All about Leprosy PVS Prasad
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Historical Aspectsone

The word ‘lepra’ indicates essentially any disease producing scaly lesions on the skin. It was not clearly known at which point the word was refer-red to leprosy. The medical writings of antiquity contained partial descriptions of this disease.
In the middle of the second century AD, the description of leprosy was first given by Aretaeus of ‘Cappadocia’. He referred to the disease as “elephantiasis”.
There are two possibilities of mode of spread of leprosy to Europe. Alexander and his men were probably responsible for the spread of leprosy from India to Europe and the Near East. Persians had introduced the disease into Europe during their invasions.
During the high medieval period there were medical writings in which leprosy was clearly described, as it is known today. Two polar forms were also described and it was considered that only one form required hospitalization.
Hospitals for leprosy patients were called as ‘leprosaria’ and were founded by noble families. There were many such hospitals in the 12th to 13th centuries. By the thirteenth century leprosy patient could not share anything in life or dead. A ‘leper’ was excluded from all contacts with other persons. Legally he was considered as a dead person. Leprosy was conceived as a punishment for sin.
Moller-Christensen's work revealed that 80 percent of the skeletons excavated at Naestved in Denmark showed the pathognomonic bony changes. There were lot of discrepancies in the incidence, age group and clinical features among the various countries. The Naestved study revealed that many patients acquired the disease during childhood and the incidence was around 20 per1000 persons per year.
There was a relationship between plague and leprosy. Many leprosy patients died of plague. Isolation of leprosy patients in the leprosarium was responsible for the decline in the incidence of the disease.
A Jesuit priest founded San Lazarus Hospital at Havana in 1677, and persons with leprosy were isolated at this hospital.
Leprosy was spread to the United States from Canada and African countries by slavery. In 1919, a National Leprosy Hospital was established at Florida.
Norway forms a classical example for the control of the disease. Over 8,000 patients were registered in Norway between 1855 and 1950. The highest prevalence occurred before the 1860s. There were no new cases after 1950s at which time only 11 cases remained. Isolation of the patients and emphasis on birth control measures might have played a crucial role in elimination of the disease from that country.
Rafael Lucio of Mexico (1819–86) was a distin-guished leprologist of that country after whom Lucio leprosy and Lucio phenomenon were named.
Leprosy in India has been mentioned in Vedic writings dated around 1400 BC. In Sushruta and Samhita of 600 BC one could find a reasonable account of clinical features and treatment of leprosy. A ‘leper’ was regarded as a most sinful person. In the 15th century an Indian physician named Gopal Krishna produced a comprehensive work on the Materia Medica of India in which he described about ‘galita kushtari rasa’, which was used for the treatment of leprosy. It was a 2combination of mercury, sulfur, iron, copper and vegetable oils.
For several centuries leprosy was a dreaded disease all over the world, including India. The Dutch built the first asylum for lepers in Cochin of Kerala state in 1728. Chaulmoogra oil was applied externally and taken internally as a cure for leprosy. Door to door survey was first carried out in the year 1951 in India.
Mouat, a British surgeon of the Indian Medical Service in 1859 formally introduced ‘chaulmoogra oil’ as a therapy for leprosy. Remedial treatment was begun largely through Christian missionaries.
In the middle age, when leprosy was at its peak in Europe, every country brought ruthless laws to isolate leprosy patients in an attempt to protect the community against the spread of the disease. At that time the hereditary theory predominated in the European medical circles. Boeck and Danielssen who were the two leading Norwegian clinicians were also of the same view.
In the year 1868 a young physician Gerhard Henrik Armauer Hansen (1841–1912) (Fig. 1.1) was appointed to assist Danielessen. He was convinced that leprosy was an infectious disease but was unable to change Danielssen's view. Hansen was reappointed in 1871 by the Norwegian Medical Society to study the cause of leprosy. During this period he made an effort to prove his infectious theory and demonstrated the rod-shaped bodies in stained preparations made from nodules of leprosy patients. His observations were first published in 1874 under the title ‘Causes of Leprosy’ in the Journal of Norwegian Medical Society. This publication was in the form of an annual report for 1873, thus establishing 1873 as the year of discovery of leprosy bacillus. It was recorded on 28 February, 1873. The discovery of tubercle bacillus followed that of leprosy bacillus by 9 years. Hence, the Mycobacterium leprae (M.leprae) has become the first bacterium to be identified. Hansen was the first person, who made an attempt to culture M. leprae in animals but all his efforts to infect animals have failed. This was possible only in 1960 by Shepard who successfully transmitted M. leprae into animals. M. leprae is the only human pathogenic bacterium, which is yet to be cultured. Hansen married his own professor's daughter as a gift for his discovery. The Norwegian medical society banned Hansen from practice as he inoculated M. leprae into a woman's eye who subsequently lost her vision.
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Fig. 1.1: Gerhard Henrik Armauer Hansen (1841–1912)
In 1882 Ehrlich described the property of acid fastness but its mechanism was unclear.
In 1908 Fromm and Wittmann synthesized Dapsone for the treatment of leprosy. However, adequate studies were not done to determine its margin of safety and it was considered to be highly toxic and was returned to the shelf for several years. In 1940, while working as a medical officer at Carville, Louisiana, Guy H. Faget first tried sulfones in leprosy. In 1943, promin treatment in leprosy was reported successfully. While Cochrane in 1949 prescribed dapsone intramuscularly, it was Lowe and Smith in the same year, used dapsone orally.
Pettit and Rees first reported dapsone resistance in 1964. Browne and Hogerzeil in 1962 from Nigeria effectively administered clofazimine. 3Opromolla in 1963 administrated rifampicin intra-muscularly in ten patients with leprosy. Jacobson and Hastings detected M. leprae resistance to rifampicin.
Sheskin in 1965 prescribed thalidomide as a sedative in ENL patients and incidentally found that ENL lesions improved.
World Health Organization (WHO) in 1981 recommended the combination of drugs to over-come resistance.
In an article in 1955 Yeoli traced the origin of leprosy to 1411–1314 BC. He described the finding of a clay jar in a section of the Amenophis III temple. On this jar, a face similar to advanced nodular leprosy was depicted.
The Hebrew word “saraath” was translated as ‘leprosy’. It covered a large number of skin conditions.
The word ‘leprosy’ translated in Biblical writings should be rendered ‘defiled’ or ‘cursed’ and it had no bearing on the disease we know as leprosy today.
In Babylonian time the word ‘leprosy’ has been translated as covered with dust or scaly.
Munro in his article in Edinburgh Medical Journal in 1877, referred to an Egyptian record of 1350 BC of leprosy occurring “among Negro slaves” from Sudan.
Hippocrates was born in 467 BC. From a study of translation of his work it was doubtful whether the father of modern medicine really recognized leprosy.
Leprosy was mentioned in the Vedic writings in India. It was mentioned as Kustha in the Vedas in about 1400 BC. Dharmendra in 1960 stated that in ‘Sushruta and Samhita’ (600 BC) one can find a reasonably good account of features and treatment of the disease.
Similarly references to leprosy in China appeared in 600 BC. Leprosy was known in China over five thousand years ago.
It can be concluded that leprosy was introduced into the Mediterranean countries somewhere between the time of Hippocrates (467 BC) and the time of Galen (131 AD) and that by 150 AD it was a well-known disease. Evidence of the disease in India and China dates back to 600 BC and in China possibly much further back. At least one thing is certain; leprosy is an ancient disease and has been the dread and horror of mankind for many centuries.