THE STRANGE CASE OF LEPROSYBy DR. EMMO GEHR AND DR. ELISABETH GEHR

There is no tleed to plead for the reader's interest in a subjectsuch as leprosy. F'rom time immemorial it has e:rerci,ed a hor/'or-filledfascination on the imagination of men. But it i8 only in recent yearsthat stride8 have been made in the knowledge of this strange plague.Among the leading scientists in the field are the authors of our article.

Dr. Emmo Gehr has the rare distinction of having passed e:rami/w­tion, both in medicine and in Oriental languages at the University ojBerlin. Rence he possesses unusual quali/,ica.tions for the study ojm.edical problems ,in Asia. Tho'ugh still quite yowng, he has made u, 1'l(I1I'W

for himself in lepr08Y research and in 1939 wa,s 0716 of the founde'rs ofthe [,eprosy Study Group in the German Research Council. His wife, D1'.Blisabeth Geh1', r/Jceived her medical degree at Hamburg University andp'ract'iced medicine in Berlin. After their marriage the Geh:rs comb'inedthei'r forces in th6 stmggie against leprosy atld studied the disease inRumania, Bulgaria, Tltrkey, Greece, Spain, and Portugal. Since spring191,1 they have bee1l engaged in the 8tudy of it in the Orient and are atp'resent liv'ing in Tokyo.-K.M.

LEPROSY is one of the oldest andmost dreaded of all the diseases

of mankind. There are few countriesin the world which have been entirelyspared by it; and there is scarcely apeople which does not have legendsbuilt around it. We are reminded ofthe gruesome descriptions of the MiddleAges and of stories in the Bible (inthe latter case mistakenly, for, accord­ing to recent discoveries by medicalhistorians, the Zaarath of the OldTestament was not leprosy but thename given to several other relativelyharmless skin diseases). The Japaneserecall their Empress Komyo, who, likeSaint Elizabeth, used to wash andnurse beggars and lepers. Indians canfind a description of the scourge in theRig Veda (1400 B. C.); and the oldestChinese reports of it date back tolegendary times. On the other hand,the remarks contained in the ancientEgyptian papyrus discovered by Ebersprobably do not refer to leprosy, andthe tourists in Angkor Wat whogaze in awestruck horror at the "roilepreux" are deceived by the lichenand the weathered condition of thestone. Map 1 shows how we imag­ine the disease to have spread from

its places of origin in India andCbina.

AGE-OLD SUPERSTITIONSSo man has had at least 3,500 years

to become acquainted with leprosy, tostudy it, and to fight it. The result?Even today people still have a super­stitious fear of leprosy such as theyhave of no other disease and which isscarcely justified. It is the remainsof medieval religious ideas of divinepunishment and branding. In sixteenthcentury China, for example, leprosywas called t'ien hsing (J:... ll'j), meaning"punishment from heaven."

Tuberculosis is far more dangerous,and many more victims fall prey to itthan to leprosy which, contrary togeneral opinion, is not very infectious.There are other incurable diseaseswhich are more murderous, more pain~

ful, and more repulsive than leprosy..but none of them is surrounded bysuch an atmosphere of horror anddespair.

The fate of tbe leper is no morepitiable than that of the mutilated,the crippled, or the incurably insane­unless the world makes it so. And

338 THE XXth CENTURY

doctors, mISSIOnaries, and nurses whohave devoted their lives to the care oflepers are neither martyrs nor heroes,but people who do their job like thou­sands of others who work in hospitalsand sanatoriums. Many doctors andhospital employees have died of typhus,cholera, yellow fever, malaria. plague,and typhoid. but scarcely one has everbeen infected with leprosy. Indeed.not even doctors who have inoculatedthemselves with leprous material havebecome infected.

LEPROSY'S STRANGEPREFERENCESDiseases have their own laws, their

own preferences and aversions. Someprefer the summer, such as dysenteryand infantile paralysis; others, such astyphus, reach their peak in winter.Sleeping s1ckness depends 011 the tl:ietlSefly j plaguo on rQts Qod thoil' ROQg_

T9ufRuonm.1ulhi (Japanese river fever)follows rivers; while dengue preferstowns. So leprosy, too, bas a numuerof J>(lcl1linriti~~. many of which stillseem strange and mysterious to us. Itavoid5 town5 and, in direct contrast

to tuberculosis-whose bacillus underthe microscope exactly resembles theleprosy bacillus-is not spread in thepoor districts of large cities. In theslums of London, in Marseilles thereare dozens, and in cities like Hongkongand Shanghai even hundreds of lepers,come there from other places, and yet-with very rare exceptions-the peoplearound them do not become infected.

