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History of dermatology, venereology and leprology in India. DM ThappaDepartment of Dermatology and STD, JIPMER, Pondicherry - 605 006, India. , India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 12215711 Keywords: Dermatology, history,History of Medicine, 19th Cent., History of Medicine, 20th Cent., History of Medicine, 21st Cent., India, Leprosy, history,Venereology, history,
Dermatology, the science of the skin, was one of the many specialties, which evolved from general internal medicine during the course of the nineteenth century. Till this time, physicians with few exceptions were little concerned with the skin, apart from the exanthematic eruptions of acute fevers. During the last decades of that century, contributions of some, such as Heberden, Cullen and Hebra, laid the foundations on which the pioneer specialist dermatologists of the following century were able to build.[1],[2]
Therapeutics of dermatoses have been known and practised by our ancient physicians for centuries. Charaka Samhita contains one chapter on the subject. In this ancient book, worshipful Atreya Punarvasu, has described eighteen dermatoses. He attributed these dermatoses to the preponderance of morbid humours (vata, pitta, and kepha) causing disturbances of body elements and thereby diseases.[3] However, recognition of dermatology as a speciality distinct from internal medicine is recent. In the latter part of the 19th century, the health authorities in the then British India became aware of the need to have data on the prevalence of dermatoses and venereal diseases.[5] Dr Vandyke Carter, Surgeon Major, HMS Indian Medical Services was appointed to take stock of the situation. This was the first scientific endeavour to study dermatoses in the Indian subcontinent. Fox and Farquar[6] in the year 1872, precisely determined the prevalence and pattern of dermatoses in India. The first chair of dermatology was established at Grant Medical College, Jamshedji Jeejebhoy Hospital, Bombay in 1895. Major C Fernandez, MD (Brussels) made the creation of this chair possible.[3],[7] The second department, at the School of Tropical Medicine in Calcutta, was started in 1923, after a gap of nearly 28 years, under the patronage of Dr Ganpati Panja and Colonel Acton. Subsequently, in 1926, the department of dermatology and venereology was established at Seth Gordhandas Sunderdas Medical College and King Edward VII Memorial Hospital, Bombay. Dr AC Rebello as Honorary Dermatologist and Venereologist headed it. During the period from 1956 to 1974, the status of the speciality was further elevated and steps were taken by state governments to set up departments of dermatology and venereology in medical institutions.[7] The establishment of the All-India Institute of Medical Sciences with a separate department for dermatology in 1960 under the stewardship of Professor KC Kandhari, was a conspicuous landmark. Contributions of Dr. JS Pasricha need to be remembered in independent India. His contribution in exploration of various causes of contact dermatitis is worth mentioning.[8] He also modified concept of pulse therapy to achieve cures in some of the most fatal and the so-called incurable diseases such as pemphigus, systemic sclerosis, systemic lupus erythematosus.[9] Another milestone in Indian Dermatology was the plan of the IADVL Textbook project by Prof. RG Valia and Prof. Leslie Marquis in order to fill a lacuna in teaching of dermatology.[10] Its first edition was published in 1994.
