CHAPTER IV
Leprosy
James A. Doull, M.D., Dr. P.H.
EPIDEMIOLOGY
The importance of leprosy as a military problem is limited by certain of its epidemiological characteristics. The most pertinent of these are geographic distribution, low prevalence rates even in areas in which the disease is considered to be highly endemic, and relatively low attack rates in adult life.
For practical purposes, leprosy may be considered a disease of the tropics and subtropics. Rogers and Muir1 emphasize that every country with high prevalence rates is situated within the tropics and that such tropical countries are inhabited mainly by backward people living in overcrowded huts under conditions favorable to the spread of the disease.
Every country with a very high leprosy rate, that is, 5 or more cases per 1,000 of the population, is situated within the tropics. In practically all, the climate is hot and damp. The tropical belt of Africa is considered to have the highest prevalence rate in the world. In the Belgian Congo, for example, there are over 60,000 patients under treatment, or about 6 patients per 1,000 of the population, and Rogers and Muir estimate a total prevalence of 20 per 1,000. In tropical Asia and Oceania, estimated rates are about 2 or 3 per 1,000 for Indonesia and the Philippines. Rates in French Oceania are estimated to be higher. In South America, estimated rates are highest in French Guiana (14.7), Dutch Guiana (6.75), Paraguay (4.4), Colombia (3.7), and British Guiana (3.0). Brazil and Venezuela have rates of between 1 and 2 per 1,000. Rogers and Muir point out that the northern and southern subtropical zones, from latitudes 23?30' to 35?, are widely infected with leprosy but have few areas with prevalence rates higher than 1 per 1,000. Important exceptions are parts of India, southern China, and southern Japan-areas with comparatively high rainfall. The estimated rates for India and Burma are between 3 and 4 per 1,000. The total number of cases in India and Burma probably exceeds 1,200,000 and constitutes perhaps one-third or one-fourth of the world's total cases.
Leprosy has the peculiar characteristic of occurring in "clusters" rather than being evenly spread. In the Philippines , the Bureau of Health and the Leonard Wood Memorial (American Leprosy Foundation) have been carrying
1Rogers, Sir Leonard, and Muir, B.: Leprosy. 3d ed. Baltimore: Williams & Wilkins Co., 1946.
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on epidemiological studies2 for 20 years in selected localities in Cebu, which is considered to be the most heavily infected province of the Republic. In two areas of highest prevalence, where practically every inhabitant has been examined on at least two occasions, the prevalence rate has been found to be slightly under 20 per 1,000. A mitigating factor in these areas is that the lepromatous type, which is chiefly responsible for spread of the disease, constitutes less than one-half of the total. In India and certain other parts of the world, the lepromatous type constitutes an even lower proportion of total leprosy. In the United States, most of the patients suffer from the lepromatous type (fig. 2).
The only known sources of leprosy are persons suffering from the disease. The chance of encountering such sources in the general population is manifestly quite low even in areas of high prevalence. Military interest centers chiefly on the chance of contact with persons with the lepromatous type, and it is improbable that many more than 1 person in 100 is affected with this type in any country in the world.
2( 1 ) Doull, J. A., Guinto, R. S., Rodriguez, J. N., and Bancroft. H.: The Incidence of Leprosy in Cordova and Talisay, Cebu, P.I. Internat. J. Leprosy 10: 107-131, December 1942. (2) Guinto, R. S., Doull, J. A., Bancroft, H., and Rodriguez, J. N.: A Field Study of Leprosy in Cordova, Philippines; Resurvey in 1941 After Eight Years. Internat. J. Leprosy 19 : 117-135, April-June 1951.
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So little is known regarding susceptibility to leprosy of various age groups that broad generalizations on the subject should not be made. In countries in which the disease is endemic, the infection is usually contracted in childhood. In the Philippine studies referred to, it was found that for total leprosy the incidence rate, as distinguished from the prevalence rate, reached its peak at ages 10 to 14, when it was 3.7 per 1,000 per year, that at ages 20 to 29 the rate was 2.0, and that at ages 30 to 50 it was about 1.0.
