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Thesiss University of Amsterdam, Ref.-With Summary in Dutch UvA-DARE (Digital Academic Repository) Clinical aspects of nerve damage in leprosy Theuvenet, W.J. Publication date 2002 Document Version Final published version Link to publication Citation for published version (APA): Theuvenet, W. J. (2002). Clinical aspects of nerve damage in leprosy. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:26 Sep 2021 CLINICALL ASPECTS OF NERVE DAMAGE IN LEPROSY Y ^^^KjmEuïnjiL ^^^KjmEuïnjiLS^^^SmWMw S^^^SmWMw i&j^-^&L^ i&j^-^&L^ 11 -**'^*E£ ^weawe^SfeSH MWgMMfl lHANNE SS THEUVENET Clinicall Aspects of Nerve Damage in Leprosy Notess from Anandaban Leprosy Hospital, Nepal Klinischee Aspecten van Zenuwbeschadiging door Lepra Notitiess vanuit Anandaban Leprosy Hospital, Nepal Willemm Johannes Theuvenet Clinicall Aspects of Nerve Damage in Leprosy Notess from Anandaban Leprosy Hospital, Nepal Klinischee Aspecten van Zenuwbeschadiging door Lepra Notitiess vanuit Anandaban Leprosy Hospital, Nepal ACADEMISCHH PROEFSCHRIFT terr verkrijging van de graad van doctor aann de Universiteit van Amsterdam opp gezag van de Rector Magnificus prof.mr.. P.F. van der Heijden tenn overstaan van een door het college voor promoties ingesteldee commissie, in het openbaar tee verdedigen in de Aula der Universiteit opp donderdag 21 november 2002, te 10.00 uur door r Willemm Johannes Theuvenet geborenn te 's-Gravenhage. Promotiecommissie: : Promotores:: prof.dr. W.R. Faber prof.dr.. M. Vermeulen Overigee leden: prof.dr. C.M.A.M. van der Horst prof.dr.. F.G.I. Jennekens prof.dr.. A.S. Muller prof.dr.. CS. Smith prof.dr.. M. de Visser dr.. J.H. Richard us Faculteit: : Geneeskunde e Theuvenet,, Willem Johannes Clinicall Aspects of Nerve Damage in Leprosy; notess from Anandaban Leprosy Hospital, Nepal. Thesiss University of Amsterdam, ref.-with summary in Dutch Printer:: University of Amsterdam Graphic Productions, The Netherlands; p. 180. ISBNN 90-9016224-0 ©© 2002 WJ.Theuvenet, Apeldoorn, The Netherlands. All rights reserved. No part of this publicationn may be reproduced or transmitted in any form or by any means, electronic or mechanical,, including photocopy, recording, or any information storage and retrieval sys- tem,, without permission in writing from the copyright owner. Cover:: Painting of the Kathmandu valley and Anandaban Hospital by Sanu Kaje. Privatee Collection. Forr Sikiliya, Ganga, Suraj Kala and Raj Kumar, mayy their grandchildren see a world freee of leprosy. 6 6 TABLEE OF CONTENTS TABLEE OF CONTENTS Chapterr 1 Introduction: 1.. Nepal 1.1.. History 13 1.2.. Topography and Geography 15 1.3.. Climate 16 1.4.. Population 17 1.5.. Economic Situation 18 1.6.. Health Situation 19 2.. Leprosy in Nepal 2.1.. History 20 2.2.. The Social Consequences of Leprosy 21 2.3.. Leprosy in the World 24 2.4.. Leprosy Control Programme in Nepal 26 3.. Clinical Aspects of Leprosy 3.1.. Introduction 29 3.2.. Microbiology 29 3.3.. Immunology 30 3.4.. Classification 35 3.5.. Diagnosis 37 3.6.. Treatment of Leprosy 38 3.7.. Reactions 39 3.8.. Treatment of Reactions and Peripherall Nerve Function Loss 43 3.9.. Prevention of Impairment and Subsequent Disability (POID) andd Rehabilitation 44 3.10.. (Reconstructive) Surgery in Leprosy 47 3.11.. Eye Problems in Leprosy 52 4.. Scope of this Thesis 53 Chapterr 2 Mass Survey of Lalitpur District 55 Chapterr 3 Neuritis of the Lateral Femoral Cutaneous Nerve in Leprosy 69 Chapterr 4 Change of Sensation in Leprosy after Nerve Decompression byy Selective Meshing of the Epineurium 77 7 7 TABLEE OF CONTENTS Chapterr 5 Cytological Needle Aspiration of the Nerve for the Diagnosis off Pure Neural Leprosy 93 Chapterr 6 The Paper Grip Test for Screening on Intrinsic Muscle Paralysis inn the Foot of Leprosy Patients 101 Chapterr 7 Risk Factors for Type-1 Reactions in Borderline Leprosy Patients 119 Chapterr 8 Contributions of Type-1 Reactions to Sensory and Motor Functionn loss in Borderline Leprosy Patients and the Efficacy off Treatment with Prednisone 129 Chapterr 9 Psychiatric Morbidity in People Affected by Leprosy in Nepal Assessedd with the WHO Self-Reporting Questionnaire (SRQ-20) 143 Summaryy 159 Samenvattingg 165 Referencess 172 Acknowledgementss 184 Curriculumm vitae 184 FOREWORD D FOREWORD D Itt is impossible to write anything about leprosy in Nepal without putting the illness into the contextt that was created for it over thousands of years. To be involved in any attempt to eradicatee leprosy means, therefore, that you have to start looking