The medieval diagnosis of leprosy 



Jobs G. Andersen 



Modern clinical diagnosis 



In clinical praxis the diagnosis of leprosy rests on the pres- 

 ence of at least two or three symptoms: hypopigmented skin 

 lesions, reduction or loss of sensation in visible skin lesions, 

 and enlarged peripheral nerves. Demonstration of alcohol- 

 and acid-fast, intracellular rods in slit skin smears or biopsies 

 confirms the diagnosis unequivocally. 



Classification 



In the classical texts no attempts at classification are met. The 

 medieval literature abounds in terms that show a characteris- 

 tic emphasis on individual, significant symptoms. The texts 

 obviously presume a direct teacher-student situation. 



The described symptoms fit effortlessly into a description 

 of borderline lepromatous leprosy. As typical of this we can 

 refer to the famous Flos Medicina from the medical school in 

 Salerno (de Gaddesen 1492): 



De Specibus Leprae 



Tyria primo datur de flegmate qua generator, 



Inde leonina cholera generante ferina 



Triste pilos tollens allopicia sanguine nascens, 



De mclancolia tristis elephancia sacvior istis. 



In facie noli tangere, in partibus herpes, 



Inferius si sit dicitur esse lupus. 



Or in translation: 



Tyria in the beginning originates only from mucus 

 Wild is leo, and comes to our sorrow from t"gall of the 



body 

 Bom from bad blood and extracting the hair is the sad 



alopecia 

 Elephas. still more wild, it is bom from the sorrowful black 



gall 

 When it is seen in the face and breaks out in the skin, it is 



hopeless 

 Lupus we call it when only the parts further down are 



attacked. 



The first attempts at a classification that approaches our 

 understanding appear toward the end of the 19th century. 

 Here also for the first time we meet descriptions that can refer 

 to tuberculoid leprosy. 



As typical examples we can refer to the classifications as 

 described by Danielsen (1873) or Borthen and Lie (1899). 



During the first half of the 20th century most practicing 

 leprologists classified leprosy as lepromatous or non- 

 lepromatous leprosy. Ridley and Jopling in 1966 introduced 

 the now universally accepted five-point classification, based 

 on the immunological response of the host. In 1969 I intro- 

 duced the terms "high resistance leprosy" (HRL) and "low 

 resistance leprosy" (LRL). They provide a reasonably accu- 

 rate relation to the immunological classification. Since the 

 introduction of multidrug therapy (WHO Study Group, 

 1982) there is a tendency to classify leprosy as multibacillary 

 or paucibacillary leprosy for purposes of primary drug thera- 

 py. Unfortunately there is no generally accepted definition of 

 these terms. The reader is referred to Figure 1 for comparison 

 between the different classifications. 



Reading of ancient texts 



The free use of quotations, frequently without any acknowl- 

 edgment of source, makes it difficult to assess which is an 

 original observation, and which is a reference to existing 

 knowledge. There is a tendency to describe symptoms, with 

 less correlation of different symptoms to define a particular 

 disease. It can be difficult to determine if a particular term 

 covers a subgroup of a given disease or rather a disease in 

 itself. We should not overlook the confusing use of the terms 

 derived from elephas and lepra, indicating the same disease. 

 Direct translations can cause misunderstandings: The 

 Greek p«M,v and <7j<'/V, usually translated as /laW and/oof. are 

 frequently used to indicate the whole extremity. The same is 

 true about the Latin pes and manus. Extremitas manus can 

 thus mean either the upper extremity or the distal part of the 

 hand, that is, the tips of the digits. 



Zagreb Paleopathology Symp. 1988 



205 