LEPROSY IN THE ARMY BEFORE WORLD WAR II
There are no records of leprosy occurring in the United States Army before the Spanish-American War. The Revolutionary War was fought in areas in which the disease was rare or absent. During the War of 1812, troops were engaged in New Orleans in the vicinity of an old endemic focus, but the number of men involved was small and the duration of the conflict short. If cases occurred either during or following the war, the incomplete medical records of the period do not mention them. The Mexican War of 1846 involved possible exposure of appreciable numbers of soldiers for about 2 years. Records are available in some detail, but leprosy is not mentioned as having occurred during the war or in the period which followed. Nevertheless, as Aycock and Gordon3 comment, the disease may well have occurred years later among veterans of the Mexican campaign and the association with military service may have been overlooked. The Civil War was fought chiefly in nonendemic areas; no cases of leprosy were reported.
The earliest records of leprosy in the armed services of the United States relate to cases in men who served in the Spanish-American War, the Boxer Rebellion, or the Philippine Insurrection. Actually, the cases did not occur during the hostilities; they were reported at intervals over several subsequent decades, and the onset dates are not known with exactness. One or perhaps two of the cases may have occurred as early as 1901, according to Aycock and Gordon. From 1921 to 1940, 32 veterans were admitted to the U.S. Marine Hospital, or National Leprosarium, at Carville, La. Of these, 28 had served in the Army, 3 in the Navy, and 1 in the Marines. Thirty patients had had military service outside the United States in places known to be focuses of leprosy; 25 of the 30 had served in the Philippines. There is no record of foreign service for two of the patients; one was born in Louisiana and the other in Texas. Five were born outside the continental United States; 19 were born in parts of the United States where the disease rarely occurs. For 18 of the latter, Aycock and Gordon state that the periods of service in endemic areas ranged from 9 months to 32 years. Hasseltine4 has emphasized the fact that a large portion of the Spanish-American War veterans who had been
3Aycock, W. L., and Gordon, J. E.: Leprosy in Veterans of American Wars. Am. J. Med. Sc. 214: 329-339. September 1947.
4Hasseltine, H. E.: Leprosy in Men Who Served in United States Military Service. Internat. J. Leprosy 8: 501-508, October-December 1940.
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admitted to the National Leprosarium were born in nonendemic areas and that the average age on admission of the entire group of Spanish-American War veterans was 52. The dates at which first signs of the disease are stated to have appeared ranged from 1901 to 1938, but, of 27 patients for whom dates are given, all except 4 are stated to have observed their first symptoms after 1910. It should be noted that a number of veterans who developed the disease had remained in the Philippines in military or civilian capacity for some years following termination of the war.
From 1921 to 1940, 51 World War I veterans were admitted to the National Leprosarium. Forty-one had service in the Army, one in the Students Training Corps, eight in the Navy, and one in the Marine Corps. Records show that 33 had no service outside the continental United States, 12 had served in France, 2 in Mexico, and 1 each in Hawaii, Panama, the Philippines, and Puerto Rico. There were 18 who had been born outside the continental United States, and, of the remaining 33, 15 had been born in Louisiana, 10 in Texas, 5 in Florida, 2 in Mississippi, and 1 in Georgia. None had been born in the Northern States. Age on admission to the Leprosarium averaged 33.2 years and ranged from a minimum of 22 to a maximum of 43 years. In 35 patients, or 68.6 percent, the first signs of the disease are said to have been noticed during the years 1917 to 1923, inclusive.
PREVENTIVE MEASURES DURING WORLD WAR II
Because of the lack of knowledge about the mode of spread of the disease and because there were no effective vaccines or chemical prophylactics, there was not much that the Preventive Medicine Service, Office of the Surgeon General, could do to provide protection against leprosy for troops and other military personnel. Dependence for protection had to be placed almost entirely upon recognition of the disease when it occurred and upon avoidance of contact. At the same time, measures were invoked to counteract the fears, the military and public alarm, and the dangers of irrational behavior that were aroused by age-old superstitions about the disease. The Preventive Medicine Service recognized that leprosy, because of its long latency and low incidence of adult infection, could not be a disease of military significance insofar as loss of manpower during World War II was concerned. It was recognized also that the area of exposure was vastly extended and that the number of possible contacts was increased by large multiples by the placing of thousands of U.S. soldiers among populations where incidence of leprosy was high, particularly in the Pacific regions. The late consequences of acquisition of leprosy during the war by soldiers exposed in the course of their service were also matters of grave concern. A balanced program designed to stimulate awareness of the disease and at the same time to support reasonable precautionary measures was adopted. The program of such preventive measures was carried out by the assembly and dissemination of information.