Leprosy is an infectious disease, andwe believe that long and close contactwith lepers is necessary for infection;but, in all leper countries, only two tosix per cent of all healthy peoplemarried to lepers contract the disease.Among blood relations, on the otherhand, that is, parents, children, brothersand sisters, nephews and nieces, cous­ins, etc., the percentage of infectionis high-fifty to sixty per cent. Almosteverywhere, for quito unlmown rensons,twil'~ aR many men as women becomeleprous; only in a few small areas,such as Lithuania and the island ofOC:lel, ia it othcrwisc. Bofore puhe.rtyand after the menopause, however, bothsexes are equally liable to infection.The greatest discrepancy is to be

Map I. How Leprosy Has Spread

THE STRANGE CASE OF LEPROSY 839

found between the ages of twenty-fiveand thirty-five. In the case of allinfectious diseases a certain length oftime passes-usually a fixed number ofdays or weeks-between the infectionand the outbreak of the disease. Inthe case of leprosy that period isusually two to three years, oftenlonger, and sometimes as much asthirty years!

IS IT CLIMATE. IS IT FOOD?Map II shows the present extent

of leprosy in the world. The totalnumber of lepers is very variouslyestimated. Three million is certainlytoo low, ten million perhaps too high.In India and China alone there aremost probably a million each. Wenotice at once that the main areas ofleprosy are in the hot zones. But thiswas not always the case. The diseasealso raged for more than a thousandyears in northern and central Europe,in England and in Scandinavia. Inthe Mediterranean countries and Portu­gal, in Iceland, Norway, the Balticstates, and Russia it is still endemic.In Europe today there are altogetherfifteen to twenty thousand lepers. Soit seems hopeless to try and explainthe extent of leprosy by climaticconditions.

In central Europe the disease diedout in the fifteenth and sixteenthcenturies without any effective meas­ures having been taken to fight it.Moreover, during the period of famineand poverty of the Thirty Years' Warit did not flare up again. This factspeaks against any connection withundernourishment and lack of hygiene.Food conditions in northern Japan areless favorable than in the south andFormosa; yet the incidence of leprosyincreases toward the south, whileHokkaido is almost entirely free ofthe disease. Conditions of hygiene areconsiderably better in Japan than inNorth China and Manchuria; yet thetwo latter regions are not disease­ridden in spite of the constant im.migration of lepers. Among the Maorisof New Zealand leprosy disappeared inthe second half of the last century, at

a time when, through the settlementthere of adventurers, whale catchers,and English deportees, alcohol, syphilis,starvation, filth, and misery werespread among the inhabitants.

OR IS IT FISH?Hardly a single case is known of a

European or American becoming in­fected in Japan or China. So theattempt was promptly made to link upthe spread of leprosy with racialfactors. Yet these same Europeanswere not only affected during theMiddle Ages but still contract leprosytoday in South America, for example.The majority of the fifteen lepersnow living in Germany and severalthousand of the lepers on the Iberianpeninsula became infected in Brazil.Frenchmen and Englishmen caught itin the colonies.

All theories seeking to explain thegeographical extent of leprosy, whetherfounded on the resistance-loweringeffect of other diseases, on lack ofvitamins, or on animal carriers, havebeen exploded. At the beginning ofthis century a sensation was caused bythe theory that the excessive consump­tion of either rotten or poorly preparedfish heightens the disposition to leprosy.But negro tribes in the interior ofAfrica, who eat no fish, are not freefrom leprosy; and even in a countrythat consumes as much fish as Japan,this staple forms only three to four percent of the daily diet of the peasantpopulation. And it is the peasant pop­ulation which is most highly susceptiblein every country.

AN INDIAN REMEDYMedical knowledge has made great

progress during the last half century,and effective preventive measures orencouraging methods of treatment havebeen discovered for a large number ofdiseases. Inoculations afford protectionagainst cholera and typhoid fever.Malaria, syphilis, and relapsing fever,and, to a high degree, even tuberculosis,are curable today. Even the dreadedcancer is curable in eighty to ninety

840 THE XXth CENTURY

per cent of all cases, if the patient doesnot consult the doctor too late.

