The Leper Hospital
Winchester
25 March 2001

Leprosy in Britain

The following is adapted from the LEPRA (Leprosy Relief Association) publication Leprosy in Britain. For details of how to order this and other booklets on the history of leprosy, click here.

Surprising as it may seem, there is leprosy in Britain today – some 300 people resident in the UK are registered leprosy patients. All of these are on treatment and none contracted the disease here. Comparisons with the past are difficult because it is only since 1951, when the disease was made notifiable, that any precise figures were kept.

The arrival of leprosy in Britain
The disease is thought first to have been brought into Britain by the conquering Roman armies, many of which had been in campaigns in Asia and the Middle and Near East. It is thought likely that the six-year campaign of the armies of Alexander the Great (circa 312 BC) through Persia, Afghanistan, and the Indus Valley carried the disease back to Macedonia. From there it was spread by the army of Pompey to Roman Italy and then through Europe as imperial Rome extended its conquests and control.

In view of the long contact time required for infection, the disease was transmitted not necessarily by individual soldiers, who in the Roman legions attained a high standard of hygiene, but rather by captives taken during these campaigns to provide the slave labour force. The Greek physician Galen (130–203 AD), in describing leprosy, said it was seldom found in Germans, but more often in Celts and in particular the Gauls. If this observation was accurate – and Galen was the supreme medical authority of the Roman world – then the disease seems to have remained endemic in the Celtic lands; it is mentioned in the lives of the Celtic saints of the post-Roman era and its healing was their most common miracle.

The extent of leprosy

The earliest evidence of leprosy in Britain that we have comes from the 4th century AD in a skeleton unearthed from a Romano–British cemetery at Poundbury Camp, Dorchester. It is not yet known if any of the other 600 skeletons of people buried in this cemetery show evidence of leprosy. A couple of centuries later, in a Saxon burial ground at Beckford, in Gloucestershire, the skeleton of a man about 30 years old was found whose feet bones had been damaged by leprosy; and at St Catherine's in the town of Thorpe, near Norwich, a skull was found with markings on it again very reminiscent of leprosy.

Also, in another location not far away at South Acre in Norfolk, a whole collection of bones came to light when road-widening works were being undertaken. The dozen skeletons found showed signs of leprosy; in fact this was probably a cemetery near a hospice or 'leper house', and written records exist of the hospice and its activities. The dates of burial of these skeletons are not known, but it is probable they were in the 11th or 12th centuries.

The most extensive piece of research into excavated bones from this period found that 0.62% of individuals showed lepromatous changes. If this figure was typical of the whole population, it would have meant some 10,000 people with leprosy must have been living in Britain by the 12th century. Another possible indication of the prevalence of leprosy lies in the number of church dedications to St Giles. Widely venerated throughout Europe during the Middle Ages, St Giles was the 'patron saint of cripples and lepers' and 150 churches were dedicated to him in England alone.

From the 6th to 13th centuries, Church councils and popes debated upon leprosy and took different steps to combat it. In England, Church ordinances and regulations were made. Following the Mosaic law in the Bible, the leper was excluded from human society. Marriage by lepers was prohibited in 660 AD and later it became an acceptable ground for divorce. Lepers had to wear distinctive dress, and were given a staff and a warning rattle or bell. They were forbidden to speak to others, to enter inns or to drink at the public fountain. They could not enter churches, but were allowed to look through hagioscopes or 'squint windows'. They could not live in towns except where 'leper houses' or 'lazarettos' were provided for those of their kind to segregate them from normal society. Monetary provision was made through local taxes and tolls and a prescribed proportion of food brought into a town was earmarked for their sustenance. Charitable alms and relief were given to them in the name of appropriate saints – St Elizabeth, St Louis, St Francis, St Giles and St Mary Magdalene, as at Winchester.

Medieval 'leper' with his bell. From a British Museum manuscript. Copyright of The Wellcome Trust.

Medieval leprosy
In English, the word 'leper' originally signified the disease itself, not the person affected by it. However, the word 'leprosy' has changed its meaning over the years, perhaps as a result of the lack of precision on the part of the person diagnosing the original condition – often a priest – or again perhaps because the English language and usage were undergoing development and change at this time. The chronic inflammation of the skin might embrace a huge number of conditions, such as scabies, syphilis or TB, or little-understood changes in pigmentation of the skin, such as vitiligo, or scaly conditions, such as psoriasis. Any 'dirty' condition of the skin, such as dermatitis, might also be called leprosy.