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The prevention of contact of military personnel with leprous persons within the service had been a longstanding practice, specified by Army regulations. Leprosy was a fixed basis for rejection of men coming up for induction through enlistment or draft. In spite of provisions for rejection on account of leprosy, the records, examined later, showed that 15 men infected with leprosy before 1941 were inducted into the Army during World War II. Of these, five were men who had been discharged from the National Leprosarium as "arrested cases." The other 10 men were from various parts of the United States and Hawaii and, at various periods after induction, were discovered to have leprosy (pp. 31-32). No secondary cases among military personnel are known to have arisen from these sources.
During 1942 and the first half of 1943, an increasingly close and mutually beneficial relationship developed between the Preventive Medicine Service and the Leonard Wood Memorial. The president of the Memorial, Mr. Perry Burgess, urged that a survey of the distribution of leprosy throughout the world be made and offered his personal services and the services of the Memorial. These offers were accepted. Mr. Burgess was appointed consultant to the Secretary of War. In the Preventive Medicine Service of the Office of the Surgeon General, the undertaking of assembling and issuing information was made a cooperative project of the Medical Intelligence Division, the Epidemiology Division, and the Commission on Tropical Diseases of the Army Epidemiological Board. The survey and collaborative work with the Leonard Wood Memorial were conducted chiefly through the Commission on Tropical Diseases. The official information was prepared for the Office of the Surgeon General by preventive medicine staff personnel in that office.
As a result of these studies and efforts, two important publications were issued. The first was Circular Letter No. 180, dated 30 October 1943, on the subject of leprosy, published by the Office of the Surgeon General for distribution to all medical officers. The product of many consultations, this circular letter presented in summary form the latest available knowledge about the disease-its prevalence, geographic distribution, recognition, differential diagnosis, etiological agent, source of infection, incubation period, communicability, susceptibility and immunity, and treatment and control. Regarding control, the following statement was made:
* * * Recognition of the early clinical manifestations is of the greatest importance with confirmation of diagnosis where possible by bacteriologic examination. Immediate segregation should be carried out. All cases in troops should be reported to The Surgeon General and held in isolation pending final disposition. Medical officers should make inquiry locally concerning the existence of highly endemic foci, and such areas should be avoided where possible. Military personnel should be excluded from any dwelling in which a leprous person lives or is known to have lived recently. In endemic areas all prospective native food handlers and personal attendants should be carefully inspected and if known or suspected of having leprosy should not be employed in handling food or rendering other personal service.
The information gathered and analyzed by the staff of the Leonard Wood Memorial was made available to the Preventive Medicine Service and was used
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in connection with military operations in areas in which leprosy was endemic. The final assembly, with data on geographic features, populations, leprosaria, and citations of specific publications, was arranged and edited by the author and was published by the Western Reserve University Press as a supplement to the December 1944 issue of the International Journal of Leprosy under the title, "World Wide Distribution and Prevalence of Leprosy."
INCIDENCE IN MILITARY PERSONNEL DURING AND SUBSEQUENT TO WORLD WAR II
Preliminary data for the Army indicate that 26 cases of leprosy occurred during the period 1942-45. Of these, 13 were in the United States and 13 overseas. The distribution by area is given in table 4.
TABLE 4.-Total cases of leprosy in the U.S. Army, by theater or area and year, 1942-451
Theater or area | 1942-45 | 1942 | 1943 | 1944 | 1945 |
Number | Number | Number | Number | Number | |
Continental United States | 13 | 4 | 7 | 1 | 1 |
Overseas |
|
|
|
|
|
| Europe | 1 | --- | --- | --- | 1 |
| Mediterranean | 2 | --- | --- | 2 | --- |
| Southwest Pacific | 1 | --- | --- | 1 | --- |
| Central and South Pacific | 8 | 5 | --- | 2 | 1 |
| Latin America | 1 | --- | --- | --- | 1 |
| Total overseas | 13 | 5 | --- | 5 | 3 |
| Total Army | 26 | 9 | 7 | 6 | 4 |
1The annual case rates per 1,000 average strength were all less than 0.005, with the following exceptions: The 1942 rate overseas was 0.01; the 1942 rate in the Central and South Pacific, 0.03; and the 1945 rate in Latin America, 0.01.