Dr. UB Narayan Rao, a pioneer in the speciality, gets the credit for the creation of an association of dermatologists and venereologists in Bombay.[11] On July 1, 1947, this Bombay association was inaugurated and it organised an All-India Conference of Dermatologists and Venereologists, on December 27 and 28, 1947, at JJ Hospital, Bombay. In February 1962, it was decided to affiliate the association of dermatologists and venereologists with Association of Physicians of India (API). From 1963, the conference became an annual fixture, being held jointly with API. This continued until 1974, after which this affiliation was severed and the association became an independent body. The first independent conference of the association was held in 1975 at Trivandrum under the chairmanship of Dr BM Ambady. The members of the Calcutta branch parted company from the parent association and formed the Dermatological Society of India (DSI).[7],[12] The Indian Journal of Dermatology was their official organ, the first issue of which was published in the year 1957. The two bodies met at Udaipur on January 28, 1973 and unanimously agreed on the reunification.[7] They amalgamated into one association, which has since been named the Indian Association of Dermatologists, Venereol-ogists and Leprologists (IADVL). Until recently, dermatology remained a purely medical speciality in India, although our Western counterparts worked exhaustively on its surgical dimensions.[13] The last 20 years or so have witnessed a tremendous growth and dermatologists have adopted various surgical techniques and associations like Association of Dermatological Surgeons of India (now, Association of Cutaneous Surgeons of India) and Cosmeto-logy Society - India (CSI) have been established. Since 20-30% of cases in paediatric practice have dermatological problems, a need was felt to constitute Indian Society for Paediatric Dermatology (ISPD).[14] It came into existence in 1996 and two years later the first issue of Indian Journal of Paediatric Dermatology rolled out of the press.[15]
The Indian Journal of Venereology, a publication owned by Dr UB Narayan Rao, which was started in 1935 and later renamed as Indian Journal of Venereal Diseases and Dermatology in 1940, was magnanimously offered to the association for adoption.[7],[8] Four years later, the first issue of the official journal was delivered in 1955 under its new name, Indian Journal of Dermatology and Venereology, with Dr UB Narayan Rao as its managing editor. The stalwarts, Drs. Rajam, Panja, and Chatterji, provided lustre and academic dimensions to the office of Editor-in-Chief. Since 1976 this bimonthly journal is being published under the title Indian Journal of Dermatology, Venereology and Leprology.
Forty years ago, there was just a score of dermatologists in India. In 1991, Ministry of Health and Family Welfare put their number around 2000 for a population of 843 million. Now the situation is much better. However, these dermatolo-gists are concentrated in the cities and large towns. The rural population, which is around 80% of the total, has no easy access to a dermatologist.[16] Regarding the quantum of dermatological problems in the community, a reliable estimate is that one in twenty people has a skin disease in India. [17] An analysis of records of out-patient attendances of primary health care centres had found that 25-35% of these patients had dermatological problems.[18] Ten common skin diseases seen in primary health centres are scabies, pediculosis, tinea, leprosy, vitiligo, pityriasis versicolor, pityriasis alba, dermatitis, urticaria, impetigo, and boils.
In spite of having some share in the curriculum, dermatology remains a neglected subject because of its non-inclusion in the qualifying examination at MBBS level.[18] Knowledge of dermatology of interns and young practising doctors has been found to be negligible. In fact, there has been no uniform standard of teaching for undergraduates anywhere in India until recently, when Medical Council of India (MCI) set new guidelines for MBBS teaching and curriculum content in dermatology, venereology and leprology.[19] There is a great need for uniformity in postgraduate courses in dermatology. Like American Board of Dermatology, Indian Board of Dermatology may be set up for this purpose.[3] Research facilities in postgraduate teaching departments are still meagre in this country. Very few institutions can claim of good research facilities in dermatology for first-rate work.
Sir William Osler called venereal diseases the most formidable enemy of the human race, an enemy entrenched behind the strongest human passion and deepest social prejudices, and this view still holds good in our country. [22] When syphilis was first introduced into North India nearly 500 years ago with the invasion of armies and trading ships from European countries to the region,[23] so explosive was the nature of the epidemic in this region and so deep was the cultural and national impact that various religious/cultural communities started blaming each other as the source. In the past, some attempts have been made to identify syphilis and gonorrhoea in ancient Indian texts, but the evidence strongly suggests that syphilis at least was unknown in India before the early 16th century.[24] Some of the first references to the disease and its treatment are to be found in the Bhavaprakasa, a mid-sixteenth-century text. During that period, and subsequently, for a long time, syphilis was known in India as firanga or firangi roga, terms, which identified it with the firangis (“Franks”) or Europeans. By the early 19th century, syphilis was widely disseminated, though the extent of its incidence could only be guessed at. In the second half of the 19th century, sexually transmitted diseases (STDs) stood second only to “malarial fevers” as a cause of hospitalisation in British troops. In Kullu Valley in Punjab in 1959, the incidence of STDs was reported to be as high as 30%.[24] At the end of the First World War, few Indian hospitals and dispensaries had facilities for the investigation and treatment of STDs and many wished to avoid the stigma of association with them.[24] As late as 1933, it was remarked that in Calcutta there existed “practically no organised treatment” for STDs. Bombay was more enlightened and in 1918, a special clinic was opened there by the local branch of the Empire-wide League for Combating Venereal Diseases, intended to serve the city’s red light district.[24] In nineteenth century India, the military authorities did not rely solely upon mercury to try to deal with STDs in the army (mainly contracted from prostitutes). [24] From about the 1780s onwards, lock hospitals were used to confine and treat prostitutes associated with the army who were found to be suffering from STDs. After the introduction of salvarsan, 50 years earlier, a further therapeutic breakthrough came only with the penicillin. By 1954, India was producing penicillin for its own use. Little advantage was taken of this and India’s first five year plan (1951-56) virtually ignored STDs and only with the second, in 1957, they were brought into the mainstream of government health planning and funding.[24] Historically and statistically, STDs in India have posed two particular problems.[24] The stigma attached to such diseases has, as elsewhere, encouraged their concealment while their apparently non-fatal nature has resulted in their virtual absence from the mortality data. The emergence of AIDS in India was not at first regarded as a serious threat, with probable thinking that it is a white man’s disease and is due to Western immorality.[24] In 1988, AIDS began to spread rapidly in India, thus awakening the health authorities. India too has a drug culture. Certainly this is one of the routes by which AIDS has spread in the northeast India, close to drug producing areas of northern Burma. Institute of STD (formerly known as Institute of Venereolo-gy), Madras was the only institute of its kind in South-East Asia.[21] In the early formative years, the strength and solidity was given to this institute by Col. Vasudeva Rao. Dr RV Rajam was its founder director, an international figure for his research work on venereal diseases. Successors to Dr Rajam were Dr PN Rangiah and Dr CN Sowmini.
In the year 1935, Dr UB Narayan Rao started a private publication, the Indian Journal of Venereology, which subsequently merged with Indian Journal of Venereal Diseases and Dermatology in 1940 and renamed as Indian Journal of Dermatology and Venereology in 1955.[3],[7] In the year 1980, this speciality under the banner of Indian Association for the Study of Sexually Transmitted Diseases, started its own exclusive journal “The Indian Journal of Sexually Transmitted Diseases” with Dr. Sardari Lal as the founder editor.[25]
The annual incidence of all STDs in India is estimated to be about 5%.[26] Thus, it is estimated that each year approximately 40 million new infections with STDs occur. Since HIV infection and STDs are associated with the same risk behaviour and the presence of an STD facilitates the transmission of HIV infection, prevention and control of STDs has been recognised as one of the major strategies to control of HIV/AIDS.
Programme for control of STDs among the population of India is present for many decades.[27] Even before the country achieved independence, a National STD Control Programme was started in 1946. This programme continued to operate till 1991 and with the arrival of HIV infection in the country and because of its strong relation with STD, the programme was brought under the purview of National AIDS Control Organisation (NACO) in the year 1992. The National AIDS Control Programme existed from 1987. This programme emphasised more on health seeking behaviour of the individuals having STD and removal of the social stigma attached to the problem of STD.
Somehow venereology did not prosper as much, even though it led in front of dermatology and leprology in teaching and in starting of its own journal in early part of 20th century. The monograph by Rajam and Rangiah on donovanosis (granuloma inguinale, granuloma venereum) is testimony to the teaching and research standards set by these two giants at Institute of Venereology, Madras. [28]
The earliest records, which give accurate descriptions of leprosy, come from India.[32] In Sushruta Samhita (600 BC), one finds a reasonably good account of the clinical features and treatment of the disease.[33] Sushruta described the different forms of leprosy, and these forms fit in fairly well with the forms of the disease as recognised at the present time. In this ancient book, references to leprosy are made under Vat Rakta or Vat Shonita and Kushtha. Vat Rakta or Vat Shonita is characterised by presence of loss of sensation and deformities etc. without any patches. The term Kushtha is used for the skin diseases in general but one variety (Arun Kushtha) corresponds to leprosy. Two kinds of skin diseases have been described under Arun Kushtha; in one, the prominent symptoms are loss of sensation and deformity, and in the other, ulceration, falling off fingers etc. Sushruta described the treatment of the disease with Chaulmoogra oil (hydnocarpus oil), which till 1940s was the mainstay in the treatment of the disease. Reference to Kushtha is also made in even earlier Indian literature, for instance in the Manu Smriti and Atharva Veda.[36] During the dark ages, before the introduction of dapsone, when fear was foremost in the minds of public, patients and the profession alike, the only strategy devised by humanity to control leprosy was to segregate the sufferers in leprosaria or colonies away from habitations and treat them with folk remedies.[37] The first known asylum for leprosy patients was established in Calcutta early in the 19th century, followed by another in Varanasi. Later, becoming aware of the plight of the suffering humanity, a few Christian missionaries took to leprosy work. The Mission to Lepers (now known as the Leprosy Mission) was started in 1875 at Chamba in Himachal Pradesh.[37] However, no organised effort existed in India till the formation of the Indian Council of the British Empire Leprosy Association (BELRA) in 1925, renamed after Independence as the “Hind Kusht Nivaran Sangh (Indian Leprosy Association) with a view to ascertain the rough distribution and prevalence of leprosy in various parts of the country. The Indian Council of BELRA under the charge of Dr. Issac Santra established an All India Survey Team in 1925. Following the surveys, the All India Leprosy Survey Team estimated the cases of leprosy in India to be one million which remained the official figure for long-even many years before the Government of India launched its National Leprosy Control Programme (NLCP) in 1955. This official figure was changed to 3.9 million only in 1985-86 when the statistics of the National Leprosy Eradication Programme showed the estimated cases to have gone up by 2.9 million. The Indian Council of BELRA formed in 1925, a year after the establishment of the parent body in London, was doing notable work in research, treatment, survey and propaganda and published its quarterly journal “Leprosy in India”. [37] In association with Sir Leonard Rogers, Dr. Ernest Muir and Dr. Robert Cochrane, our own stalwarts Dr. Issac Santra, Dr. Dharmendra, Dr. SN Chatterjee and several others came up with their own contributions to leprosy work. Dr. Dharmendra straddled the scene of leprosy in India like a giant and is known for lepromin test, Indian classification of types of leprosy and the journal “Leprosy in India”. Dr Robert Cochrane devoted his working life to the study and control of leprosy in India.[38]
“Leprosy in India” was started by Dr. Ernest Muir in 1929 initially in the form of Quarterly Notes, later on transformed itself to a full fledged scientific journal.[37] Consistent with its contents and nature, the “Leprosy in India” was renamed as the “Indian Journal of Leprosy” in 1984.
The National Leprosy Control Programme (NLCP) was started in 1954-55. The mainstay of the NLCP was early detection and sustained regular treatment of patients with dapsone monotherapy. [31] For nearly two decades, the NLCP moved ahead very slowly, presumably for want of clear-cut policies or operational objectives.[39] The programme gained momentum after it was converted into a 100% centrally sponsored scheme in 1969. In 1980, the Government of India declared its resolve to eradicate leprosy by the year 2000. [30] In view of scientific advancement and availability of highly effective treatment of leprosy, the programme was redesign-ated as National Leprosy Eradication Programme (NLEP) in 1983. The strategy of NLEP was early case detection, prompt treatment with multidrug therapy and prevention of disability among patients. One of the achievements of NLEP has been fall in caseload in India, achieved in a span of 17 years because of the efficient use of multidrug therapy. In spite of this, India still has 75% of leprosy cases in the world. In 1991, the World Health Organisation set a target of elimination of leprosy as a public health problem by the year 2000.[40] The target has already been reached by December 2000 in over 120 countries. About 10 countries including India will need an additional five years to reach the target.
In the pre-sulphone era, hydnocarpus oil (chaulmoogra oil) was used in injectable form for the treatment of leprosy in India. [41] The period between 1955 and 1965 may be regarded as the golden era of sulphone monotherapy in the history of leprosy. The euphoria associated with dapsone monotherapy ended in 1965 on detection of sulphone resistant M. leprae strains. In 1962, clofazimine was found useful for the treatment of leprosy and for the prevention and treatment of erythema nodosum leprosum. In the period between 1965 and 1982, vigorous efforts were made to find newer and more effective drugs for leprosy therapy. Rifampicin was found to be very effective, ethionamide and prothionamide were reported to be useful for treatment of leprosy. Introduction of multidrug therapy projects in India came into operation in 1983. [41]
In 1950s, instructions on leprosy were often completely omitted from the medical undergraduate training and when given, were very poor and inadequate. Fortunately, there has now been considerable improvement in the matter.[42] Postgraduate classes in leprosy for medical men have been a distinctive feature of anti-leprosy work in India.[42] Such a training course was first started at the Leprosy Department of the School of Tropical Medicine, Calcutta in 1925 under the auspices of BELRA. Later on, this activity was taken over by Hind Kusht Nivaran Sangh, successor of the Indian council of BELRA after the independence of the country and subsequently by the Indian Council of Medical Research. Later on, facilities for postgraduate training were also made available at other centres such as Lady Wellington Leprosy Sanatorium, Chingelpet (the present Central Leprosy Teaching and Research Institute), Ackworth Leprosy Home in Bombay, and Leprosy Hospital at Dichpalli near Hyderabad, etc. The growth of leprosy centres and institutions over the past 50 years has been phenomenal, and these institutions were responsible for treatment as well as research, in addition to training and rehabilitation.[43] Till the 1950s the only important facility for leprosy research was the Leprosy Department of the School of Tropical Medicine at Calcutta. But from 1955 onwards several institutions came up, namely, the Central Leprosy Training and Research Institute and Schieffelin Leprosy Research Training Centre in the 1950s, the Japanese Leprosy Mission for Asia (JALMA) in the 1960s, the Father Mueller Research foundation in the 1970s, the Central JALMA Institute for Leprosy. Field Unit in the 1980s, in addition to several other small institutions during those periods.
The position of leprosy in India as acknowledged now by the Government of India (GOI) is that in the five states of Bihar, Uttar Pradesh, West Bengal, Orissa and Delhi, the achievements are very poor, and elimination target may be reached in these states only by 2005.[44] In the remaining states, it is said that elimination will be achieved by 2003. However, the GOI says that even in these states, 52 districts have a very high prevalence of the disease.
Bombay led the way in postgraduate education.[7] From its inception in 1926, Seth GS Medical College had the post of honorary dermatologist and venereologist and an honorary lecturer. In 1942, Bombay University appointed a committee to frame rules and regulations for a diploma in dermatology and venereology (DVD). It was a course of 1-year duration and the first DVD examination was held in October 1945. In 1947, the College of Physicians and Surgeons (Bombay) allowed candidates to appear for their fellowship examination in dermatology and venereology. Since then, many more medical colleges have been recognised for training of postgraduates. In the south India, Andhra Pradesh and Tamil Nadu, postgraduate degrees are given separately for dermatology, venereology and leprology whereas most of other medical institutions in India offer it as combined degree.
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