The English chronicler, le Baker, who lived through the Black Death (1348), recognised it as bubonic plague and noted its symptoms. Yet when describing the extension of this pestilence into Scotland, he called it 'lepra'. So, too, we have in the chronicles 'the leprosy that is smallpox'. Also, 'leprous' could imply nothing more than 'infirm' and in the ancient manuscript known as the Wurtzburg Glosses, Latin terms for weakness and infirmity are translated into old Irish as 'leprosy'. 'Leprosy' too, was used for mange and scab in animals and diseases of plants. And it was often used to describe a miserable and pitiable state where there was no question of disease of any kind.

To add to this confusion, the extent and importance of the disease was exaggerated out of all proportion by ecclesiastical example and commandments. The 50 references to leprosy in the Bible, the common usage and religious pronouncements of the words 'leper' and 'leprosy' as meaning sinner and sinfulness, kept it forever in the mind.

Identifying the disease
Following the prescribed biblical practice, identification of leprosy was made by a priest. Bishop Bronescomb, of Exeter, exclaimed: 'It belongs to the office of the priest to distinguish between one form of leprosy and another.' As the priests would have received no medical training, the accuracy of their diagnosis becomes questionable. Indeed, clerics were not allowed to practise medicine or surgery, since it was forbidden by several 12th-century Church councils – although the repeated proclamations suggest that this ban may not have been regularly observed. Monks were not covered by the prohibition, however, and many achieved fame as practitioners of medicine. Admission to the 'leper house' seems to have been at the discretion of the warden or master, who, in those houses founded by monastic charity, would be a monk.

The only indications of the methods used in identifying the disease are the few statements in the medical writings of the times. John of Gaddesden, in his book Rosa Angelica (circa 1315) says: 'No one is to be adjudged a leper and isolated from his fellows until the appearance and shape of his face be destroyed.' If admissions to leper houses had been based on this criterion, then the disease would already have been far advanced and the consequent stay in the home would have been considerably less than the average duration from admission to death of around ten years.

Up until 1847, the word 'leprosy' was used in a loose and imprecise way by doctors and laymen alike, covering a multitude of diseases and conditions of the skin. Then, in that year, two Norwegian scientists, Daniellssen and Boeck, published an illustrated atlas of leprosy and tried to define the clinical disease. It was a further 25 years, though, before doctors were able positively to confirm that a particular skin condition was in fact leprosy. This was when another Norwegian doctor, G Armauer Hansen, identified tiny microscopic rods – 'staff-like bodies' as he called them – in material taken from the skin and nose of patients suffering from leprosy.

When Hansen first announced his findings, they were treated with scorn, because the common belief was that leprosy was not something you caught, but something that you inherited. At length, however, it was proven that the little living rods really were the cause of leprosy, and eventually they were named – Mycobacterium leprae – and it was thereafter accepted (in the medical world at any rate) that this germ, and only this germ, caused leprosy. From then on, leprosy became accepted as a single disease entity, characterised by certain recognisable features, and ceased to be a kind of rubbish-bin into which all chronic conditions of the skin were thrown, such as scabies, syphilis or psoriasis.

Rogues, vagabonds, saints and martyrs
It would be generally true to say that from the time of its introduction until the end of the 14th century, leprosy was hated and feared. There were the occasional saints and kings who tolerated it – during the 10th century in France it was believed that leprosy could be cured by the king's touch – but they were very much the exception. Most people looked upon it as a loathsome thing, which resulted from sin. Its victims were despised and, even in those countries where the laws were not strict, would be cast out by society.

The horror that the 'leper' inspired did not quickly disappear. This is shown in the lines from Margaret of Anjou's speech in Shakespeare's Henry IV. She is addressing the suspicious Henry IV after the murder of his uncle, the Duke of Gloucester: 'Why dost thou turn away and hide thy face? I am no loathsome leper, look on me.'

Testimony is borne to the prevalence of the disease by national laws, by hospital authorities and by the charitable public. Schemes of taxation refer constantly to 'lepers', and measures were repeatedly taken for their expulsion from towns.