Efforts were made to obtain individual case histories of all patients in whom a diagnosis of leprosy was confirmed and who had served in any branch of the armed services of the United States. The author personally searched the records of the National Leprosarium, and additional data were provided by the president of the Board of Health of Hawaii and by the Secretary of Health of the Philippines. Doubtless there are some omissions. The total number of patients on record to 31 July 1951 was 69. Of these, 20 were diagnosed in the Army during the period 1942-45, as compared with 26 shown in table 4. The distribution of these 69 cases according to year of diagnosis and branch of the armed services is given in table 5.
It is not surprising, considering the rapid mobilization during the early years of World War II, that a few patients who had been discharged from the National Leprosarium in an arrested condition were inducted; nor was it sur-
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Year of diagnosis | Total | Army | Navy | Marine Corps | Coast Guard | ||
In service | After discharge | In service | After discharge | After discharge | After discharge | ||
| Number | Number | Number | Number | Number | Number | Number |
1942 | 6 | 5 | 1 | --- | --- | --- | --- |
1943 | 7 | 5 | 2 | --- | --- | --- | --- |
1944 | 9 | 6 | 3 | --- | --- | --- | --- |
1945 | 11 | 4 | 6 | --- | --- | --- | 1 |
1946 | 17 | --- | 5 | --- | 2 | --- | --- |
1947 | 9 | 2 | 4 | 1 | 1 | 1 | --- |
1948 | 6 | 2 | 4 | --- | --- | --- | --- |
1949 | 7 | 2 | 4 | --- | 1 | --- | --- |
1950 | 3 | --- | 2 | 1 | --- | --- | --- |
1951 | 4 | --- | 3 | --- | 1 | --- | --- |
| Total | 69 | 26 | 34 | 2 | 5 | 1 | 1 |
1Two cases in veterans of the Marine Corps, discovered in 1946 and reported as following tattooing, are not included. These patients were not admitted to a leprosarium. (See Porritt, R. J., and Olsen, R. E.: Two Simultaneous Cases of Leprosy Developing in Tattoos. Am. J. Path. 23:805-811, September 1947.)
Source: Records of the National Leprosarium and of leprosaria in Hawaii and the Philippines.
prising to find that some individuals with lesions of leprosy had been overlooked in the necessarily hurried medical examinations. The case records of all 69 patients have been tabulated to show the time of onset in relation to induction (table 6).
Time of onset | Total | Army | Navy | Marine Corps | Coast Guard |
| Number | Number | Number | Number | Number |
Antecedent to active service: |
|
|
|
|
|
| Known | 5 | 5 | --- | --- | --- |
| Probable | 10 | 10 | --- | --- | --- |
During active service | 31 | 29 | 2 | --- | --- |
Subsequent to active service | 23 | 16 | 5 | 11 | 21 |
| Total | 69 | 60 | 37 | 1 | 1 |
1This patient was born in Montana and lived there exclusively before enlistment in 1939. There is no history of leprosy among his relatives. From 1939 to 1942, he was stationed at San Diego, Calif. From September 1942 to December 1943, he served in American Samoa. First symptoms were noted in the fall of 1945, and a diagnosis of tuberculoid leprosy was made in September 1947.
2This patient was born in Hawaii.
3Includes 2 patients born in the Philippines, 1 in Hawaii, and 1 each in California, Florida, Louisiana, and Texas. Of the 4 born in the continental United States, 3 have histories of previous leprosy in their families; in the fourth, onset occurred within 6 months following enlistment.
