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serious reactions such as the Stevens-Johnson syndrome and toxic epidermalnecrolysis are not rare. Therefore, short course chemotherapy regimens containingthiacetazone may not be the ideal treatment in India.

At present there appears to be no alternative to using rifampicin throughout thestandard 9 month or 6 month short course regimens. The cost of treatment may bereduced if rifampicin is administered biweekly in the continuation phase althoughthe effectiveness of unsupervised bi-weekly treatment is yet to be evaluated.Government subsidies have considerably reduced the cost of rifampicin in India(Rs 2.50 for a 450 mg capsule) thereby making it affordable for most patients.However, success in controlling tuberculosis in India depends not only upon theeasy availability of short course chemotherapy to patients but also to generalimprovements in environmental sanitation, nutritional status, and the level ofeducation.

REFERENCESI WHO expert committee on tuberculosis. Ninth report. WHO Tech Rep Ser 1974;552:17-22.2 British Thoracic and Tuberculosis Association. Short-course chemotherapy in pulmonary tuberculosis

A controlled trial. Lancet 1976;2:1 \o2~.3 Second East African/British Medical Research Council study. Con nulled clinical trial of 6·month

regimens of chemotherapy for pulmonary tuberculosis. Second report. Am Rev Respir Dis 1976;114:471-5.

4 Trivedi SS. Desai SO. Primary antituberculous drug resistance and acquired rifampicin resistance inGujarat, India. Tubercle 1988;69:37~2.

5 British Thoracic Association. A controlled trial of six months chemotherapy in pulmonary tuberculosisSecond report: Results during the 24 months after the end of Chemotherapy. Am Rev Respir Dis1982;126:460-2.

6 Oangadharam PRJ. Isoniazid. rifampin. and hepatotoxicity. Am Rev Respir Dis 1986;133:963-5.7 Parthasarathy R. Raghupati Sarma O. Janardhanam B. et 01. Hepatic toxicity in South Indian patients

during treatment of tuberculosis with short-course regimens containing isoniazid. rifampicin andpyrazinamide. Tubercle 1986;67:99-108.

8 Third East African/British Medical Research Council study. Controlled clinical trial of four short-course regimens of chemotherapy for two durations in the treatment of pulmonary tuberculosis. Secondreport. Tubercle I980;61:59"'{)9.

Surgery for Leprosy

The fear of leprosy is the fear of the deformities associated with the disease. Theunsightly leonine facies and contractures, ulceration, loss of the fingers and toes and,in endemic areas, early signs such as the thickening of the ear lobule or the loss of theeyebrows are recognized even by the lay person. These universally known deformi-ties, have always made the patient with leprosy an outcast of society. The Atlas ofLeprosy (1848) by Boeck of Norway was the earliest medical record of leprosy.'Though it has been known since 1873 that leprosy is caused by a mycobacteriumsome members ofthe medical profession have refused to treat the disease. Like AIDSthe fear is particularly manifested in surgeons who are exposed to contact withinfected tissue. As a result the myth has been propagated that leprous tissues are•rotten and fall off on their own, hence surgical wounds will not heal in leprosy'.

The surgical care of leprosy had, therefore, to await the discovery of dapsone(DDS) when, for the first time, there was a medical cure for the disease. Cochrane/started the large-scale treatment of leprosy with DDS at the Victoria Hospital (nowthe Central Leprosy Training and Research Institute) at Chingleput, and stimulateda young orthopaedic surgeon, Paul Brand, at the Christian Medical College, Velloreto try and correct the deformities. Thus began the era of surgery in leprosy. Brandsoon realized that the deformities of the hands and feet were similar to those resultingfrom traumatic nerve damage. He used the uninvolved forearm muscles, extendedwhen necessary by plantaris tendon grafts,' to replace the paralysed intrinsic muscles

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of the hand. He devised and popularized the extensor as well as the extensor-to-flexortendon transfers to correct clawed fingers and the ring finger sublimis transfer for thethumb. The Bunnel sublimis transfer, however, resulted in over-correction of thedeformity in the supple Indian hand. Standardized procedures were developedbecause the nerves were involved at specific superficial sites due perhaps to the lowertemperature locally. Later, however, it was postulated that these sites were involvedbecause of nerve entrapment. Nevertheless, the probably incorrect earlier hypothe-sis led Storrs to use the low body temperature armadillo for the multiplication ofMycobacterium leprae

Brand then turned his attention to the deformities of the feet and rehabilitation ofthose whose deformities were corrected but whose persistent sensory loss posed apermanent disability problem. Physiotherapy, re-education of the surgically cor-rected but anaesthetic hands and feet, provision of protective gloves and especiallyof cheap footwear were important contributions.

