Among the diseases and afflictions encountered throughout history, leprosy is perhaps second only to plague in its associations with suffering, disfigurement and death. Images of sufferers cast out from society, forced to live in leprosy colonies and advertise their condition with a bell, have become clichéd portrayals of medieval leprosy – but they are far from the whole accurate picture.
The chronic illness known today as Hansen’s disease is a bacterial infection that causes skin sores and ultimately, if untreated, damage to the bones of the face, hands and feet, as well as breathing difficulties and blindness. Unlike plague victims, sufferers can live with their symptoms for several years or even decades, so leprosy patients have constituted a recognisable component in past societies, probably present in Britain from the fourth century AD or earlier. Until very recently, there has been no effective treatment for leprosy; past therapies have been palliative rather than curative, including medicinal baths, bandaging and dietary regulation.
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The history of leprosy and its sufferers is complex and sometimes ambiguous. The disease is mentioned in several passages of the Bible. It affected people in Europe in the Middle Ages, when numerous leprosy hospitals were founded, but declined across most of the continent from the 16th century, though it continues to occur in Africa, Asia and South America.
Colonial encounters with sufferers in other parts of the world in the 19th century caused Europeans to reflect upon the presence of leprosy in the medieval west, and to construct a narrative of a stigmatised, excluded group. This narrative has been questioned in recent decades; historians now emphasise the fact that leprosy patients were viewed as a special religious group, selected by God to suffer on earth and attain salvation, and were a major focus of Christian charity. Furthermore, although leprosy hospitals were located outside towns and cities, their residents remained connected with mainstream society, and received spiritual as well as bodily care – they were not shunned.
Our understanding of past views of leprosy is also complicated by ambiguity in the disease’s identity in historical sources. From antiquity until 1873, when the bacterium Mycobacterium leprae was identified by GH Armauer Hansen, the word leprosy did not necessarily signify one single disease. Indeed, in the ancient Greek texts attributed to Hippocrates, lepra described a range of different skin disorders. Similarly, in the Latin Vulgate Bible lepra was not clearly associated with a single medical condition. In fact, in the ancient world the disorder that most closely manifested the symptoms of Hansen’s disease was called elephantiasis.
In the medieval and early modern periods, not all people who were diagnosed with leprosy suffered from Hansen’s disease – other skin complaints, such as psoriasis, could be mistaken for the disease. Nonetheless, archaeological excavations of cemeteries associated with leprosy hospitals have confirmed that these institutions accommodated Hansen’s disease sufferers: changes caused by the disease, ranging from bone lesions to the loss of fingers and toes, are clearly visible in skeletal remains. Recent scientific analysis of the DNA preserved in medieval bones has shed further light on the presence of Hansen’s disease, and on the relationship between historical and modern strains of the infection.
By the 16th century, when markedly fewer incidences of leprosy were occurring in Europe, a finely tuned diagnostic procedure was in place; evidently, correct identification of the disease was considered important. Indeed, much was at stake: a positive diagnosis would affect an individual’s professional and legal status, and would necessitate entry to a leprosy hospital. To make the diagnosis, physicians and urgeons examined the exterior of the patient’s body and his or her blood and urine, and took a detailed case history. Other people who were considered to have expertise relating to leprosy, including the sick residents of leprosy hospitals, were also involved in diagnostic examinations.
At any point in time leprosy affected only a very small proportion of the population. It is not highly contagious, a fact recognised by many medieval and early modern people. A woodcut of a leprosy examination in a 16th-century surgical fieldbook shows a surgeon freely touching a suspected sufferer, placing his hands on the examinee’s head. Yet the disease provoked fear and anxiety disproportionate to the threat that it actually posed. Many of these responses stemmed from the physical impairment and shocking disfigurement seen in advanced cases of leprosy.
In addition, leprosy became bound up with concerns about contagious illness in general – fears that increased dramatically following the Black Death of the mid-14th century and the arrival in Europe in the 1490s of the pox (syphilis). In many late medieval and early modern images, pox, plague and leprosy sufferers are depicted in much the same way, with their bodies covered in ulcers, suggesting that they were considered together as one large category of ‘the sick’.
Though attitudes to leprosy have varied through history and across locations, responses to leprosy have been characterised by both compassion and stigma. Today, effective treatment with antibiotics is widely available, but in India many sufferers still do not seek treatment until their symptoms are advanced, because of the associated stigma and shame. Historically, leprosy has stood out as a special illness, associated with divine grace, but has also become representative of sickness more broadly. Further historical study of the disease will help us understand the social impact of diseases in the past, present and future.
Elma Brenner is the Wellcome Library’s subject specialist in medieval and early modern medicine
This article was first published in 2017 in BBC History Magazine‘s Story of Medicine Special Edition