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Of the 15 patients with Army service either known or considered from their histories to have contracted the disease before enlistment or induction (table 6), 5 had been admitted to the National Leprosarium-1 in 1935, 2 in 1937, and 2 in 1940. All of the 10 others considered to have had the disease before entering the Army had had less than 2 years' service:
Number of patients: | Length of service (months) |
1 | Less than 1. |
1 | 3 |
2 | 4 |
1 | 5 |
1 | 6 |
1 | 10 |
3 | Slightly less than 24. |
According to their records, all, except one Hawaiian patient for whom the only available information is that the disease was noticed during the month of induction, had had definite evidence of leprosy before entering the Army. In one case there is evidence that the disease was present at the age of 10 years.
Among the 45 patients in whom the first signs of the disease were observed either during or subsequent to Army service, it is known that 7 had prior contact with leprosy within the family, a factor which certainly should be given priority in determining the probable source of the disease. Five had been exposed to the disease through contact with one or more siblings known to have had leprosy, one through association with a parent and one through contact with an uncle and two cousins known to have had the disease. The records of the remaining 38 patients with Army service have been classified to show birthplace and theater of service (table 7). The average age at onset for those born in endemic areas was 27.2 years. For 13 who had served in nonendemic areas, it was 26.5 years and for 19 who had served in endemic areas, 27.6 years. On the other hand, the average age at onset of the six patients born in nonendemic areas was 42.5 years. Other facts of interest in the data concerning these six patients are shown in the case reports which follow.
Case 1.-White man, born in Arkansas on 16 March 1911. Family moved to Sweetwater, Tex., when patient was 4 years old. Family history negative. Enlisted in Army on 15 June 1938; discharged on 13 March 1946. Was prisoner of war in the Philippines 1941-45, confined at Cabanatuan and also Bilibid (Manila). About April 1950, noticed "spot" on left foot, size of 50-cent piece. Admitted to National Leprosarium on 19 January 1951. Diagnosis: Tuberculoid leprosy.
Case 2.-White man, born in Arizona on 23 April 1910. Reared in Mexican section of Tucson. Moved to Los Angeles when 12 years old. Family history negative. Became professional boxer, toured United States, fought in Mexico City 1932-33. Enlisted in Army on 17 September 1940 ; discharged on 2 October 1941. Reenlisted on 12 December 1941; redischarged on 25 March 1944. Served in United States only. Onset occurred about March 1942. Admitted to National Leprosarium on 9 December 1944. Note on Carville record states that patient was honorably discharged with nervous and mental disorder. Diagnosis: Lepromatous leprosy.
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Birthplace | Total | Area of service | |
Nonendemic area2 | Endemic area3 | ||
| Nonendemic areas: | Number | Number | Number |
| Arkansas | 1 | --- | 1 |
| Arizona | 1 | 1 | --- |
| Indiana | 1 | 1 | --- |
| Mississippi | 1 | --- | 1 |
| Missouri | 1 | --- | 1 |
| Ohio | 1 | 1 | --- |
Endemic areas: |
|
|
|
| California | 3 | 3 | --- |
| Florida | 2 | 1 | 1 |
| Louisiana | 1 | 1 | --- |
| Texas | 7 | 3 | 4 |
| Hawaii | 3 | 1 | 2 |
| Puerto Rico | 1 | 1 | --- |
| Virgin Islands | 1 | --- | 1 |
| Mexico | 3 | 3 | --- |
| Philippines | 10 | --- | 10 |
| Samoa | 1 | --- | 1 |
| Total | 38 | 16 | 22 |
1Patients with onset before service or with history of exposure in the family are omitted.
2Nonendemic areas constitute continental United States, either alone or in combination with Alaska, Greenland, and Europe.
3Endemic areas include North Africa, Hawaii, the Central Pacific, the Philippines, Canal Zone, and Puerto Rico.
Case 3.-White man, born in Indiana on 4 February 1895. Family history negative. Enlisted in Army on 28 June 1916; discharged on 20 October 1920. Reenlisted on 2 December 1920; redischarged on 14 August 1922. Served in United States, chiefly in Texas (San Antonio). Lived in Brownsville, Tex. (endemic area), 1922-42. Reenlisted on 16 February 1942 and served in United States and France. Discharged to enter National Leprosarium on 19 July 1948. Diagnosis: Tuberculoid leprosy.
Case 4.-Negro man, born in Mississippi in 1906. At age of 7 moved to endemic area in Louisiana, his present home. Family history negative. Enlisted in Army on 14 June 1942; discharged on 20 September 1945. Served in Europe and North Africa. Onset occurred in 1944 when "spots" appeared on individual's back and he experienced periods of nervousness. Diagnosis: Leprosy, type not determined.