In 1958. Antia. a plastic surgeon, devised operations to correct deformities of thenose, lagophthalmos, eyebrows and facial skin laxity." Working at the KondhwaLeprosy Hospital with only elementary surgical facilities, he simplified complicatedoperative procedures which later became standard even in the West. The palmarislongus motor for correction of clawed fingers' and radical metatarsectomy forchronic plantar ulceration" were also part of this process of simplification.

Various dynamic as well as static procedures have been developed by Srinivasan,'Fritschi! and Palande.? The limited facilities in most leprosaria and other centres haveresulted in the description of simple procedures such as the fasciocutaneous palmarexcision and the nasolabial and forehead lining flaps for nasal reconstruction, freegrafts for the eyebrows and the nasolabial face lift. Arlokar (personal communica-tion) has demonstrated that most of these operations including tendon transfers tocorrect the dropfoot which traditionally required two weeks in hospital can now beundertaken as outpatient procedures. Combined with release of the posterior tibialnerve, this helps in the healing of plantar ulcers.

It is estimated that about 10% of India's 4 million leprosy patients have physicaldeformities as well as sensory loss. Even if a small percentage of these were offeredsurgery, they would swamp all the available reconstructive surgical facilities in thecountry. The intelligent surgeon who perceives surgery to be only a means toalleviate the problems of patients with leprosy cannot also fail to be interested inmeasures to prevent deformities. While most simplified procedures can be under-taken by surgeons at hospitals or leprosaria with modest facilities under localanaesthesia, it must be realized that the major effort has to be 'towards the preventionof deformities. This can be achieved by early diagnosis and regular treatment,preventing and treating reactions, physical therapy to prevent contractures, caring foranaesthetic hands and feet and developing suitable tools and footwear,

While surgery may help only a very small proportion of those who can bebenefited, it has had a wide impact because for the first time, it has been demonstratedthat deformity need no longer be a permanent stigma. Leprosy surgery has hence hada far greater impact on leprosy than the mere technical correction of deformities.

During the 1950s and 1960s not only was surgery for leprosy patients begun butthe disease was introduced into non-missionary medical teaching institutions. TheTata Department of Plastic Surgery at the J. J. Group of Hospitals and the GrantMedical College in Bombay was one of the first to do so. This reduced the stigma andfear of leprosy in the medical and nursing professions. The public were also mademore familiar with the disease as these patients were admitted to the general medicaland surgical wards. This also helped to create an interest in leprosy researchespecially into the causes of tissue and nerve damage resulting from the disease.Nerve biopsy has contributed to a better understanding of the pathogenesis ofperipheral nerve damage and its Schwann cell damage. 10 There has been an increasedinterest in the surgery of the nerves, an aspect of surgery which will play anincreasingly important role in the prevention and even reversal of the nerve damagewhich is responsible for the majority of deformities. It has also contributed to theadvances in plastic, orthopaedic and general reconstructive surgery. Surgery has thus

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played a major role in the treatment of leprosy by attracting other disciplines likeneurology and immunology.

The management of patients with leprosy has undergone a radical change over thepast four decades. New drugs and multi-drug therapy are playing an increasing rolein the control of this disease. The role of the reconstructive surgeon and the rehabili-tation team cannot be underestimated because this deals with the personal problemsof these patients and not merely with their disease.

Finally it is a matter of pride to record that the major developments in the surgeryof leprosy and the rehabilitation of patients with this previously dreaded disease havebeen due to the efforts of doctors working in India.

REFERENCESI Danielssen D. Boeck OW. Atlas colorie ck Berge». Norway. 1847.2 Cochrane RO. Leprosy in theory and practice, Bristol:John Wright. 1964.3 Brand PW. Paralytic claw hand. With special reference to para1ysis in leprosy and treatment by the

sublimis transfer of Stiles and Bunnell. J Bone Joint Surg 1958;408:618-32.4 Antia NH. Reconstruction of the face in leprosy. Ann R Coli Surg Engll963;31:71-98.5 Antia NH. The palmaris longus motor for lumbrical replacement. Hand 1969;1:139-45.6 Bhasin D. Antia NH. Radical rnetatarsectomy for intractable plantar ulceration in leprosy. Lepr Rev

1972;43:53-8.7 Srinivasan H. Surg~ry and management of insensitive hands and fUI in leprosy. Chingleput:Centra1

Leprosy Training and Research Institute. 1979.8 Fritschi EP. Brand PW. The place of reconstructive surgery in the prevention of foot ulceration in

leprosy.lnt J Lepr 1957;15:1-8.9 Palande DO. Correction of intrinsic·minus hands asoociated with reversal of the tfansverse metacarpal

arch. J Bone Joint Surg 1983;65A:514-21.10 Antia NH. The 'signiflCance of nerve involvement in leprosy. Plast Reconstr Surg 1974;54:55-63.