DR. JAY F. SCHAMBERG: Interest in the subject of leprosy will doubtless increase in this country owing to our acquisition of the various insular colonies, Hawaii, the Philippines, and Porto Rico, in at least two of which countries leprosy is endemic. Despite the vigilance of the officers of the Marine Hospital Service, lepers in whom the disease is not conspicuously present will doubtless enter the country every now and then.

At the Municipal Hospital of Philadelphia we have from time to time had a few lepers in isolation. Most of these were Chinamen; one was a native of the island of Olsen in the Baltic Sea; and one was a woman, 70 years of age, a native of this city who had never been beyond the confines of Philadelphia and its suburbs. This brings up the subject of the transmissibility of the disease. It is evident that leprosy did not arise de novo in the woman referred to; she had never been out of Philadelphia; therefore the disease must have been brought to her. There is some vague history of her family having been visited by two sailors who were brothers, one of whom was said to have had "elephantiasis." Last summer I saw a gentleman from the South who was passing through this city and who had been told by several physicians that he had Addison's disease, doubtless owing to the bronzing of the skin. The man clearly had leprosy; he had never been outside of the United States.

Medical opinion in regard to the contagiousness of leprosy has undergone fluctuation from time to time. In 1867 the Royal College of Physicians of England, after studying the subject, concluded that there was no sufficient evidence to regard leprosy as contagious. In 1897, just thirty years later, at the Lepra Congress in Berlin, authorities were practically all agreed that leprosy is transmissible from one individual to another.

If we recognize in Hansen's bacillus the cause of leprosy, and this view is accepted by nearly all leprologists, then it is evident that the disease must be transferable from an infected subject to another. But the disease is in no sense contagious after the manner of the acute exanthemata. Ordinary contact or proximity, which is commonly represented by lay writers to be fraught with danger, can do no harm. Long and close association with lepers favors transmission; but even then there appear to be necessary certain personal predisposing factors. In general it may be stated that the transference of leprosy is accomplished with much difficulty, and that the laws governing individual immunity and susceptibility are but little understood. The disease is certainly much less contagious than syphilis,

and likewise less dangerously transmissible than pulmonary tuberculosis.

Leprosy is the most typical example of a bacterial disease. In no other chronic infectious process are the germs so abundantly present. The nodules in the skin swarm with them; they are in the lymphatic glands, nerve-sheaths, spinal cord, ovaries, testicles, spleen, liver, and kidneys. In an autopsy on a leper made last year I found numerous bacilli in the spleen.

Despite the abundance of bacilli in the cutaneous nodules it has never been found possible to experimentally produce the disease in man or the lower animals. Daniellsen tried repeatedly to inoculate himself with blood, fragments of nodules, and other leprous tissue, but always with negative results; he also tried inoculation on a score of other people, their consent having been obtained. Profeta and Hansen were also unsuccessful in attempted inoculations.

Despite this negative evidence of the transmissibility of leprosy, it must be remembered that natural transmission may be very different from experimental inoculation. Furthermore, there has accumulated a mass of clinical evidence in favor of the inoculability of leprosy which is most suggestive, and in certain individual instances almost conclusive.

It must be remembered that one undoubted example of positive contagion outweighs a score of negative experiments.

I was very much interested in Dr. Boston's report of the finding of lepra bacilli in the blood. With the exception of the presence of bacilli in the blood during the terminal stage of the disease and during acute febrile attacks, such findings have been, according to the work of many investigators, excessively rare. I should like to inquire of Dr. Boston whether the portion of the finger which was incised to obtain blood was the seat of a leprous nodule or diffuse infiltration. One of the simplest means of finding lepra bacilli in the nodules in the skin is to clamp the elevation with a specially-devised instrument, incise it, and collect the serum or blood on a coverglass. I think it would be well, before concluding that the germs were present in the circulating blood, to exclude the possibility of their derivation from the source mentioned.

DR. MATTHEW WOODS said he had nothing of practical value to offer, never having seen a case of leprosy like the one under consideration, but that he saw many suffering from Arabian leprosy, elephantiasis Arabum, while spending a summer in the West Indies a few years ago, especially in the island of St. Bartholomew, where it seemed to be quite prevalent, as in the course of an afternoon-walk you were likely to encounter a half-dozen cases; but that

the discussion, he might say the luminous discussion, of the subject of leprosy to-night by experts suggested certain circumstances connected perhaps as much with the general literature and history of the disease as a sort of undulating entity of the ages, as with the disease itself.

For example, since no allusion was made by any of the appointed speakers to the description of the disorder as given by Moses, and which we have been in the habit of accepting as accurate, he would like to know if Moses could be regarded as an authority on dermatology in this particular as he has been in law, and if the leprosy he described so minutely in Leviticus is the same as the leprosy under discussion.

Dr. Daland would seem to have implied that the disease was probably "hereditary, as indicated by the fact that it had appeared for generations in the same family," although we know now that this does not prove, but only suggests probable heredity. Among the first descriptions of the disease are to be found in Hebrew literature, and the people of Palestine are mentioned as its frequent victims.

If hereditary, therefore, why is it that, since the dispersion of the chosen people over the face of the earth, they did not carry leprosy with them?

There are no people more particular about the preservation and protection of racial distinction than the Hebrews, so that things hereditary are apt to manifest themselves in a conspicuous way, and yet there are no people more exempt from even ordinary skin blemishes than they, even the poorest Hebrews, those coming from half-civilized countries, where they have been brutally persecuted, for centuries, and deprived of the common means of cleanliness, are, as it would seem, exceptionally exempt not only from leprosy, but other skin distempers.

Can this be because of the strict segregation and surveillance of the Hebrew leper in the dim past, or is it that, just as in relation to individuals certain diseases are self-limited, so in relation to nations or races in a broader sense diseases are also self-limited and in time subside and disappear?

The preventive and sanitary methods resorted to in those early days were severer than anything practiced since. Might its elimination be due to this? For example, lepers were separated from kindred and family and compelled to live apart until death or cure (the cures evidently due to mistakes of diagnosis). On the approach of a stranger they were obliged to cover their faces and cry out "Unclean! Unclean!" (ceremonially unclean). They were not allowed to rest under the shadow of a tree for fear the un

affected might afterward do likewise and become contaminated by touching the same soil; they were not allowed to come between a traveler and the wind, and not permitted to drink from a running stream for fear of conveying the disease by water, showing evidently that both wind and water were regarded as probable vehicles of transmission. There were a number of others, as it would seem, as we now know, unnecessarily severe restrictions, that make the sanitary precaution of modern times seem like child's play.

Again, as with the Hebrews scattered abroad, so with the English at home. There was a time when leprosy was prevalent in England, and leper colonies, not exactly hospitals, but rendezvous for lepers were to be found in all much frequented parts of the kingdom, and if he was not mistaken, the speaker continued, it existed to such an extent that a certain order of knighthood took upon itself the care of lepers, and yet to-day there are no lepers in England.

How, therefore, was its elimination effected? How can we account for its diminution and final disappearance?

The above were a few of the things Dr. Woods said that occurred to him as he listened to the more than interesting elucidation of the subject, and that might suggest food for thought.

In conclusion, he thanked the speakers, and especially Dr. Stelwagon, because that in this germ-burdened community, where men are al

most afraid to kiss their own wives for fear of contracting or transmitting some dreadful distemper, he made it clear that there was but slight, if any, danger of the community being affected because of its coming in contact, even with lepers, and that our sometimes too severe treatment of these unfortunates in dread of the supposed easy transmission of their disease was unnecessarily austere and unjustified by the facts.

DR. L. N. BOSTON: In reply to Dr. Schamberg I would say that at the point of incision for the blood-examination I could see no infiltration, and that there was no involvement apparent at that portion of the finger. The blood was taken on two occasions and more bacilli were found in the second specimen than in the first. Most of the bleeding had taken place from the first incision, which was rather deep.

DR. J. V. SHOEMAKER: Dr. McFarland nade a number of sections of the tissues, and found the lepra bacillus unmistakably present. I am grateful to my colleagues for their opinions, especially as regards contagion. I now recall to mind my first case of leprosy, many years ago in Jefferson Medical College. I thought that it was both my duty and privilege to present the patient to the class. Out of a class of two hundred stu