Case 5.-White man, born in Missouri on 24 September 1894. Family history negative. Enlisted in Army on 14 April 1917; discharged on October 1919. Reenlisted in 1922; retired in 1944. In World War I, served in France and Germany; 1922-34, stationed in Texas, principally at Galveston and San Antonio; 1934-39, Philippines ; 1939 (8 months), Texas ; 1939-43, Hawaii. Onset occurred about June 1948, with numbness of the right foot and toes; in June 1950, an eruption appeared on the man's body. This man was
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said never to have been on sick report in the Army. Admitted to National Leprosarium on 25 August 1950. Diagnosis: Lepromatous leprosy.
Case 6.-White man, born in Ohio on 27 July 1904. Lived in Ohio, 1904-16; Indiana, 1916-22. Family history negative. Enlisted in Regular Army in 1922; discharged in 1925. Reenlisted in 1927; redischarged in 1945. Stationed in Brownsville, Tex., 1922-25 and remained there until 1927. Stationed in San Antonio, Tex., during 1927; Panama, 1928-31; Kansas, 1931-34; San Antonio, 1934-40; California, 1940-41; Oklahoma, 1941; Mississippi, 1942, when leprosy was diagnosed. Onset occurred probably in 1936. A diagnosis of syringomyelia was recorded at an Army hospital in 1939. Admitted to National Leprosarium on 18 August 1946. Diagnosis: Lepromatous leprosy.
While the source of infection can never be stated with certainty, it would appear probable that in cases 2 and 4 the infection was contracted in civilian life. On the other hand, it is quite likely that, in cases 1, 3, 5, and 6, the infection occurred during military service, but the only history which clearly points to exposure during World War II is that of case 1. This patient developed obvious signs of the disease about 6 years after release from a prisoner-of-war camp in the Philippines in which he had been confined for about 4 years.
PROGRESS IN THERAPY DURING WORLD WAR II
Significant advances were made in the therapy of leprosy during World War II. For many years, the standard treatment had been administration of chaulmoogra oil or its esters, and, although there was controversy as to the results, there was nothing better at hand. In 1940, sulfanilamide was given to a group of patients at the National Leprosarium. The report by Faget, Johansen, and Ross5 stated that, although secondary infections were cleared up, little or no improvement was noted in leprous lesions.
Feldman, Hinshaw, and Moses6 reported in 1940 that one of the sulfone drugs, which differ from the sulfonamides in having two phenyl groups instead of one and which have in common the diaminodiphenylsulfone radical, had a strikingly deterrent action on tuberculosis in the guinea pig. This drug was Promin, released in soluble form for clinical study in 1938. In March 1941, Faget and his coworkers7 at the National Leprosarium placed the first group of leprosy patients on Promin. At first it was given orally, and toxic symptoms were so severe that it had to be discontinued. Shortly afterward, a preparation for intravenous use was obtained and found to be well tolerated by a majority of patients in doses as large as 5 gm. daily. Clinical improvement observed was slow but definite; as a rule, it did not become manifest until after 6 months of treatment. Lesions of the mucous membranes of the
5Faget, G. H., Johansen, F. A., and Ross, Sister Hilary: Sulfanilamide in the Treatment of Leprosy. Pub. Health Rep. 57: 1892-1899, 11 Dec. 1942.
6Feldman, W. H., Hinshaw, H. C., and Moses, H. E.: The Effect of Promin * * * on Experimental Tuberculosis: Preliminary Report. Proc. Staff Meet., Mayo Clin. 15: 695-699, 30 Oct. 1940.
7Faget, G. H., Pogge, R. C., Johansen, F. A., Dinan, J. F., Prejean, B. M., and Eccles, C. G.: The Promin Treatment of Leprosy. Progress report. Pub. Health Rep. 58: 1729-1741, 26 Nov. 1943.