Expulsion often ended in death, and even when it did not, it still caused a great deal of suffering. An example was provided by the case of Aelfward, the Bishop of London. Early in the 11th century, this good and highly respected man contracted leprosy. He fled from the capital to the monastery at Evesham, of which he happened to be the Abbot. But the monks there refused to let him in and he was forced to wander around the countryside seeking shelter. Eventually he found it in the Abbey of Ramsey and there he died, in 1044. If this was the treatment meted out to a man of Aelfward's position, it is not difficult to imagine what happened to those in a more lowly situation.

Hark! Hark! The dogs do bark
The old nursery rhyme 'Hark! Hark! the dogs do bark, the beggars are coming to town' was once something more than a meaningless jingle, for an unending war was waged by the authorities of London against the beggars whose lawlessness and tumult were a perpetual threat to peaceable folk. Lepers, however, had a right to beg, a privilege ordinarily denied to most others under the heavy penalties of whipping, branding, and even death.

This valuable concession must have given great encouragement to imposters, for an imputation of leprosy provided the easiest means of livelihood then available to rogues and vagabonds. In 1346, Edward III (1327–1377) issued an edict expelling all the lepers living in London. Its wording shows that these people had been accustomed to roam about as they pleased. Indeed, one declared reason for the measure is that they had endeavoured to contaminate others: 'that so, to their own wretched solace, they may have the more fellows in suffering.'

Social ostracism
Public perception of the 'leper' came from the Church's attitude. In the 13th century, this was one of compassion and charity – nevertheless, a Requiem Mass would be held over the leper. Following this ritual, the leper's social ostracism was complete. After Mass and the singing of 'Libera me Domine', the leper was led out into the fields and the prohibitions read. They were obliged to wear distinctive clothes, easily recognisable as a leper's dress, with a bell or a clapper attached to their belt. They were to touch nothing they wished to buy other than with their staff, and if they drank it was to be from their own cup. If someone were to speak to them on the highway they were to go leeward before answering, and never enter a narrow lane lest they should meet someone they were unable to pass without touching.

It would be easy, but probably wrong, to suggest that prevention of infection was the reason for the instruction that a leper should move downwind before conversing with anyone. Indeed, if containment of infection was the purpose of seclusion in leper hospitals and lazar houses, why let inmates out at all (they were allowed out for farmwork and begging), and how can the punishment or expulsion from hospital for misbehaviour be explained? The regulations of the hospital of St Julian, near St Albans, put the general position with brutal simplicity: 'Amongst all infirmities the disease of leprosy is held in contempt.' The regulations continue by quoting Leviticus, ending that: 'When he is leprous and unclean he is to dwell alone without the camp.' (Leviticus 13 v 45)

The very strict programme of isolation for those with leprosy, as was practised in Europe, does not appear to have been either continuously or completely enforced in Britain. The Bishop of Exeter, in 1163, confirmed the rights of lepers to visit the market twice a week and collect food and alms, although in 1244 this right was rescinded. King John (1199-1216), in 1204, gave lepers the right to collect corn from the market at Shrewsbury; and at Chester lepers were granted a portion of all corn, cheese and fish sold on market day.

Old 'leper' hospital of St Bartholomew's, Oxford. Copyright of The Wellcome Historical Medical Museum and Library.

The institution of 'leper houses'
On the outskirts of a town in medieval times, travellers would have noticed a well-known landmark – a group of cottages with an adjoining chapel, clustering round a green enclosure. At a glance they would recognise it as the 'lazar house', and would prepare to throw alms to the crippled and disfigured representatives of the community.

There are many indications that leprosy slowly and insidiously made its way across Britain. One of these was the establishment of these 'leper houses': Nottingham in 625, York in 936, London and Beverley (both before the Norman Conquest in 1066), and Chatham in 1078. Rochester and Harbledown were both founded before 1100 and they were followed (before 1135) by foundations at Alkmonton, Whitby, Lincoln, Colchester, Norwich, Newark, Peterborough, Oxford, Newcastle, Wilton, St Albans, Bury, and Warwick. Within the next 20 years hospitals are mentioned at Canterbury (St Laurence), