53,2^ Editorials^ 289

Understanding of Leprosy in Ancient China

China has a proverb which states, "Anearlier generation blazes a trail on which alater generation follows." The chief recordof this trail of understanding in leprosy asit developed in China through the T'angdynasty is chronicled in Table 1 and de-tailed in the text for both this early periodand also for later periods. Some of the ac-counts appear fanciful to modern thinking,but they serve to indicate that leprosy waspresent and illustrate the thought of theirperiod.

Records before the Common Era (B.C.)

The recorded understanding of leprosybegan with the most ancient of medical texts,the Nei Ching, and the first case record withthat noted in the Lun Yu ("Analects of Con-fucius," c. sixth century) which states that"Pai Niu is sick. The Master went to seehim and, holding his hand through the win-dow, exclaimed: 'Fate kills him. For such aman to have such a disease! For such a manto have such a disease!' " 1,2 Pai Niu (alsoPo Niu) is venerated as one of the 12 sagesattending Confucius in his temples, wherehe is depicted without signs of leprosy incontrast to Hawaii's official statue of Da-mien who is shown with the ravages of thedisease. Concerning this incident, Feenycommented:

There is no proof what the disease inquestion was, and this illustrates howeasy it is to argue backwards. Pai Niuhad a disgraceful affliction, therefore itmust have been leprosy because leprosyis still looked upon as a disgraceful af-fliction . . . . In other words, leprosy hasbecome a scapegoat for fear and hatredthat dates back to times when the dis-ease itself may not even have existed.'

' Wong K. Chi-min, "The early history of leprosy inChina," Chinese Med. J., 1930,44,737-743, p. 737.

Chu Hsi, Sze Shu Ta Chuan. [Four great books].In: Wang Yun-wu, ed., Chin Ting Ssu Ku Chuan Shu.[Imperial authorized books of four treasures]. (Taipei,Taiwan: Commercial Press, 1976), Vol. 6, p. 21. Pho-tocopy of 1189 text in Chinese.

Patrick Feeny, The fight against leprosy. (London,1964), p. 18.

Feeny, however, did not offer a creditablealternative diagnosis, which has also beenthe weakness of others who have sought todeny the presence of leprosy in the ancientpast of both the Orient and the Fertile Cres-cent. In this case the disease was indeedleprosy, as has been nicely shown by theetymology of the characters used in the ac-count by Wong4 and more recently by Luand Needham.' The latter demonstrated thatcommentators through the centuries havedetermined that the illness termed Chi was0 Chi and that this was the equivalent ofthe terms Lai, Li and Ta Feng, all beingsynonyms for leprosy. The character 0 usedin the designation 0 Chi for leprosy was alsoused in other designations such as those forvulgar pictures, evil thoughts, evil desiressuch as lust, evil recompense, foul, unclean,and abominable. When Buddhism later ar-rived in China, 0 was in time incorporatedinto the expression, "The evil way" — thedesignation for the lowest transmigration.

It is evident that the social opprobriumapplied to leprosy has existed from earliesttimes and was continued through succeed-ing generations, as will be evident in sub-sequent quotations. The difficulty of re-moving the stigma of leprosy from thelanguage of one quarter of the world's pop-ulation, in view of the multiplicity of termsused and their permeation into other as-pects of the language, is obvious.

The Nei Ching ("Canon of Internal Med-icine") is the oldest as well as the most ven-erated Chinese medical text. Tradition as-cribes its authorship to Huang Ti (2698-2598), the legendary third emperor. For anumber of reasons it is thought that its ac-tual authorship lies at the period represent-ed by the end of the Eastern Chou (771-255) and the early part of the Chin (221-207) dynasties. This was roughly the periodof the three great philosophers, Lao Tzu (b.604), Confucius (551-479), and Mencius(372-289) and was a period of fermentation

4 Wong, (n. 1), pp. 737-738.Gwei-djen Lu and Joseph Needham, "Records of

diseases in China," In: D. R. Brothwell and A. T. San-dison, eds. Diseases in antiquity. (Springfield, 1967),pp. 236-237.

290^ International Journal of Leprosy^ 1985

TABLE 1. Chronology of major leprosyresearch through the T'ang dynasty.

CHRONOLOGY OF LEPROSY RECORDS

DYNASTIEStraditional^dates

RECORDINGS

CHOU NEI-CHING,^medical^compendium

1122-221 YUE LING,^"Calendar of Seasons"

CONFUCIUS 8 Po Niu,^incident

PIEN CH'IAO,^physician

CH'IN HUPEH BAMBOO BOOK,^archeology

221-206

W.^HAN206^B.^C.

I ^0 ^25 A.^D.

E.^HAN CHANG CHUNG - CHING,^physician

25-220

"THREE KINGDOMS" HUA T'o,^surgeon

220-265

CHIN Ko HUNG, physician265-420

6 DYNASTIES420-589

SUI CHAO YUAN - FANG,^pathologist

589-618

TANG SUN SZE -MO,^physician

610-007 WANG TAO,^recorder

and codification of thought, so the socialmovement of the time may well have alsobrought forth this work. The contents aremuch older than this period and do not comefrom the pen of a single individual but area compilation by various writers. It sumsup the experimental, physiologic, and the-oretical knowledge from the centuries whichpreceded it and presents the earliest at-tempts to systematize the medical thoughtsof those ancient times. The most popularedition is divided into two distinct books—the Su Wen, comprising 24 volumes, andthe Ling Shu, containing 12 volumes, eachbeing divided into 81 chapters. 6 This ar-rangement has held together since the edi-tion of 762 A.D. The English translationentitled "Huang Ti Nei Ching Su Wen"("The Yellow Emperor's Classic of Internal

6 Wong K. Chi-min and Wu Licn-tch, History ofChinese medicine. (Shanghai: National QuarantineService, 1936), 2nd ed., pp. 28-29.

Medicine") by Ilia Veith 7 covers the first34 chapters of the Su Wen, while that pro-vided by Wong Man 8 covers all 81 chaptersof each book in commentated abstract form.Neither provides the sections on leprosytranslated by Wong and Wu' as:

Those suffering from to feng [lepro-sy] have stiff joints, the eyebrows andbeard fall out.'

The wind scatters throughout themuscles and comes into conflict withthe wei chi or defensive forces. Thechannels being clogged, the flesh be-comes nodular and ulcerates. And be-cause of the stagnant movements of thisdefensive force numbness results. Thevital spirits degenerate and turn cloudycausing the bridge of the nose to changecolor and rot, and the skin to ulcerate.The wind and chills lodge in the bloodvessels and cannot be got rid of. Thisis called li .feng [leprosy]."

For the treatment of li .feng prick theswollen parts with a sharp needle, letthe foul air out until the swelling sub-sides.' 2

In speaking of acupuncture therapy ofleprosy it is noted that acupuncture is ap-plied only on diseased parts of the fleshwhich have lost all sensation of feeling."

In the period of the Warring States (476-221), the Yu Ling ("Calendar of the Sea-sons") stated, ". . . if in the middle of winterthe proceedings of government proper tospring were observed, locusts would appearand work harm, springs would all becomedry, and many of the people would sufferfrom the itch and from leprosy. "14' 15 The

7 Ilia Veith, Huang Ti Nei Ching Su Wen. The Yel-low Emperor's classic of internal medicine. (Baltimore,1949).

8 Wong Man, "Nei ching, the Chinese canon of in-ternal medicine," Chinese Med. J., 1950, 68, 1-33.

9 Wong and Wu, (n. 6), p. 210.'° Yang Shang-shan, lIuang Ti Nei Ching Tai Shu.

[Huang Ti's canon of internal medicine]. (Beijing: Peo-ple's Health Publisher, 1981), pp. 397-398. Repro-duction of Sui dynasty (589-616) text in Chinese.

" Yang Shang-shan, (n. 10), p. 521.' 2 Yang Shang-shan, (n. 10), p. 392." Yang Shang-shan, (n. 10), p. 396.14 Wong, (n. 1), pp. 739-740." Hu Kwang, Li Chi Ta Chuan Yu Ling. [Chou dy-

nasty calendar of the seasons]. In: Wang Yun-wu, (n.2), 1976, Vol. 6, p. 82. Photocopy of Ming dynasty(1593) Chinese text.

53, 2^ Editorials^ 291

implication was that if inappropriate gov-ernment ritual was followed, disaster wouldstrike.

Two additional accounts from this periodindicate that leprosy was indeed a part ofthe life of the community. The first comesfrom Liu Hsiang who, in his book the ChangKuo Tse ("Warring States Bamboo Book"),tells of Yu-van, an assassin who shaved hiseyebrows and used varnish to mark his skinas a disguise for leprosy in order that hewould not be arrested (453)." The secondaccount, from the Chang Szu Wai Pen("Chang S:u's Extraordinary Writing")dated to 343 by Chang Kuo Tse, tells of aleprous midwife who delivered a baby atnight and utilized a light to examine theinfant's body to see if it had any marks likethose on herself.' 7

Pien Ch'iao, traditionally dated to 407-310, has so many dates and medical accom-plishments attributed to him that it isthought by some that this may have beenthe name for a composite person. He was,for example, reputed to have transplantedthe heart of a melancholy man to an exu-berant subject, and vice versa, thus estab-lishing the proper psychic balance in eachsubject (Fig. 1). The book of memoirs at-tributed to him, the Hsin Shan, states that,". . leprosy may be caused by sleeping onwet ground on a summer night, or by evilair entering the body after sexual congress,thus causing both eyes to swell, the skin tobe numb and senseless, and the flesh ulcer-ating." I8

Also from this ancient period there is therecently excavated "Bamboo Book" comingfrom the tomb of magistrate Hsi in YunMeng, Hupeh, and dated to 217. This isessentially a book relating to laws and reg-ulations, but in it there appears the follow-ing account:

Cha went to see Bing and said to Bing,"I think you have leprosy (Li)." Bing

16 Liu Hsiang, Chang Kuo Tse. [Warring states bam-boo book]. In: Wang Yun-wu, (n. 2), Vol. 6, p. 9.Photocopy of Sung dynasty (1147) Chinese text.

' 7 Lai Shang-h'u, Chung Kuo Lai Ping Ilsueh ChiliYen Pien. [Leprosy in Chinese history]. (Taipei, Tai-wan: Department of Public Health, National TaiwanUniversity Medical School, mimeographed c. 1954),1-107, p. 24 (in Chinese).

18 Wong, (n. 1), p. 739.

Fin. 1. Pien Ch'iao demonstrates heart transplant.The hearts are represented in the form of the ancientcharacter for "heart," one in reverse of the other.(Painting by Johnny Shek)

replied, "At age three I was sick, myeyebrows were swollen and nobodyknew what the sickness was. I was di-rected to see a doctor, Ting. The doctorsaid, you don't have eyebrows becausethey are rootless. Your nostril is de-stroyed; you cannot sneeze on irrita-tion; your legs are halt because one ofthem burst, and your hands have nohair." He asked Bing to shout and thevoice was hoarse. That is leprosy."

This reference is of great significance to lep-rosy history since its excavation demon-strates concepts that were present at the timeof writing whereas many of the old bookscan be regarded as having been edited bylater generations.

Ts'ao Shi(c. 206-195) of the Han dynastywas the son of the premier Ts'ao Tsan ofEmperor Kao Tsu, founder of the dynasty.

19 0. K. Skinsnes, "Leprosy in an archeologicallyrecovered bamboo book in China," Int. J. Lepr., 1980,48, 333. [The terms "Cha, Bing, and Ting" are notproper names, but the equivalent of A, 13, and C.]

292^ International Journal of Leprosy^ 1985

According to the "Historical Records,"Ts'ao Shi was also an able administratorand was military governor of Ping Yang(present Lin-Fen county, Shansi province).He had to resign his command and returnhome after contracting leprosy. 2°

Thus, before the turn of the millenia,Chinese literature contains clear referencesto a disease described as leprosy and accom-panied by social opprobrium similar to thatassociated with it today.

The Common Era (CE) through theT'ang Dynasty (1-906 A.D.)

Two Chinese physicians were approxi-mately contemporaneous with the threeWestern doctors, Cornelius Celsus (25 B.C.to 37 A.D.), Claudius Galenos (130-201),and Aretaeus Kappadox (c. 200). They hada significant influence on the developmentof Chinese medicine, just as the above threedid on Western practice. They were ChangChung- thing (150-219), and Hua T'o (diedc. 208). Chang Chung-ching is often re-ferred to as the "Hippocrates" of China andHua T'o as China's pre-eminent surgeon.

In his classic book on typhoid and otherfevers, the Shang Han Lun ("Essay on Ty-phoid"), Chang Chung-ching stated that aperson having leprosy has very little hairand eyebrows left and his body is full ofsores which have a fishy and stinking sme11. 2 'This odor of leprosy, now almost forgotten,was well known before the advent of mod-ern chemotherapy and could be alleviatedby good nutrition and general care includingcleanliness. Father Damien, much later inhis report of March 1886 to the HawaiiBoard of Health, wrote:

The smell of their filth, mixed withthe exhalation of their sores was simplydisgusting and unbearable to a new-comer. Many a time . . . . I have beencompelled not only to close my nostrilsbut to run outside to breathe the freshair . . . . As an antidote to counteractthe bad smell, I made myself accus-tomed to the use of tobacco, where-

20 Wong, K. Chi-min, "Some famous lepers inChinese history," Leper Quart., 1941, 15, 5-10, p. 6.

21 Chang Chung-ching. Shang Han Lun. [Essay ontyphoid]. In: Wang Yun-wu, (n. 2), 1974, Vol. 7, p.22. Photocopy of Ming dynasty (1593) text in Chineseas edited by Fong Yu-chi.

upon the smell of the pipe preservedme somewhat from carrying in myclothes the obnoxious odor of the lep-ers. At that time the progress of thedisease was fearful, and the rate of mor-tality very high. 22

In the preface of the Chia I Ching ("Acu-puncture Classic") by Huang Fu - ini (215282), it is recorded that when Wang Chung-hsuan, one of the "Seven Geniuses" of thereign of Chien An (177-217), was 20 yearsold Chang Chung - thing said to him, "Youare suffering from a disease which will causeyour eyebrows to fall when you are forty,and death will follow in half a year's time."Wang did not believe the famous physicianand ignored his advice. After 20 years hiseyebrows fell, and death followed in 187days. 23

Ilua T'o (Fig. 2), who lived during theperiod of the "Three Kingdoms" (220-265),recorded the use of sutures in his surgeryand is widely reputed to have used an an-esthetic, perhaps aconite. He is famed infolklore for his operation on the arm ofKuang Kung, who was later deified as theGod of War and also of Good Fortune, whenthe latter suffered an arrow wound in battle.Hua T'o is also credited with devising theoperation for castration. It is reputed thathe was finally killed by Tsao Tsao, ruler ofthe State of Wei, but not before he hadburned all his books and writings. Appar-ently relying on this tradition, Wong andWu 24 state that the two books attributed tohim are forgeries, but represent works of anancient age. Nevertheless, there are twobooks, the Nei Chao Tu ("Reflections ofInternal Conditions"), and the Chung TsangChing ("Internal Organs Text") which, to-gether with a third, the Hua T'o Sen Yi PiCh'uan ("Hua T'o's Secret Prescriptions"),are generally attributed to him and said tohave been smuggled out of his prison. Inthese, leprosy is described as being of fourtypes: Ta Ma Feng, General Lai, Black Laiand White Lai. 25

22 J. Damien DeVeuster, "A personal experience ofthirteen years' residence and labor among the lepers atKalawao," Hawaii Board of health Records, AppendixAl, March, 1886, 60-73, p. 61.

23 Wong, (n. 20), pp. 6-7.24 Wong and Wu, (n. 6), p. 56.25 Lai, (n. 17), pp. 26-27.

53, 2^ Editorials^ 293

Ta Ma Feng— The symptoms first appearon the skin but the poison is actually storedin the internal organs. The skin is first numbwithout sensation; gradually red spots ap-pear on it, then it is swollen and ulceratedwithout any pus. Later the disease developsto such an extent that the eyebrows fall out,the eyes become blind, the lips deformed,and the voice hoarse. The patient may alsoexperience ringing in his ears, and the solesof his feet develop rotted holes; his fingerjoints may become dislocated and the bridgeof his nose flattened. [Lepromatous lepro-sy ]26

General Lai—All forms of leprosy resultfrom evil pneuma or from having provokedthe deities. At first the skin is senseless, butgradually it becomes itchy as if somethingis running underneath [formication]. Itshould be treated immediately. [? Early, in-determinate leprosy]

Black Lai— At the beginning the symp-toms are similar to those mentioned above,but gradually there are purplish-black swell-ings of the size of a peach found in the skin.Both feet and hands become numb withoutfeeling any pain; the feet cannot step on theground and then the whole body becomescovered with sores. ["Mixed" neural andlepromatous = ? Borderline leprosy]

White Lai—The patient who suffers fromthis disorder will find his voice hoarse, hisvision blurred, all four limbs without sen-sation and then white spots appear on theskin. The pupil of his eye is gradually cov-ered with white matter and gradually all vi-sion is lost. [Lepromatous leprosy] 27

Also, during the "Three Kingdoms" pe-riod there appeared the account of TungFang, otherwise named Chun I, who wasvery familiar with Taoism. He lived in iso-lation on Lu Shan of Yu Chang where hetreated sick people every day without col-lecting any fees. Whenever a severely ill per-son was cured he was requested to plant fivealmond trees. If only a slight illness wascured, the request was that only one tree beplanted. After several years these trees had

26 Hua T'o, Hua To Sen Yi Pi Ch'uan. [Hua To'ssecret prescriptions]. (Shen-yang, Liaoning: LiaoningScience and Technology Publisher, 1983), p. 79. Re-production in Chinese of 1762 text edited by PangShin-san from a copy of 682 by Sun Sze-mo.

27 Hua T'o, (n. 26), pp. 255-256.

FIG. 2. 'Ilia T'o described several forms of leprosyand their clinical characteristics. (Shihwan ceramic fig-ure, c. 1972)

grown into a thick forest and the ripe al-monds were exchanged for rice for the poor.At Lu Shan, a person dying of leprosy wascarried to Tung Fang for treatment.'

The epoch of Chinese history (280-589)lying between the end of the "Three King-doms" and the beginning of the Sui dynasty,and which included the Tsin dynasty, wasan era of confusion and political disunitywith many small contending states. Therewas little medical progress. Nevertheless, itwas during the Tsin dynasty that the MoChing ("Pulse Classic") was compiled byWang Shu-ho, who is generally acknowl-edged as the greatest authority on the pulseand who lived in about 265-317. A spuriouswork known as the Mo Chueh ("Secrets ofthe Pulse") was published much later andtranslated into French by Hervieu, on the

28 Lai, (n. 17), p. 24.

294^ International Journal of Leprosy^ 1985

FIG. 3. ho Hung, an alchemist and physician, not-ed many of the clinical signs of leprosy. He is shownworking with an "elixir of life." (Fukien "blanc dechine" figure, c. 1981)

assumption that he was dealing with theoriginal work. This was also mistakenlycommented on by Chang Shih-hsien of theMing dynasty. 29 In volume eight of the"Pulse Classic" (280), there is a paragraphwhich states, "The disease can be cured ifthe Tsin Yin Chuang [leprosy] is spread fromthe mouth to the four limbs, but if it spreadsfrom the four limbs to the mouth, it cannotbe cured."'"

Almost contemporaneous with this workwas the Chou Hou Pei Chi Fang ("Prescrip-

29 Wong and Wu, (n. 6), p. 83.30 Wang Shu-ho, Aio Ching. [Secret of the pulse].

(Shanghai: Han Fan Lu Bookstore, n.d.), Vol. 8, p. 24.Reproduction of Sung dynasty (1068) text as edited byLin I, et at.

tions for Emergencies" ) 31 written by the fa-mous Taoist Ko flung (281-361). It is aneight-volume work dealing with therapeu-tics and contains perhaps the first authenticdescription of smallpox. Being an ardentTaoist, Ko Hung devoted much time to ex-perimenting with the elixir of life (Fig. 3)and retired into the Lo Fou mountains inKwangtung province at the age of 81 to con-tinue his studies, although his original homewas in Nanking, Kiangsu. In volume five itis stated, "At first the skin is senseless; grad-ually there is itching as if insects are crawl-ing underneath, and the vision becomesblurred, or black swellings are found in theskin."

In another volume, the Pao Pu Tzu, KoHung tells of a patient named Chao Ti whosuffered from leprosy for years without find-ing any cure. Dying, he was relegated withsome food to a mountain cave by his sonand grandsons. He was so distressed by hismisfortune that he cried day and night. Af-ter some time a fairy passed the cave, wassurprised to find Chao Ti there and tookpity on him. Chao Ti knew that this wasnot an ordinary mortal and told him of hisdistress, asking for help. The fairy gave hima packet of medicine and taught him howto take the medicine. After taking it for overa hundred days, Chao Ti was completelycured. His skin was again smooth and colorwas restored to his face. The fairy again cameto see him and Chao Ti, thanking him, askedfor the prescription. The fairy said, "It isonly pine cones. There is a great deal of thison the mountain. If it is taken after it hasbeen refined it will make you an immortal."

In a third volume, Ko hung describedanother patient, a military official namedTsui Yen who was suddenly afflicted withleprosy. "His eyes grew dim; he could notdistinguish either objects or men. The eye-brows and hair fallen off, the nasal bridgedropped and the skin was covered withsores." Everyone said that it was an evildisease which could not be cured. A Taoist,who refused to give his name, gave Tsui Yena prescription consisting of one or two cat-ties (c. 600-1200 grams) of saponin groundinto a powder after repeatedly being steamed

31 Wong and Wu, (n. 6), p. 82.

53, 2^ Editorials^ 295

and dried in the sun, to be taken togetherwith rhubarb solution. Following this treat-ment the hair grew again and the patientwas considered cured. 32

Pine cones and saponin are still part ofthe Chinese pharmacopeia, the latter for thetreatment of scrofulous swellings and severeulcers and the former has been listed as use-ful in leprosy.

As part of this period of political confu-sion, which was essentially a struggle betweenthe Tartars in the north and the Chinesein the south, a usurper named Ilsiao Yentook the dynastic title of Wu Ti and set upa Chinese dynasty named the Liang (502-557). Wu Ti was favorably inclined to learn-ing and established Confucian schoolsthroughout the country. He had an ex-tremely learned scholar, Chou Hsing-ssu(died 521), as a minister. This minister firstsuffered from abscesses on both hands.Within the year he was diagnosed as havingleprosy and his left eye became blind. Theking went to console him and, stroking hishand, repeated the statement of Confucius,"That such a man should have such a dis-ease.""

In 589 Yang Chien, known to posterityas Kao Tsu or Wen Ti, who, although hehad been in the employ of the NorthernTartar Kingdom, was a Chinese by birth,seized the throne and established over thewhole country a new dynasty known as theSui (589-618). This was followed by theT'ang dynasty (619-907), and the wholecountry was once more united under therule of the Chinese.

In 610 a famous work on pathology, theCh'ao Shih Pin Yuan ("Chao's Pathology")was compiled by a committee of physicianshaving Ch'ao Yuan fang at its head and is-sued under imperial orders. The work com-prises 50 volumes, divided into 67 headingswith 1720 chapters. Later, in the Sung dy-nasty, this was used as a textbook for statemedical examinations. It was influential inKorea and Japan. Not much is known aboutthe life of Ch'ao Yuan fang (Fig. 4) exceptthat he was an Imperial physician of the Suidynasty in the Imperial Medical Academy,

" Lai, (n. 17), P. 28.Wong, (n. 20), p. 7.

FIG. 4. Ch'ao Yuan -fang, pathologist, who sug-gested that leprosy was caused by "worms." (Paintingby Johnny Shek, after a Hakim M. Said illustration)

that he was a native of Chang-an, Shensi,and lived in 550-630. 34 ' 35 An account ofleprosy is found in his book which states: 36

The disease of Ta Feng is caused byhaving absorbed water during perspi-ration; or when cold water has enteredthe muscles; of sleeping on wet groundafter drinking wine; or lying or sittingbeneath a tree or on wet grass whenthere is a draught; or having itchingsores that do not heal. [It is also statedthat fish without gills should not be eat-en because this will cause leprosy.]

3° Wong and Wu, (n. 6), pp. 83.35 Shanghai Chinese Medical School Traditional

Medicine Study Committee, Ku Tai I Ilsuch lienIlsuatz. [Selected topics from ancient Chinese medi-cine]. (Shanghai: Science and Technology Publisher,1980), p. 72 (in Chinese).

36 Ch'ao Yuan-fang, Ch'ao Shih Pin Yuan. [Chao'spathology]. In: Ch'ou Hsueh-hai, ed., Chu Bing YuanHon Lin. [Diagnosis of disease]. (Beijing: People'sHealth Publisher, 1955), Vol. 2, pp. 14-16. Repro-duction of 1891 Chinese text.

296^ International Journal of Leprosy^ 1985

All kinds of leprosy are the result ofevil pneuma. In the beginning the skinhas lost all sensation; gradually the pa-tient feels worms moving under his skin[formication]; then his vision becomesobscure. This disease should be treatedat its very beginning.

The symptoms of this disease in theearly beginnings are not noticeable, butif not treated in time the person mayfind himself unable to perspire, his fourlimbs ache, and his whole body tingles.If he scratches, sores may be formed.Or he may be unable to move his fourlimbs, his eyes swollen, his urine red-dish-yellow and his face pallid.

If the poisonous worms eat the per-son's liver his eyebrows will fall off, ifthey eat the lungs the bridge of his nosewill be deformed or little lumps of fleshwill grow in the nostrils thus causingdifficulty in breathing; when they eatthe spleen the voice becomes hoarse;when they consume the kidneys the earswill ring with drumming noises; if theydestroy the muscles the joints will bedislocated; when they attack the skinand flesh the patient will not feel pain.If the symptoms of the disease startfrom the head and face it is called theShun Fung ("With the wind"); if it startsin the feet it is called Ni Fung ("Againstthe wind").This description reflects the Chinese con-

cept of external relationships with the var-ious viscerae which is the basis of acu-puncture. It also presents the first statementof "worms" causing the disease. This con-cept may have been suggested by the pres-ence of formication which is not uncommonin leprosy and which was also noted by HuaT'o 26 and Ko Hung. 32 The microscope nothaving been invented, the germ theory ofdisease was unknown. For its time this wasa remarkably close approximation. The ba-cillus, or "microscopic worm," which is thecause of leprosy was not discovered until1873 by Hansen in Norway. The earliest ofthe microscopists was Athanasius Kircher(1602-1680) of Fulda, Germany, who wasprobably the first to employ the microscopein investigating the causes of disease. Inter-estingly, it is said that he found that theblood of plague patients was filled with a

countless brood of "worms" not perceptibleto the naked eye. 37

Sun Sze - trio (581-682) was a native fromthe southeast of the present Yao Hsien,Shensi. He authored the Pei Chi Chien ChinYao Fang (627) ("Thousand Golden Rem-edies for Emergencies") which is a generalencyclopedia of medicine in 30 volumes. Asupplement, the Ch'ien Chin I Fang inwhich are several chapters on incantationand magic, was written 30 years later. Healso wrote of "worms" causing leprosy,quoting Chao Yuan -fang. The twenty-thirdvolume of the original set contains one essaywith ten prescriptions and the supplementhas seven short discussions with eleven pre-scriptions. Wong's 38 literal translation of aportion of one of the essays follows.

There are several varieties of leprosyand the symptoms in each case vary.In some varieties the eyebrows andbeard drop off and there may be noother signs. Others have sores all overthe body and yet the eyebrows andbeard remain intact. Some look likenormal people but the extremities andback have indurated spots. In severecases the fingers and toes drop off. Somehave violent chills; heavy clothing willnot make them warm. Some have slightfever and are afraid of cold. In somethe body may be dry and wrinkled,while in others there is incessant sweat-ing and copious secretions. Some feelintense suffering night and day, whileothers are so numb that they cannot feelanything.

The color also varies with differentpersons. Some are green, others yellow,purple, white, black, shiny and dull. Al-though the symptoms are different, theresults of treatment depend more onthe patient than on the doctor. For oncea person contracts the disease, be heclever or stupid, it is very difficult tomake them understand. Invariably, theywill refuse to take the doctor's full ad-vice, but rather pin their hope on drugsalone. Therefore, I say that the prog-

" Fielding H. Garrison, An introduction to the his-tory of medicine. (Philadelphia, 1929), p. 252.

38 Wong K. Chi-min, "Sun SZ11-1770, the first Chineseleprologist," Leper Quart., 1939, 13, 66-74, p. 70.

53, 2^ Editorials^ 297

nosis depends rather on the patienthimself and not on his treatment. I havetreated more than 600 cases, with onlyten percent cures. And all these curedcases I nursed personally. So whentreating such patients it is necessary togive the most explicit directions. If theydecline to listen to advice, it is betterto refuse to treat them, for in the longrun the disease will be incurable and itwill be a waste of energy. 39

This author also indicated that persons whosuffer with leprosy (lepromatous) may notlive more than ten years and some die with-in five or six years.

Wang Tao, although not himself a phy-sician but an official, wrote the Wei Tai PiYao ("Medical Secrets of an Official"), pub-lished in 752, after diligent work at the HungWen Library where he had available severalthousand reference works. Many newly re-corded methods of treatment had been in-troduced as a result of influences from In-dia, but no significant new treatment wasavailable for leprosy. Wang Tao had no faithin acupuncture, holding that its techniqueshad been lost. Hence he omitted this fromthe treatments he recommended. Volume30 deals with leprosy and in it a well knownprescription repeated by the author wasmade up of Siao Shih (potassium nitrate)refined into medicine and mixed with ShengWu Ma You (raw black sesame oil). Beforetaking this medicine the patient should bemade to sweat in a warm room. 4°

In the Yiu Yang Miscellany, written byTuan Ching-shih of the T'ang dynasty (618-906), it is recorded that Tsui Chang-hsin, acousin of Li Shu, had leprosy. Li had nobeard or whiskers and people called him the"natural eunuch." One day Tsui said, jok-ingly, to Li, "I'll teach you how to raise abeard. Just bore some holes in your lip andplant them with hairs." "A good prescrip-tion," replied Li. "Try this on your eye-

" Sun Sze-mo, Pei Chi Ch'ien Chin Yao Fang.[Thousand golden remedies for emergencies]. (Beijing:People's Health Publisher, 1955), Vol. 23, p. 427. Re-production of Northern Sung dynasty (1123) Chinesetext.

4° Wang Tao, Wei Tai Pi Yao Fang. [Medical secretsof an official]. In: Wang Yun-wu, (n. 2), 1974, Vol. 30,p. 61. Photocopy of Chinese Tang dynasty (618-906)text.

brows first and when I see the results I willfollow your example." Both men lived inthe Northern Chi (479-501) period. 41

Finally, there lived in the latter part ofthe T'angdynasty one of the four great beau-ties of Chinese history. Yang Kuei-fei(Kuei-fei = Precious Consort) was cooptedinto the harem of Emperor Hsuan Tsungfrom the harem of his eighteenth son in 745,when the emperor was about 60 and sheabout 26 years old. He fell completely underher influence and she encouraged him in alife of extravagance and pleasure, leading tothe neglect of his imperial duties. An Lu-shan, who had risen to power by repressingsome of the raids of the Khitans and hadbecome a favorite of the Emperor and YangKuei-fei, organized a revolt in the northeastand obtained mastery of the country northof the Yellow River. He proclaimed himselfEmperor and Hsuan Tsung was compelledto flee from Changan to Szechuan. On 13July 756, a small imperial cortege with atroop escort secretly abandoned the cityahead of the victorious rebel army and ar-rived at Ma-wei on the second day. TheEmperor's troops demanded the death ofYang Kuei-fei, being under the apprehen-sion that she was causing Hsuan Tsung toneglect affairs of state. The Emperor grantedher wish that she be strangled before aBuddhist chapel. Her death put an end tothe troop insurrection and the soldiers, afterviewing her corpse, swore eternal allegianceto the T'ang dynasty. 42

However, in the folklore of South China,leprosy opprobrium has the effect of chang-ing the ending of the account. There it iscommonly said that, as the flight continued,the soldiers wre enamored by the beautifulbody of Yang Kuei-fei lying by the roadsideand had sexual congress with it. All who didso are said to have developed leprosy andthis is said to be the origin of this disease."

Treatment by segregationThe account of Pai Nizt suggests that seg-

regation, probably because of disfigure-

41 Wong, (n. 20), p. 7.42 Howard S. Levy, Harem favorites of an illustrious

celestial (Taichung, Taiwan, 1958), pp. 116-121.43 0. K. Skinsnes, "Leprosy in society. I. Leprosy

has appeared on the face," Lepr. Rev., 1964, 35, 21-35, p. 23.

298^ International Journal of Leprosy^ 1985

ment, was practiced at the time of Confu-cius—perhaps not generally but at leastselectively for important personages.

In the period of the "Three Kingdoms,"Twig Fang treated those living at Lu Shan,a famous mountain probably the one of thisname in Kiangsi.

In the Chin dynasty, Chao Ti was sent offto a mountain cave because of his illness,as was also the case with Lu Chao-lin of theT'ang dynasty, who was required to moveto the mountain Chu Tzu Shan, located inHonan, where there was a colony.

Narendryasas, Chinese name La-lin-ti-li-ye-sha, an Indian monk who died in Chinain 589, established Li-yen fang (houses forthose with leprosy), divided into male andfemale quarters, and provided the inmateswith adequate food. This was at Changan,Shensi, which was the capital of the Sari dy-nasty."

Sun Sze-mo, also from Shensi province,treated 600 patients. There must have beenavailable a concentration of a considerablenumber of patients, perhaps from the facil-ity established by Narendryasas. He record-ed that there were nearly 100 persons wholeft their earthly possessions to live asTaoists because they suffered from an evildisease." •

It is further recorded that the Buddhistmonk, Si Tsi-yen, who died in 654, went to"Stone City" (near the present Nanking, theancient name for which was "Stone City")to preach. He stayed in the homes of thosewho had leprosy, took care of the patients,washed their wounds, and did everythinghe could for them. He died in a leprosyhome, but it is not recorded whether or nothe had leprosy." Perhaps he was an unsungequivalent of Hawaii's Father Damien.

In a T'ang book, the Wu Chung Kee, itis recorded that as from the reign of EmpressWu-hau (684-704), Li Yen Fang (leprosyhomes) were cared for by monks. At thesame time, she also established governmentofficials to administer affairs concerningleprosy. During the Sung and Yuan dynas-ties there also were government officials ap-pointed to deal with leprosy problems."

44 Fan Hsian-chun, ("hung Kao Yu Fang I MuchSzu lIsian Shih. [Principles of the history of preventivemedicine in China]. (Beijing: People's Health Publish-er, 1955), p. 87 (in Chinese).

43 Lai, (n. 17), p. 40.

Then, also in the T'ang dynasty, at thetime of the famous general Kao Pien (died887), whose home was in Yangchow, thereis recorded the account of a Taoist who hadbeen sentenced to death for having set fireto several thousand houses. Kao Pien wasminister of Wei Yang (presently Yangchow).The culprit said to the executioner, "I havea little knowledge which may be beneficialto the people. If this could be handed downI would face death without regret." Hearingthis, Kao Pien personally came to make in-quiries. The culprit said, "I have no otherknowledge than the skill to cure leprosy."When asked how he could prove this hereplied, "I could try my skill on one of themost serious sufferers from leprosy at FitTien Yuan." The account does not indicatewhether or not he was successful. Its im-portance lies in the fact that the Chinesecharacters for Fit Tien Yuan refer to therough garments worn by Buddhist monks,raising the supposition that this referred toa charitable Buddhist home of that name,probably located near Yangchow, whereleprosy patients were cared for."

Chien Chen (Japanese: Kanjin;Pinyin: Jianzhen)

The famous monk Chien Chen (688-763)made five unsuccessful attempts to reachJapan from his home in Yangchow afterhaving been invited by the Japanese monksEiei and Fusyo. On his sixth successful voy-age he became blind, perhaps from closedangle glaucoma. 47 While in Yangchow hewas widely known for his charitable worksin caring for the poor. While in Nara, Japan,he was medical consultant to the EmpressKotnyo whose tragic life led her to have amajor interest in the care of leprosy pa-tients. 48 He spent ten years in Japan andwrote many medical books. The Japaneseworshipped Kanjin as the ancestor of med-icine. With Ko Hung having worked earlierin Kiangsu, with the record of a leprosarium

" Ming Chiang-kuan, Ming I Lui All. [Famous phy-sicians' medical records]. In: Wang Yun-wu, (n. 2),1976, Vol. 9, p. 47. Photocopy of Ming dynasty (1549)Chinese text.

' Chen Yao-zhen (Eugene Chan), "The courageousand brilliant blind monk Jianshen," Chinese Med. J.,1980, 93, 130-133.

" 0. K. Skinsnes, "History, art and a congress meetin Tokyo," Int. J. Lepr. 1972, 40, 306-309.

53,2 299Editorials

located in the Nanking District (nearYangchow) and with the record of a Fu TienYuan being in Yangchow, which was hishome, and finally with his association withEmpress Kotnyo, it would be surprising ifthis humanitarian monk was not involvedin leprosy work. Thus far, however, no rec-ords have been found of such work.

Summary through the T'ang DynastyIn the absence of specific information re-

garding the distribution of leprosy in China,it is possible to make a determination onthe basis of where the evidence of leprosywas found, on the residences of the physi-cian who wrote of the disease, and on therecorded location of leprosy asylums. Thishas been done in Figure 5. It is evident thatleprosy was prevalent in the area where theChinese empire first developed since that iswhere the records were made. There are norecords as to the presence or absence of lep-rosy in the areas regarded as underdevel-oped, although the presence of leprosy inthe southwestern, southern, and southeast-ern parts of the country is generally regardedas having occurred early due to commercebetween these areas and southwest Asia. Itis, however, of interest that the area of therecorded prevalence in these ancient timesis, for the most part, the area of relativeabsence of leprosy in later times.

Table 2 demonstrates the early develop-ment of diagnostic observations for leprosy.It is evident that the clinical characteristicsof leprosy were recognized in the earliestrecords.

Use of chaulmoogra oil in ChinaChaulmoogra oil is obtained from the seed

of the Hydnocarpus tree which is native toThailand. It is also common in Cambodia,Malaysia, Assam, the Indian Archipelago,and other parts of eastern India. Chaul-moogra is the Indian vernacular for the drug.The Burmese call it Kalaw, in Thailand, itis known as Lentam; and in China it isknown as Ta Feng Tzu. 49 It was probablyintroduced into China in the Southern Sungperiod (1127-1278). Ta Feng Tzu refers tothe seeds and Ta Feng Yao to the oil.

Chau Ta-kuan, after a trip to Cambodiatogether with the Chinese Ambassador in

FIG. 5. Pre-Sung dynasty distribution of leprosy inChina based on available records. (Painting by JohnnyShek)

1295-1297, described the fruit in his ChenLai Chi ("Diary of Cambodia") as beingshaped like a coconut and having a seed thatis white when fresh but turning yellow as itbecomes stale and useless as a medicine. 5 °Chu Chen-heng (1281-1358; alias Chu Tan-chi or Tan-chi) in his Tan Chi Chuan Yao("Tan Chi's Collected Important Records")was the first to record the use of the oil andstated that many herbalists often used TaFeng Tzu oil in their prescriptions, but sincethey were not aware that the nature of theoil is very hot and it is very harmful to theblood, many patients became blind justwhen the disease was beginning to get bet-ter." Hsueh Li-chars (1488-1558) Lei YangChi Yao ("Confidential Text Regarding Ma-lign Ulcers"), written in the Ming dynasty,indicated that Ta Feng Tzu was used in thetreatment of all kinds of sores; 51 while MiaoHsi-yung (died 1627, alias Miao Chung-chuan), native of Changshu, Kiangsu, in hisPen Ts'ao Ching Shit ("Simplified Herbal

s° Ts'u Ilai. [Chinese encyclopedia]. (Shanghai: En-cyclopedia Publisher, 1979), p. 459.

5 ' Lai, (n. 17), pp. 66-67.39 Wong and Wu, (n. 6), pp. 114-115.

300^ International Journal of Leprosy^ 1985

TABLE 2. Signs and symptoms of leprosy recognized in China throughout the T'angdynasty.

Text"), also indicated that the drug was usedfor leprosy, ringworm and all kinds of sores.It also noted that Ta Feng Tzu had a "bittertaste and its nature is hot and poisonous." 52

52 Chou Tze - lin, Pen Ts'ao Yung Fa Yen Choi. [Ap-plications of the great herbal]. (Shanghai: China BookCompany, 1951), pp. 932-933.

Li Shih-chen (1518-1593) stated in thePen-Ts'ao Kang-inu ("The Great Herbal"),that the chaulmoogra fruit could be foundin Hainan Island. This work describes thepreparation of Ta Feng Yao as follows:

Take three catties of the seeds, dis-card those that have turned yellow, re-

53,2^ Editorials^ 301

move the husks and grind into a linepowder. Pack in earthenware jar andseal up tightly. Put the jar into a pot ofboiling water and seal the pot so thatno steam can escape. Boil until the oilassumes a black and tar-like appear-ance. It is administered in the followingway:

Chaulmoogra oil 1 ounceSaphoro flavescens 3 ouncesMix into a paste with wine and make

into pills the size of a stercula seed.Sig: Take 50 pills with hot wine be-

fore meals."' 54

Developments from the Sung through theCh'ing Dynasties (907-1911)

Much of the writing related to leprosyduring this period was concerned with treat-ment or with largely repetitious statementsof prior descriptions of this disease. Thelarge number of prescriptions tried will notbe reviewed since none of them have provento be of significant value. There were. how-ever, a number of reports of changing ideasor reports which represent the thinking dur-ing this period.

A hint of opprobrium is contained in thefollowing account. Liu Pan was a poet andhumorist, and a friend of the famous poetSu Tung-po (1037-1101) of the Sung dy-nasty. His eyebrows and whiskers had fallenoff and his nose had collapsed. One day hedined with Su Tung-po and other friends.Everyone had to quote a humorous passagefrom the classics so Su Tung-po plagiarizeda familiar poem, substituting a few char-acters so it read, "Oh! the great wind: theeyebrows flown. Where to find a strong manto guard my nose!" The crowd roared withlaughter, to Liu's annoyance. His legs alsowere affected and he had difficulty in walk-ing."

Chen Yen, in his San Yin Fang ("ThreeDiagnostic Principles," 1174), held that alldiseases resulted from one of three causes:a) external causes, b) internal causes, and c)neither external nor internal causes. Lep-rosy was held to be in the third category and

" Wong and Wu, (n. 6), p. 211." Li Shi h-chen, Pen Ts'ao Kang Mu. [The great her-

bal]. (Shanghai: Commercial Press, 1930), Book 5, Vol.35, p. 68. Reproduction of original Chinese text of1578.

55 Wong, (n. 20), p. 9.

Chan Yen was the first to suggest that it isan infectious disease."

Chang Chung-cheng, also known asChang Tse-ho, was a skillful physician, anative of Honan province who lived in1156-1228, and recorded the case of a pa-tient.

Chang Tzu-pe had been sufferingfrom leprosy for more than ten years.His hair and eve-brows had all fallenoff and his skin was hard and dry likethe bark of a tree. He was put in a blaz-ing hot room and an herbal, Et: ShengSan, administered. The patient sweat-ed as if he were floating in water. Theperspiration was sticky and had an aw-ful, stinking smell. His sputum smelledlike the saliva of fish and there was per-spiration under his two feet. He wasthen given two other herbals severaltimes and was cured."

Chu C'heii-heng (1281-1358), a native ofChing Hua Hsien, Chekiang, who traveledin Kiangsu and Anhui, was also known asChu Tan Chi or Tan Chi, as noted above.In his Pen Ts 'ao Yien I Pit I ("Revision ofthe Great Herbal"), written during the Mon-gol Yuan dynasty, he utilized a "Five deaths"classification for leprosy: a) skin death, whenthe skin is numb and senseless; b) pulsedeath, when blood may form pus; c) fleshdeath, when the flesh is without pain whencut; d) muscle death, when the four limbsare without strength; and e) bone death,when the nasal bridge is flattened. If any ofthese "deaths" is found, the disease cannotbe cured." Possibly, "cure" in these in-stances meant restoration to normal. He firstrecorded the use of chaulmoogra oil but dis-approved of its use because of the irritatingeffect of the stomach."

With the Ming dynasty (1368-1643), thetempo of contact with the West began tospeed up, but the medical literature showsno significant Western influence and con-

" Chen Yen, San Yin Fang. [Three diagnostic prin-ciples]. In: Wang Yun-wu, (n. 2), 1973, Vol. 15, p. 22.Photocopy of Ching dynasty (1775) text.

37 Chang Chung-cheng, Yu Men Tzu Chin. [Medicalcare of patients]. In: Wang Yun-wu, (n. 2), 1978, Vol.6, p. 5. Photocopy of Ming (1■. nasty (1541) Chinese textedited by Shao Fu from 1228 original copy by ChangChung-cheng.

" Lai, (n. 17), pp. 47-48.

302^ International Journal of Leprosy^ 1985

cepts concerning leprosy did not change sig-nificantly. The area of China firmly underthe control of the central government hadexpanded greatly.

Hsueh Li Chai, alias Hsueh Chi, was anImperial physician during the reign of ChengTe (1506-1521). The Much Shi I An (com-pleted in 1554) is his collection of worksincluding surgery, medicine, obstetrics, pe-diatrics, etc. One set of three volumes is theLei Yang Chi Yao ("Confidential Text Re-garding Malign Ulcers"), which has a chap-ter on "treatment of leprosy." Hsueh Li Chaiwrote that "Lepers are found mostly inHonan, Fukien and Kwangtung." He notedthat chaulmoogra oil was an importantmedicine for treating all kinds of sores.

Hsueh Li Chai noted that leprosy doesnot only infect one organ but by the bloodcirculation may cause secondary infectionsin other viscerae (bacillemia?). It may takemany years for the lesions to appear. Beforetreatment good nourishment should be pro-vided so as to build up the health of thepatient.

I fan accumulation of bad blood is noticedin the skin it should be bled with a stoneprobe (an arrowhead-like instrument), whilefor infections of internal organs laxativesshould be used. For lesions chiefly in theupper trunk, the interphalangeal spaces andcubital areas might be bled or the "DrunkenGoddess Powder" used to drive the con-taminated blood from between the toothspaces. For lesions on the lower trunk, thestone probe was used in the intertarsal spacesand "reconstructed powder" was taken tolet the "worms" pass out through the diges-tive system. Bleeding should be done onceor twice daily until fresh blood flow is ob-tained.

He noted that mercury powder was com-monly used in leprosy treatment. However,a number of side effects occurred, such asstomach pain and diarrhea with dischargeof large amounts of mucosubstances in thefeces, pain and swelling of the tongue andmouth with increased secretion of saliva ac-companied by thirst, bleeding from themouth with fever and constipation, ex-haustion of salivary flow with tongue andmouth still uncomfortable and with con-tinuing thirst. For each of these complica-tions a remedy was provided. Imbalance ofthe pneuma will cause the "worms" to grow

in the internal organs and then break throughto the body surface.

The causes of nonresponding cases weregiven as: a) improper nutrition and exercise,b) injury to internal organs by secondaryinfection, c) loss of blood through over-treatment, and d) failure to follow the doc-tor's instructions, or refusal to take medi-cine. The causes of relapse are noted as: a)failure to control the diet, b) failure to con-trol sexual activities, c) failure to controltemper and emotions, d) a residue of toxicpneuma causing secondary infection, and e)imbalance in the "six airs," e.g., wind, cold,heat, wetness, dryness, and fire. 59

The Tung I Pao Chien ("Eastern MedicalTreasury"), compiled by Imperial physi-cians of the Ming dynasty, relates threecauses of leprosy, namely: a) the "luck" ofthe place (Feng-shut), e.g., a grave or a housewhich brings bad luck, b) direct transmis-sion of infection from parents, husband,wife, or other members of the family, andc) infective fomites, such as are associatedwith public lavatories, bedding, and cloth-ing. 60

The Ch'ing dynasty (1644-1911) pro-duced a tremendous volume of medical lit-erature including extensive compendiumswith medical subsections such as the K'uChin T'u Shu Chi Cheng ("Library Collec-tions, Ancient and Modern"). This work,printed in 1726, consisted of 5000 volumesand contained three times as much materialas the Encyclopedia Britannica of the1930s. 6 ' This period was, nevertheless, atime of decline in indigenous medical prac-tices. Thus, while there were medical schoolsthroughout the empire in T'ang and Sungtimes, there now existed only the ImperialCollege of Physicians in Peking which con-cerned itself with the training of physiciansfor the Imperial family. There being no su-pervision or licensure of the profession, vir-tually anyone who would spend a short timeperusing some medical work, or who in-herited a few medical prescriptions, could

59 Shanghai Traditional Medicine Study Committee,(n. 35), pp. 165-168.

6° Hsu Tsun, Tung I Pao Chien. [Eastern medicaltreasury]. (Seoul, Korea: Nan Shang Tang Book Com-pany, 1976), pp. 556-557. Reproduction of Ching dy-nasty (1766) text in Chinese.

61 Wong and Wu, (n. 6), p. 169.

53,2^ Editorials^ 303

set up practice. The better trained practi-tioners obtained their knowledge by servingas apprentices to established physicians, andthere was a strong tendency to keep medicalobservations and successful treatments assecrets within the clan. The most favoredpractitioners were those with the longestfamily history in the art.''' There were, ofcourse, physicians who wrote their ownworks.

Under these conditions there was littleopportunity for significant medical ad-vances and the concepts regarding leprosyshowed little change from those of preced-ing times. A complete review of the writingsof this period is not feasible but a few ref-erences will illustrate the continuing threadof thought respecting leprosy.

Hitherto medical writers invariably com-piled from the works of ancient writers, nev-er daring to correct the errors or criticizethe teachings of the old masters. As a par-allel it is recalled that "Up to the time ofVesalius (1514-1564), European medicinewas one vast argumentatum ad hominemin which everything relating to anatomy andphysiology, as well as disease, was referredback to Galen as the final authority fromwhom there could be no appeal. After hisdeath, European medicine remained at adead level for nearly fourteen centuries.""

Yu Chang had the rare courage to expresshis own opinions freely, a characteristic notevident, however, in his brief statement re-garding leprosy. He was a native of HsienChien, Kiangsi, but made his career inCh'ang-shu, Kiangsu. He died at the age of80 in about 1690 and was buried at Nan-chang, Kiangsi, where his grave was still tobe seen in the 1930s just outside the city bythe side of Lu Tso's temple."

Yu Chang (1585-1664) in the I Men FaLu ("Standard Methods in Medicine") dis-cussed three treatments for leprosy. The firstrecommended was chaulmoogra oil as beingbest for killing the leprosy "worms." Thesecond was the "Drunken Goddess Pow-der" consisting of a 1.5 ounce mixture ofseven herbs together with 0.2 ounce of mer-curic chloride. However, he stated that if

62 Wong and Wu, (n. 6), pp. 141-143.6' Garrison, (n. 37), p. 113.64 Wong and Nu, (n. 6), p. 147.

this was taken internally it would cause theteeth to fall out before the leprosy was cured.The third method consisted of sulfur elixirin wine, of which he wrote, "Its taking willcause the head to burst!" All medicines forthe treatment of leprosy must be taken inappropriate dosage. If too little the diseasewill not be cured; if too much, the diseasemay be cured but the overdose effect maybe more harmful to the body than the dis-ease."

In the fourth year (1740) of the reign ofEmperor Ch'ien Lung, 80 writers under theImperial physicians Wagt Ping and WuChien began the compilation of the I TsungChin Chien ("Golden Mirror of Medi-cine"), which was issued in 1749. It consistsof two major sections, one on internal med-icine and the second on general surgery. Thework is predominantly a compilation of ex-tracts, revisions, corrections, and summa-ries of earlier medical writings and was ac-cepted as a standard authoritative work onChinese medicine." It lists three causes ofleprosy: a) climate of areas too thickly pop-ulated, b) direct infection from persons withleprosy, or filthy conditions of public lav-atories and houses, and uncleanness of bed-ding and clothing, and c) neglect of personalhealth such as catching cold while bathing,sleeping in the open air or on wet groundso that poisonous air (mal-air) could enterthe body!'

There were individual physicians writingwho had fresh ideas. Two of these were SiaoHsiao-ting and Ku Shih-cheng. Siao Hsiao-ling was a native of Chian, Kiangsi, whosebook the Fling Man Tsuan Shu ("Hand-book of Leprosy")" was completed in thesummer of 1796, but was not published un-til 1845. It is not known where he practiced.During the interval between its writing andpublication, it accumulated five prefaces bywould-be publishers. The third of these,written in 1832, notes that during the time

65 Yu Chang, I Men Fa Lu. [Standard methods inmedicine]. In: Wang Yun-wu, (n. 2), 1971, Vol. 5, pp.29-30. Photocopy of Ching dynasty (1781) Chinesetext.

66 Wong and Wu, (n. 6), p. 172.6I (n. 17), p. 59..

Siao Hsiao-ting, "'zing Man Tsuan Shu. [Hand-book of leprosy]. (Shanghai: Health and Science Tech-nology Publisher, 1959), pp. 3-4. Reproduction ofCh'ing dynasty (1845) Chinese text.

304^ International Journal of Leprosy^ 1985

of the Emperors Ch'ien Lung (1736-1796)and Chia Ching (1796-1820) leprosy wasrarely seen in Kiangsi province but "now-adays (1845) we can find it among villagershere and there within a circumference offive to ten miles." It has been noted in Fig-ure 5 that there were no records of leprosyin Kiangsi, save for the refuge at Lu Shan.Lu Shan, however, was just across theYangtze River and probably was an outpostreceiving persons having leprosy from theNorth. If this be so, then it suggests thespread of the disease to a new area of lowresistance, much as was the experience ofHawaii at about the same time, and a littlelater for Nauru. In the fifth preface it is not-ed that:

Ilo Sze -ch'ing of Kwangtung, whowas a publisher and also interested inmedicine, after carefully reading thisbook was surprised at such a wonder-fully detailed book. Since he knew therewere many leprosy patients in Kwang-tung, he rapidly put it into print in largenumbers. While editing the book intoa simplified and clearly understandableform, he cured a family of three whohad leprosy.

Siao's concept of the contagiousness ofleprosy is given by his statement, "Do notshare the same utensils, do not eat togetherand use separate beds." He also proposed aclassification of 36 types of leprosy and lep-rosy-like conditions. This can be regardedas an early attempt at differential diagnosis.Figure 6 reproduces some of his illustra-tions. Numbers 1,2,10,13-17,19, and 36he called true leprosy, and most of theseinvolving loss of eyebrows and widespreadnodularity suggested that the lepromatousform of the disease was the type concerned.Indeed, this has been the case with all thereferences reviewed. It seems that it was thelepromatous type that was the source of theopprobrium noted. This is consonant withthe general public reaction up to the presentwhere there is little fear expressed of thetuberculoid variety unless markedly de-formed. In those classified as leprosy-like,there are descriptions, notably number 18,which may well have represented tubercu-loid leprosy, or as it was then known in theWest, neural leprosy. This was termed"chicken claw feng." Its description reads,

"Because of many years of illness, blooddoes not flow efficiently. There is loss ofsensation and all the fingers are curled likea chicken claw.""

Ku Shih -cheng's family had been in-volved in the practice of medicine for threegenerations when he completed the Yang ITa Tsuan ("Complete Treatise on Ulcera-tive Disease"). It comprised 40 volumes,one of which was devoted to leprosy, andit was completed in 1760, also during thereign of Ch'ien Lung. In this work he de-clares that leprosy does not manifest itselfin some people until middle age, but that itdoes occur in adolescence and, in some, ap-pears as early as in infancy. It was opinedthat when the disease becomes manifestduring middle age its cause is probably dueto over-indulgence in sexual congress thusleaving the body weak and without resis-tance to disease. When leprosy appears inadolescence it does so because the body isnot fully developed and negligence on thepart of the parents with respect to the child'shealth makes the body further susceptibleto disease. Once leprosy develops in suchan adolescent it progresses so rapidly thatonly four or five out of 100 afflicted willsurvive. When the disease occurs in a childfour or five years of age, it is even worse forthen it is congenital and entirely the faultof the parents:7°

Summary through the Ch'ing Dynasty

Thus, by the reigns of Emperors ChiaChing (1796-1820) and Tao Kuang (1821-1850), the diagnosis of lepromatous leprosyhad long been firmly established and therewas more than a hint of recognition of tu-berculoid disease. Leprosy was regarded asa systemic disease rather than an afflictioninvolving only skin and nerves for, as HuaT'o wrote, "The symptoms first appear onthe skin but the poison is actually stored inthe internal organs." Chaulmoogra oil andmany other treatments were in use. Therewas a recognition and constant reiterationof the value of good nutrition and promo-tion of good health, and there were claimsof cure, approximating ten percent. Leprosywas recognized as being contagious, and the

69 Siao, (n. 68), pp. 8-20.70 Lai, (n. 17), p. 60.

53,2^

Editorials^ 305

FIG. 6. Selected illustrations of leprosy from Siao Ilsiao - ting."

significance of contaminated clothes, bed-ding, and other agencies in its transmissionwas noted. There was speculation that thedisease was caused by "worms" and that itcould spread from organ to organ (fore-shadowing concepts of "germs" and "ba-cillemia"?). It was recognized that lepro-matous patients tended to live five or sixyears, sometimes ten, after contracting thedisease. There was a recognition of child-hood susceptibility in terms of childhoodlack of development of resistance. The con-cept also appeared that the childhood dis-ease is congenital. This concept that leprosyhas a congenital basis was also widely heldin European medicine at about this time.Danielssen (1815-1894) in Norway was oneof its chief exponents. It would be left toHansen (1841-1912) also of Norway, to ex-plode this idea for both the West and theEast.

From the earliest records, leprosy was as-sociated with fear and opprobrium center-ing chiefly around the thought that it wasrelated to sexual excesses, supported by itsmutilating effects and by the belief that itwas hereditary and largely incurable. How-

ever, as far as has been determined therewas no significant body of nonmedical lit-erature, in terms of novels, poetry or art,related to the disease, as there was in theOccident. 7 ' Thus, we arc unable to repro-duce a single Chinese or Japanese art rep-resentation of leprosy as is so extensivelyseen in Western churches.''

It was as if the world of leprosy was poisedfor significant discoveries that would followon the discovery of the method of discoveryitself and lead to means of eradicating theage's long plague. There followed four sig-nificant findings that would permit the erad-ication of the disease. These were: the un-derstanding of the disease that followed onthe work of Danielssen and Boeck, Hansen'sdiscovery of the leprosy bacillus, the dis-covery of the value of segregation in con-trolling the disease as demonstrated in Nor-

7 ' 0. K. Skinsnes and Robert M. Elvolve, "Leprosyin society. V. 'Leprosy' in occidental literature," Int.J. Lepr., 1970, 38, 294-307.

7 ' William B. Ober, "Can the leper change his spots?The iconography of leprosy," (Parts I and 11), Am. J.Dermatopathol., 1983, 5, 43-58, 173-186.

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306^ International Journal of Leprosy^ 1985

FIG. 7. Leprosaria in China, 1948. (Map by Johnny Shek)

way and Hawaii, and the discovery ofdefinitive treatment by Faget in 1943. Tothese must be added the present rise in stan-dards of living in many parts of the world,including China, which was foreshadowedby the Chinese emphasis on good nutrition.

The Twentieth CenturyThe Twentieth Century brought an influx

of developing Western concepts, withoutspecific therapy until the middle of the cen-tury, although in Hawaii the esterificationof chaulmoogra oil made this agent muchmore effective. These were reflected in the"China Medical Journal" and in "The Lep-er Quarterly," which was the official organof the Chinese Mission to Lepers foundedin 1927." No effective or coherent govern-

" T. C. Wong, "The Chinese mission to lepers,"China Med. J., 1930, 44, 746-748.

mental leprosy eradication program was de-veloped and most leprosy work was still inthe hands of charitable organizations. Max-well, in 1937, published the book Leprosy.A Practical Textbook for Use in China74 inwhich he estimated that there were perhaps300,000 cases of overt, recognizable leprosyin the country. He concluded that if therewere added to this number those early caseswhich did not have evident stigmata of lep-rosy and which often healed without treat-ment the figure might then rise to about onemillion. This figure of one million casescame to be the accepted estimate for work-ers in the area, but a little noted over-esti-mate of 2,279,000 75 has tacitly been official

74 James L. Maxwell, Leprosy. A practical textbookfor use in China. (Shanghai, 1937), pp. 4-5.

" L. M. Bechelli and V. M. Dominguez, "The lep-rosy problem in the world," Bull. 11'110, 1966, 34,811-826.

53,2^ Editorials^ 307

in the subsequent reports of the WHO Ex-pert Committees on Leprosy.

In 1948, there were 40 foreign-mission-sponsored leprosaria with 2394 beds in allof China (Fig. 7). 76 Additionally, there wasa 100-bed teaching National Leprosariumin Shanghai, and a 900-bed leprosarium inTaiwan which was built by the Japanesegovernment. Their distribution reflects thedistribution, although not the prevalence,of leprosy. In the early 1950s, with the de-velopment of the "barefoot doctor" system,leprosy surveys became feasible under gov-ernment auspices, and it was concluded thatthere were 500,000-600,000 leprosy caseson the mainland. Approximately 800 lepro-saria with a bed capacity of about 80,000were set up, and multibacillary patients wererequired to be hospitalized. The staffs wererequired to wear caps, masks, gowns, gloves,and knee-high boots; a policy said to havebeen derived from the Russian plague ex-perience. The policy of segregation of mul-tibacillary cases together with predominanttherapy by diaminodiphenyl sulfone (dap-sone, DDS), served to markedly decreasethe prevalence of leprosy. Experience hasshown that the isolation works unnecessaryhardships on the patients separated fromtheir families, and the current trend is to-

76 Wong K. Chi-min and W. S. Flowers. Directoryof Christian work and prayer cycle. (Shanghai, 1948),pp. 20-22.

ward outpatient treatment now that the to-tal prevalence has dropped to less than200,000. The essential eradication of new,active infectious leprosy by the year 2000is anticipated. 77 If this can be achieved, itwill bring an end to the 2500-year historyof China's recorded experience with lepro-sy, and it will have been accomplished inabout 50 years by the application of theessentially simple concepts of segregation,treatment, and a rising standard of living 78

which have, however, not been simple intheir achievement. There will remain for anindefinite period the problem of the reha-bilitative care of those who have had lep-rosy and the probability of smoldering fociof the disease due to ineffective treatment.

—Olaf K. Skinsnes, M.D., Ph.D.—Peter H. C. Chang, R.M.T.

Department of PathologyJohn A. Burns School of MedicineUniversity of Hawaii at ManoaHonolulu, Hawaii 96816, U.S.A.

Acknowledgments. Mr. Johnny Shek prepared Fig-ures 1, 4, 5, and 7. Mrs. Paul Yap translated referencenumber 17. Miss Anwei Skinsnes prepared the severaldrafts of this paper.

7 ' Ma Haide (George Hatem) and Ye Gan-yun,"Leprosy work in China," Lepr. Rev., 1982, 53, 81-84.

7 ' 0. K. Skinsnes, "The decline of leprosy in Asia,"Int. J. Dermatol., 1983, 22, 348-366.