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The Legacy of Armauer Hansen

2000; American Medical Association; Volume: 124; Issue: 4 Linguagem: Inglês

10.5858/2000-124-0496-tloah

1543-2165

Venita Jay,

Leprosy Research and Treatment

Leprosy has been known to humankind from ancient times. This age-old scourge appeared in Europe several hundred years before the common era. The medieval treatment of lepers remains one of the darkest incidents of man's inhumanity to man. The extreme disfigurement caused by this disease led to segregation of afflicted persons who were regarded as social outcasts and made to live in special dwellings. With spread of the disease during the Middle Ages, numerous leprosy hospitals (leprosaria) were established. Lepers had to announce their presence with bells or clappers and wear distinctive attire. People afflicted with this dreaded scourge were dealt with as if they were no longer alive.It took the persistence and dedication of a visionary Norwegian to uncover the mystery of leprosy. In discovering the causative organism of leprosy, Gerhard Henrik Armauer Hansen touched millions of lives. Because of Hansen's work, leprosy became one of the first communicable diseases wherein a specific causative organism was demonstrated.Hansen (1841–1912) was born in Bergen, Norway, on July 29, 1841, the eighth in a family of 15 children. During harsh times in the 1840s, his father Claus Hansen, a merchant, took on additional work to make ends meet but was eventually forced into bankruptcy. Because of the family's difficult financial situation, Armauer Hansen put himself through the University of Christiania (now Oslo) by working as a tutor. He took courses in physics and zoology and had an enduring interest in botany and athletics. During his medical school years at the University of Christiania, Hansen was not afraid to contradict his teachers. He was offered a position at the university as a substitute prosector in anatomy. As a prosector, Hansen quickly gained the respect of his students, who were his age.Hansen graduated with honors in medicine in 1866 and completed an internship at the National Hospital in Christiania. Thereafter, he served as a physician in a small fishing community in Lofoten, Norway. In the winter of 1868, Hansen returned to Bergen to pursue a line of research that was to make him a household name in medicine.It is not precisely determined when leprosy first made its appearance in Norway, but it likely entered Norway from the British Isles during the time of marauding Vikings. By ad 1000, leprosy was fairly widespread in Norway. The clergy and nuns usually cared for lepers, and a few hospitals emerged to provide sanctuary to lepers. One such center was St Jørgen Hospital, founded around 1400 in Bergen.It was at St Jørgen that Hansen's predecessor, Daniel Cornelius Danielssen, embarked on leprosy research in 1839. In 1840, Danielssen began a collaboration with Carl Wilhelm Boeck. This partnership culminated in the celebrated work "Om Spedalskhed (On Leprosy)", putting Bergen in the forefront of leprosy research. This extraordinary treatise presented in meticulous detail the clinical picture of leprosy and included a large atlas of drawings.In 1849, the new Lungegaarden leprosy hospital was established in Bergen, with Danielssen as its chief physician. The hospital not only housed leprosy patients but also patients with other dermatologic afflictions, which allowed Danielssen to do comparative studies of different dermatologic conditions. Sadly, fire destroyed the building in 1853. The new premises that were designed after the fire housed more than 90 leprosy patients. This new hospital also was equipped with a laboratory and library and became an important center for research.In 1862, Danielssen produced another important work that highlighted the anesthetic form of leprosy. Both Danielssen and Boeck believed that leprosy was a hereditary disease. But Hansen would come to question Danielssen's theory about leprosy. Hansen believed that leprosy was infectious not hereditary.An increasing number of leprosy cases in Norway forced the need for more hospital beds and led to the founding of yet another leprosy hospital in Bergen in 1857—Pleiestiftelsen for Spedalske Nr 1 (Nursing Institution for Leprosy Patients No. 1). It was there in January 1868 that Hansen embarked on his important quest, with Danielssen as his chief.Hansen's first scientific publication, completed in 1869, dealt with microscopic anatomy of lymph nodes in health and disease. The study, which won a gold medal, included material from leprosy patients, in which the astute Hansen had observed yellowish brown granular masses in the lymph nodes and in other organs. In subsequent publications, Hansen described the dermatologic manifestations and nodules in various tissues and differentiated between the nodular and anesthetic form of leprosy. He noted that both forms of the disease started with skin involvement.Realizing the need to improve his knowledge of pathology and microscopy, Hansen pursued further studies. In 1870, he received a grant and studied histopathology in Bonn and Vienna. After returning to Bergen, he intensified his research into the cause of leprosy. With a grant from the Norwegian Medical Society in Christiania, Hansen traveled around Norway studying many leprosy cases. Based on clinical and epidemiologic evidence, he reported in 1872 that leprosy was a chronic infectious disease. While he described granular masses in nodules in leprosy patients as early as 1869, it is generally believed that Hansen observed the leprosy bacillus in 1873 and documented this in a communication to the Norwegian Medical Society, which was published in 1874. Thus, Hansen became the first to suggest that a specific microbe caused a chronic disease.Hansen was convinced that the brownish granular masses he had previously observed in lymph nodes and other tissues of leprosy patients were specific to the disease. It was within the lepromatous skin nodules using primitive staining techniques that he saw masses of rod-shaped bodies. The bacilli were stained by osmic acid and not dissolved by potash lye. At this time, though, the science of bacteriology was still in its infancy.In 1879, Albert Neisser, one of Robert Koch's pupils, visited Bergen to study leprosy. Neisser took some of the material Hansen had given him to Breslau and managed to stain the bacilli and claimed discovery of the leprosy bacillus. While a controversy ensued, Hansen rightfully received acknowledgment as the discoverer of the leprosy bacillus.Believing the lepra bacillus to be the causative agent of leprosy, Hansen became the first proponent of the theory that a chronic disease could be caused by a microbe. He conducted many experiments to prove this concept but was unable to grow the bacterium on artificial media, and his efforts to transfer it to animals were in vain. Having failed with numerous animal inoculations, Hansen turned to human experimentation. These experiments also were unsuccessful in transmitting the disease. In one ill-advised experiment, Hansen tried inoculating leprous material into the eye of a woman with the anesthetic form of leprosy. Apparently, he had not sought permission for such an experiment, and even though there were no dire clinical consequences, the patient sued Hansen. As a result, he was deprived of his position as resident physician at the leprosy hospital in 1880.Hansen, however, continued in his position as medical officer of health for leprosy in Norway, implementing important changes for leprosy control. The first Norwegian leprosy law was passed in 1877 and prohibited placing the poor in legd, a communal relief measure, wherein the poor were moved from farm to farm. The farm owners provided for lepers during this temporary stay, but such a roving existence probably contributed to the spread of leprosy. The second leprosy law of 1885 raised violent opposition among some circles as it called for precautionary isolation of leprosy patients. But in Hansen's lifetime, there was a steady decline in leprosy in Norway with enforcement of the Norwegian leprosy act of 1877 and its amendment in 1885.An addition to his work on leprosy, Hansen was an eminent zoologist and an ardent advocate of Darwinism. In 1886, he published a small book in Norwegian, The Theory of the Descent of Man, or Darwinism. After Danielssen's death, Hansen became chairman of the board of directors of the Bergen Museum of Natural History.In 1873, Hansen married the daughter of his chairman, Stephanie Danielssen. Unfortunately, his wife succumbed to tuberculosis the same year. In 1875, Hansen married again. From his second marriage, he had 1 son, who also went into medicine.Hansen held many other positions of honor and served on prestigious committees and medical societies. He cofounded medical publications, including an international journal of leprosy named Lepra. Unfortunately, Hansen experienced several heart attacks during his life and died from a heart attack on February 12, 1912.