepers who firmly believe they have been cured by the baths. It is a very severe treatment, but certainly very efficacious.

Leprosy in Hawaii.-The first attempt by the kingdom of Hawaii to check the disease of leprosy or to cure or alleviate the sufferers was made in 1865, when an act, entitled, "An Act to Prevent the Spread of Leprosy," was officially passed.

The native Hawaiians believed the disease to have been brought among them by the Chinese, so named it "mai pake" (Chinese disease), but it is well proven that the disease was among the natives before any Chinese had visited or lived in the Islands. In all probability it came from the South Sea Islands, as the disease was endemic there and the people of those Islands frequently visited Hawaii.

A hospital established for the examination and

Kalihi or required to report at short intervals for further examination until the presence of the lepra bacillus is firmly established.

At Kalihi there is also a very creditable home, called the Kapiolani Home, conducted by the Franciscan Sisters. Here all the girls born of leprous parents at Molokai find a good home with the Sisters.

The Leper Settlement is situated on the Island of Molokai, one of the principal islands of the Hawaiian group. The peninsula upon which the settlement is located has an area of eight square miles, and is on the northern coast of the island; it is commonly known as Kalaupapa, named after the high precipice separating the peninsula from the rest of the island. The pali is about 2,000 feet in height, and is a natural barrier against escape, by land, of any of the inmates of the Settlement. A zigzag road has been cut down this nearly perpendicular pali, which would certainly take an old and accustomed mountaineer nearly one hour to descend.

There are two separate residence portions on the peninsula, known as Kalawao and Kalaupapa, giving an appearance of two small villages, as there are churches, stores, houses and streets, which go to make up a country-town of equal population. A jail is also in evidence, as it is at times necessary to punish the unruly there as well as in other communities, therefore you will find a resident magistrate, and one or more police.

The Settlement is governed entirely by the Board of Health; the Board having sole control of the people, whether lepers or non-lepers, at the Settlement. There is the Superintendent of the Settlement, an employee of the Board, who makes regular trips back and forth from the Settlementwho also does the buying of all necessary clothing and provisions (issued by the Government), attends to all disputes between the lepers where law is not called in action, and makes regular weekly reports to the Board of Health-in fact, the Superintendent has general supervision over the entire workings of the Settlement, under the direction and approval of the Board of Health. An assistant superintendent, usually a leper, is located at the Settlement.

A skilled physician and surgeon is a resident at the Settlement, and he has but little spare time, as the ailments of the lepers are many. His position is a most difficult one to hold, as the Hawaiians are very apt to have their own medicinemen attend them at the same time the resident physician is attempting to aid them. They will accept his remedies, but most likely throw them away, preferring the crude method of their kahuna or doctor.

There are two fine institutions, the Baldwin Home for boys (so called after the donor), and the Bishop Home for girls (also named after the donor), which, carried on in an ideal way, aid very materially in taking care of the young children.

There are Catholic and Protestant churches, also a Y. M. C. A. branch, having cheerful and suitable quarters.

There is a brass band, which very often gives public concerts for the amusement of the lepers, and every holiday is carried out in the usual manner of the Hawaiians, such as with a "luau" or feast, horse racing, and games.

The number of lepers admitted to the Settlement, from January, 1866, to December 31, 1875, the first ten years of segregation, was 1,587. The number admitted during the last ten years, ending June 30, 1903, was 888.

The largest number admitted in any one year

was in 1873, when 487 were sent there; the smallest number was in 1886, there being but 43 admitted. The largest number there in any one year was 1,213, in the year 1890, and the smallest number after the first ten years of segregation was 590, in the year 1886.

At the end of June, 1903, there were 540 males, and 348 females at the Settlement, 796 being Hawaiian, 6 American, 2 English, 7 German, 49 Chinese and Japanese, and 28 of other nationality.

The present estimated population of Hawaii, including the lepers at Molokai, is 150,000, therefore the number of known lepers to each hundred of the population is one. Not knowing the length of the stage of incubation, it is extremely hard to estimate the number of lepers at large that are at the present time a source of infection to healthy people, but taking into consideration the number yearly admitted to the Settlement, and the advance condition of the disease of those taken, it is quite evident that from three to four hundred are at large. They are not a source of infection to the average inhabitant, because as soon as they realize they have the disease, they keep very close at home, or take up their abode in the high valleys and hills away from any chance of a passing stranger or police agent seeing them. Their relatives and friends supply them with food and clothing, and warn them of danger, therefore it is a very difficult matter to apprehend them.

It cost the territory of Hawaii about $116,400 per year to care for the lepers, $30,400 being paid for salaries and the balance for expenses at Kalihi and the Settlement, $86,000.

The care of lepers will soon become a national question, as it is a national calamity rather than a purely local issue. The Federal Government, with its Bureau of Public Health and Marine Hospital Service, having at its disposal well qualified and able medical men to attend to the physical wants of the lepers, and equally as well trained men capable of superintending such a Settlement, is surely better. equipped to handle such serious conditions than even the Government of Hawaii, although great credit must be given this Government for the way it has taken care of its own afflicted.

During the time the Sub-Committee on Pacific Islands and Porto Rico was in Hawaii in 1902, the question of the Federal care of lepers came before it. and the greatest objections put forth by many people here, were:

(1) That the "dumping" of the mainland lepers in Molokai would be a source of discontent and at times riot at the Settlement, but here, it would seem, the fact was overlooked that the mainland lepers are equally as unfortunate and just as law-abiding as the present inmates of the Settlement, and as capable of affiliating with the Hawaiian peopl ethere, as the people affiliate with them outside the Settle

THE DIAGNOSIS AND TREATMENT OF INTUSSUSCEPTION, WITH A REPORT OF FOUR CASES.*

BY HENRY ROTH, M.D.,

NEW YORK.

ASSISTANT ATTENDING SURGEON, LEBANON HOSPITAL, NEW YORK.

ACUTE intussusception forms about one-third of all varieties of acute intestinal obstruction. In children and infants it is the most common variety of obstruction. More than one-half of the cases occur in children, and fully one-half of these are under twelve months of age. The disease may be acute, subacute, or chronic. Four cases of acute intussusception came under the writer's observation in a comparatively short space of time. One case occurred in an adult and three in infants, less than one year old. All of these patients were admitted to the service of Dr. Parker Syms, at the Lebanon Hospital, and of these, two were operated upon by the writer.

The histories are as follows:

CASE I.-W. M. G., age forty years, single, admitted to Lebanon Hospital February 6, 1903. Good family history; venereal history is negative. Eighteen years ago the patient had a cough and expectorated blood for two years. After that he

was perfectly well up to six years ago, when he had an attack of pain and vomiting like the present one. He remained in bed for a few days and recovered without medical aid. On February 5 patient worked the entire day throwing stones out of a wagon. At 5 P.M. he stopped work and went home; while partaking of his dinner, consisting of meat and potatoes, he felt a sudden pain, dull and rolling in character, most of the pain being in the right iliac region. He had to lean against the chair and the pain became gradually worse, which compelled him to take to his bed. He could not sleep on account of the pain, and of the incessant vomiting, which began soon after the initial attack of pain. Vomiting continued all night and the next day. Bowels moved several times on the following day; he could not retain even a drop of water. During the night he was seen by his physician, who sent him to the hospital, with a diagnosis of appendicitis. When he reached the hospital his temperature was normal, pulse 88, respiration 24. On examination, a distinct mass was palpable in the right iliac region. There was rigidity and considerable tenderness over the right side of the abdomen. Abdomen somewhat distended. After admission to the hospital, bowels moved freely after a soap-suds enema. February 7, 1903, forty hours after the first symptom appeared, he was operated upon by the writer. Under ether anesthesia, the abdomen was opened through a Kammerer incision. On opening the peritoneal cavity, a quantity of serous fluid escaped. The appendix was found normal. On further examination a movable mass was felt, which proved to be the cæcum and ascending colon, with the ileum invaginated. An ileocolic intussusception was demonstrated, and an attempt made to reduce it. This was impossible and resection was decided upon. The ileum was divided about two inches above the neck of the intussusception, and an incision around the iliocæcal valve allowed removal of the entire mass. The ileum and cæcum were united with the aid of a Murphy button, reinforced by a row of Lembert The abdominal wound was closed, down to its lowest portion, which was drained with iodoform gauze. The intussuscepted ileum, which was *Read before the Medical Society of the Borough of The Bronx.

sutures.

On

constricted by the ileocæcal valve, was considerably swollen and discolored a dark brown. Attempts to unfold the mass, even after its resection, were difficult. About thirty-two inches of ileum were resected.

After the operation the patient reacted well, but complained of considerable pain. He was given nutritive enemata, which he retained. The bowels moved on the third day after the operation. On the fifth day fæces appeared in the wound. This caused considerable excoriation of the skin, and required frequent changes of dressings. The fecal fistula contracted down to a small caliber, and on March 20, 1903, an attempt was made to close it. Under ether anæsthesia, the fistula was dissected out and the gut closed with silk Lembert sutures. The patient's condition was not very good after this operation; his pulse was 120, of poor quality; vomiting was incessant; the bowels, however, moved the day after operation, and the nutritive enemata were retained. On the fourth day leakage of fæces was noticed, which continued, but the general condition improved rapidly. The fistula became smaller, and on April 29, 1903, the writer operated through an incision near the median line. With the aid of a Murphy button, lateral anastomosis was performed between the small intestine and the ascending colon. This was done to short-circuit the fecal current. The bowels moved three days after the operation, and the button passed on the ninth day. There was some leakage from the original fistula.

At the time of writing, the patient is out of bed, has some leakage, but his bowels move more freely than at any time, and his local and general conditions are improving rapidly.

CASE II.-Gertrude M., four and a half months old. Native of the United States, was admitted to Lebanon Hospital February 21, 1903. An infant brother of the patient died from acute intussusception nine years ago. On February 19 the patient suddenly started to cry, and continued to do so, apparently having a great deal of pain; vomiting set in and continued. The child's bowels did not move, but it passed blood and mucus, and strained constantly. The mother, learning from past experience, recognized the acute nature of the condition, and informed the family physician. Castor-oil and calomel were prescribed, but without any result. The child became more and more fretful and exhausted. On the 21st of February the mother was advised to take the child to the hospital for operation. On examination a tumor could be seen in the region of the sigmoid flexure. On palpation a long tumor was felt extending from the epigastrium down to the region of the sigmoid and hypogastrium; the mass was freely movable. Rectal examination revealed a tumor in the lumen of the rectum, about one and one-half inches from the anus. On withdrawing the finger it was found stained with blood. Otherwise the abdomen was not distended. The child was well-nourished, was listless, and took no notice of its surroundings; pulse 146, hardly perceptible at the wrist. Temperature subnormal; cold extremities and marked cyanosis. At the most urgent solicitation of the mother, laparotomy was performed. An incision was made through the left rectus muscle. The neck of the intussusception was found in the transverse colon. The tumor was irreducible, and on account of the desperate condition of the child, an artificial anus was made, and the rest of the wound closed. The child reacted to some extent, but only temporarily, and died six hours later.