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upper respiratory tract responded well, resulting in restoration of the voice and disappearance of nasal obstruction. Emergency tracheotomies were much less frequently required. Nodules in the skin slowly flattened. Areas of infiltration gradually subsided. Leprous ulcers of the extremities gradually healed. Occasionally, regrowth of hair occurred in the eyebrows, beard, and on the arms and legs. There was little evidence of improvement in eye lesions. Skin and nasal smears remained positive in nearly all patients even after a year of treatment, but there was definite evidence of reduction after 2 years of treatment. Biopsy findings by Fite and Gemar8 indicated that improvement in skin lesions was not accompanied by characteristic cellular changes. The changes observed were atrophic in character, similar to those observed in spontaneous remission. Slow and gradual disappearance of bacilli was confirmed. Promin appeared to act by eliminating bacillary infection from the blood vessels and bloodstream, thereby preventing formation of new lesions and permitting natural resolution of lesions to take place.
Promin was in part replaced in 1943 by disodium formaldehyde sulfoxylate diaminodiphenylsulfone, first prepared under the name of Diasone. It was given orally in doses as large as about 1 gm. daily. Other sulfones soon came into use, but the results with all of them were more or less equivalent to those obtained with Diasone. It is considered by many that beneficial effects of the sulfones on leprosy are attributable to diaminodiphenylsulfone (DDS), and this so-called parent substance is now being used extensively in Africa, India, and other countries. Its only advantage is its cheapness, and there are differences of opinion regarding its toxicity in therapeutic dosages.
Of the antibiotics, only streptomycin has been used at all extensively. It was used for the first time in leprosy by Faget and Erickson in 1945.9 The results were about as good as those obtained with the sulfones.
SUMMARY
The geographic distribution of leprosy and the relatively small chance of contact with sources of infection, even in highly endemic areas, limit the military importance of this disease. However, 32 veterans are known to have developed leprosy after the Spanish-American War. A large proportion of these were born in nonendemic areas. Their ages on admission to the National Leprosarium also suggested exposure during Army service, the average age having been 52. There is no evidence that service in the Army in World War I was related to subsequent occurrence of leprosy in veterans. None of the veterans had been born in the Northern States, and the average age at admission to the National Leprosarium was 33 years.
8Fite, G. L., and Gemar, F.: Regressive Changes in Leprosy Under Promin Therapy. South. M.J. 39: 277-282, April 1946.
9Faget, G. H., and Erickson, P. T.: Use of Streptomycin in the Treatment of Leprosy: Preliminary Report. Internat. J. Leprosy 15: 146-153, April-June 1947.
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Recordshave been found of 69 cases in individuals who served in the Armed Forces duringWorld War II. Sixty of these individuals served in the Army, seven in the Navy,one in the Marine Corps, and one in the Coast Guard.
The cases among Navy andCoast Guard veterans are probably not attributable to military service. On theother hand, the Marine Corps veteran probably experienced his effective exposureduring military service. Two Marine Corps veterans who have not beenhospitalized and who are not included in the total shown are reported to havedeveloped tuberculoid leprosy, the first lesions having occurred in tattoos madeduring service.
In 15 of the 60 Army leprosypatients, there is evidence that the disease had been present before enlistmentor induction, and 5 of the 15 had been treated at the National Leprosarium. Ofthe other 45 patients, 7 had definite histories of exposure to leprosy in thefamily. The records of the remaining 38 patients were carefully examined in thesearch for the probable loci of exposure. It was found that all but six had beenborn in the areas in which the disease is endemic. While this does not precludethe possibility of exposure during military service, it would seem moreprobable that the infection occurred at an earlier date. This is supported bythe fact that the average age of these patients at time of stated onset was 27.2years and also by the fact that there was no significant difference in averageage at time of onset between those who had served in theaters in which thedisease was endemic and those who had not.
The records of the sixpatients who were born in nonendemic areas indicate that in two instances theinfection was contracted in civilian life. In four others, the probability isthat infection occurred during military service, but in only one of these isthere a clear indication that the effective exposure occurred during World WarII.
The experience of the U.S.Army after the Spanish-American War is a strong indication that the leprosyhistory of World War II is not yet closed and that sporadic cases among veteransmay be expected to appear during the next two decades.
During World War II,significant progress was made in the therapy of leprosy. Particularly importantwas the discovery that prolonged treatment with sulfones gives favorable resultsin a large proportion of cases.