beyond the bacillus respon- sible,, namely Mycobacterium leprae, to the historic, cultural, social, economic and geo- graphicc features of Nepal itself. Too be diagnosed with leprosy in a country like Nepal means that one is struck by "the curse off God". This feeling often persists regardless of the level of education. The religious laws aree much the same as those applied by European Christians in the Mediaeval period. l This includess excluding patients from participating in religious activities, and thus contributing too the forced isolation from the rest of society. Religion and life here are entwined in the mostt intimate way. Inn a country that is already ranked amongst the poorest of this planet, having leprosy often meanss the loss of economic security. This is aggravated when deformities take their toll - still thee case in about one-third of all patients. Families often break up and planned marriages aree cancelled. Female patients face great social and economic difficulties. Often they are left withh the responsibility for the children, and this in a society where females more than males needd the protection of the family. Althoughh leprosy treatment is provided free of charge to all patients, the infrastructure of thee leprosy control programme is such that many patients have to travel by foot for many dayss and over considerable distances to collect their medicines or to receive treatment. In manyy regions the roads and passes are blocked by snow fall for many winter months, while duringg the monsoon season the rivers have high levels of water. This often prevents patients fromm attending clinics. Most of the patients are on the lowest steps of the economic ladder, thereforee the cost of a bus ticket to collect their anti-leprosy drugs or to replace damaged footwearr can be far out of their price range. Effortss to reduce the existing stigma, to provide health education and to stimulate self-care aree made harder by the high illiteracy rate. Addedd to this the many complications of immunological and micro-biological features of thee disease and you may get the impression that being involved in the treatment of leprosy patientss in Nepal is a disheartening enterprise. However, the opposite is true. Thiss thesis may hopefully reflect some of the enthusiasm felt when one realises that there aree ways to lighten the burden of this disease. It is indescribable to reflect on how much we cann learn from the patients when we join their struggle against the disease. 9 9 FOREWORD D Anandabann Hospital enjoys an excellent co-operation with several staff at the Ministry of Healthh and especially with the staff of the Leprosy Control Programme of His Majesty's Governmentt of Nepal. Ultimately, it will be through their dedication and efforts that lep- rosyy will be eradicated in Nepal. Reference: : 1.. Toth-Ubbens M. Verlorenn beelden van miserabele bedelaars. Dee Tijdstroom b.v. Lochem, Netherlands. 1987. 10 0 Chapterr 1 Introduction n 11 1 CHAPTERR 1 12 2 INTRODUCTION N Ï.NEPAL L 1.11 HISTORY Thee history of Nepal dates back to ancient time. Legend has it that Manjusri Bodhisattwa fromm China came on a Pilgrimage to worship Swayambhu. When he reached the top of Nagarkott he saw flames constantly emanating from Swayambhu in the midst of the lake "Nagarad."" Eager to reach the Divine Lotus he drained the lake by cutting the lowest part off the mountain thus creating the Kathmandu valley. The founder of Buddhism, Shakyamunii Gautama Buddha, was born in 560 BC in Rupandehi (Lumbini). Thee period of 350 to 630 AD, known as the Lichavi period, is considered in many ways to bee the Golden Age in the history of Nepal. Until the 12th century the majority of hill tribes off Tibeto-Burman origin lived in small autonomous chiefdoms. Trade with Tibet exposed themm to Tibetan traditions of animism and later to Tibetan Buddhism. In the early 13th centuryy the Islamic Mogul invaded North West India. The high caste Hindu Rajput nobil- ityy fled to the North and East into the contemporary Far West region of Nepal, bringing withh them their fourfold Hindu caste system with the attendant Brahmans (the highest caste off the priests and teachers), the Kshatriyas (the second highest rulers and warrior's caste of whichh the present caste name of Chetri is derived), the Vaisya (merchants and traders) and thee Sudra (farmers, artisans and labourers). The fifth class of untouchables are the outcastes andd the socially polluted like those who are diagnosed with leprosy.
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