For leprosy, thousands of methodsand medicaments have been applied,starting with the Japanese treatmentof baths and the ancient Chinese Moxacauterization up to modern short-waveand hormone therapy. But science wasalways obliged to return to the oldIndian folk remedy, the Chaulmoograoil. This oil has been split up into itscomponent parts and combined withother substances-yet the raw, untreat­ed oil has remained the most effective.But unfortunately this effect is verylimited. Although one can alleviate andhalt the suffering of lepers. only a fewincipient cases can be cured.IS ISOLATION EFFECTIVE'

Someone once \;aJculat.ed that measlesmU5t dioo.ppear from t.h~ lace o.c theearth if one could strictly isolate everycase of measles for only fourteen days.:But unfurtunately this cannot be done.A nd it 18 equally impoDoible to get holdof and isolate every leper in a country..Peasants are used to scratches andBoro plncco: how can they be expecte\lto pay any attention to a little spot,lump, ur rasb, that does not even hurt!Usually several years DaBS before thesick person discovers his affliction. Inita firet IStAge5, the di:5ea.:se is oIt.eu hardto diagnose with certainty: individualcases in rarely affected districts can atfirst easily go unrecognized. And many a~ick mau, who ils aware uf his condition,keeps it secret out of fear of the unavoid­able separation from family and home.

The strict measures of isolation which,tor instance, the Americans have car·ried out in t.he PhilippInes for morethan twenty years, o.t enormous costand wit.h much propaganda for theirachievements, have not succeeded inreducing the figures for leprosy there.When the fight against the diseasebegan, the number- of lepers in thearchipelago was estimated at about8,000; now some 10,000 have beenisolated, and at least another 25,000have not yet been rounded up. TheEnglish leprosy researcher Maxwellthinks there are even 65,000 and draws

the discouraging equation: 8,000 minus10,000 equals 65,000 t It is true thatin Norway the number of lepers hasbeen reduced through isolation from2,833 cases in 1856 to 58 cases in 1932.Yet among the descendants of 160Norwegian leper emigrants to NorthAmerica the disease died out withoutany isolation at all t

WHY NOT INOCULATION?Since leprosy, as we have said, is

not very infectious-it attacks at theutmost ten to fifteen per cent of apopulation group, but usually only a fewper mille-it represents for the statea problem more of finance than ofhygiene. According to Maxwell's cal­culation. the isolation of the Ip.Jlel'~ ofChina would require a starting capitalof some two hundred million USdollars, and a minimum of ten milliondollars to cover current expenRes. Tothis must be added the loss in laborfrom a part of the population whichilS walul,y cumpo:sed or able-Doll1ed men.

All t.hilS coulll ue :savt:\l 1! there weresome sort of inoculation. Rut thechances for the discovery of an effec­tive serum nro minute. The IcprolSYbacillus is only slightly toxic (which,ot cuurse, 1s shown by its low degreeof infection). so thnt the disease isextremely chronic. Not only do yearselapse uefore the actual outbreak, buteven afterwards the disease developsonly very grndually over a poriod ofdecades. Lepers can reach a· greatage; the o.ffliction is not fo.tw, andcomplications such as tuberculosis,sepsis, or diseases of the kidneys areusually the cause of death. Hence itis not very probable that the body canproduce antibodIes strong enough toform the basis for a successful inocula­tion. The best methods of inoculationhave been developed in the cases ofdiseases running a swift, violent course,such as smallpox, cholera, diphtheria,typhoid fever. Moreover, whom shouldone inoculate against leprosy? All themillions inhabiting the vast areasshown in Map II? In the case ofsmallpox the ·situation is quite different,for eighty per cent of the population

THE STRANGE CASE OF LEPROSY 3U

Map II. Extent of Leprosy Today

and more are threatened by this dilleaseand can be protected by vaccination.

MEASURES IN CHINAAND JAPANIn 1940 there were some fifty

leprosaria in China, maintained by

which must, of course, be addedtireless scientific research and thecorresponding training of doctors.

Although the Japanese leprosaria arenot luxury institutions, they are roomysettlements, laid out with an eye tolight and cleanliness, where the patient

can feel comfortable undersympathetic care. Undermedical observation he cando allldnds of work in thefields and gardens, in smallworkshops, or in the nurs­ing of the seriously ill. InJapan there is one doctorfor about every hundredpatients - specialists forinternal disorders, sur­geons, gynecologists, eye.ear, and dental specialists-while in China some ofthe leprosaria have to getalong without any doctorat all. Of course, themissions have done valu­

able though, seen as a whole,insufficient work. also in Japan beforestate control of leprosy began.

A CHEERFUL REFUGE

A model institution is to be foundin the German leprosarium in Tungkunnear Canton. It is run by the RhenishMission and has three hundred patients.Dr. Hueck, in charge of the institution,and Mr. W. Grundmann, the super­intendent, have found an excellentsolution in combining occupation andwork therapy for the patients with areduction of the maintenance costs. Amodern little industrial plant with Ger­man machinery has been created, wherelime is burnt in a kiln and pottery,especially flower pots and white andcolored cement and terrazzo tiles, areproduced in large quantities. The tiles,which are equal to the best importedquality, supply not only the lepro­sarium's own needs; for before theJapanese occupation there was anagreement with the Chinese municipaladministration of Canton by whichcontractors were urged to place theirorders with the asylum.

"1:> ••:

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about twenty-five different (mostlyAmerican) mission societies. Only afew of them were run by provincialgovernments or medical institutions.All in all 3,247 lepers were interned.that is to say, a little more than threeper mille of the total number oflepers estimated at one million 1

In Japan, on the other hand, therewere. in 1941, sixteen institutions. six ofthem maintained by the state. fiveprovincial or civic, and only fiveprivate ones. In them there areslightly over 9.000 patients, only 658of which are in the five privateleprosaria. This number representsalmost two thirds of the cases knownto the Ministry of Public Welfare, avery creditable achievement. One needhardly add that the remaining third­mostly very light cases - are underconstant medical surveillance. Thetotal number of Japanese lepers isestimated at 20,000 to 40,000. Evenif we assume it to be 50,000, it meansthat twenty per cent are isolated.This shows that an effective controlof the disease is only possible in astate with a strong, united govern­ment and a disciplined population, to

THE XXtb CENTURY

The buildings of the leprosarium,with their shining stone floors. theirwhite or colored tiled walls, and thepaths with their speckless, snow-whitetiles beneath the trees, the flowers,and the cacti, offer a charming picture.The patients work enthusiastically atthe beautifying of their quarters, andshow off their machines and equipmentto the visitor with pride.RESEARCH IN GERMANY

AND IN JAPANIn spite of the lack of opportunity

to study leprosy on a large scaleensuing from Germany's loss of coloniesin the Great War, German medicalscience has not let itself be discouragedfrom devoting more and more attentionto the problem. A German, ProfessorKlingmiiller, has written the mostcomprchenz:livc treAt.i::le on the llhsea~e,

which is genernlly tlcknowledged to bethe best on the subject (1930. with asupplementary volume in 1938).

The greatest obstacle which hashitherto gf:ood in tho wny of rescnrchinto the disease and which has madethe solution of the problems mentionedbefore so difficult, is the impossibilityof CUltivating the leprosy bacillus or ofinoculating animals with it. We oweour knowledge of such diseases astuberculosis. sYnhili~, And i1iphthpriR,as well as of the methods for theirI',.pv~nt:ion And cure. to II Illt"gn oxtonl:to these two processes of research.ProfOSDor Ota, a J apanoao, hna auccced­ed in carrying out a kind of culturethrough the inoculation of chickens;And Dr. Oberdorffer, a German. wasthe first to succeed in producina- clinicalleDrOSy in animalR (monkeys) three

years ago in Thailand. Dr. Oberdorfferhas discovered a treatment with diph.theria antitoxin (Formoltoxoid) whichpromises success in some forms ofleprosy. He has also given a stimulusto leprosy research by working out anew hypothesis. He is of the opinionthat a person who has had prolongedcontact with lepers can only be infectedif, on the one hand, he has a constitu­tional susceptibility toward the disease,and on the other hand he has continu­ally absorbed certain chemically well­defined harmful substances through hisfood. Incidentally, leprosy is not hered.itary: children who are taken awayfrom their parents at birth and areprotected against infection always re­main healthy; however, susceptibilityis prolJalJly hereditaf)', U:l in the caseof tll h~rclJlosis.

Even if Dr. Oberdorffcr's hypothesUJhas by no means yet been proved. itnevertheless goes further than anyother in solving the riddles of thedisease. A special group in thc CermanResearch Association, composed of doc.tors and chemists, has been entrustedwith the task of examining this questionand finding new means of combating andcuring the disease. Moreover. the famousTropical Institute in Hamburg and theSkin Digc:!lH~@ Clinic of th~ Hamburg Uni­versity, besides other research workersin CM'mnny !\J.'(I giving gpocinl attentionto the problem of leprosy. Japan, who,in addition to her excellent "ylltem ofleprosy control, has also produced out·standing achievements in scientific re­search, and Germany are today leading inthe field of leprosy research. May they suc·ceed where previous attempl:s have failed.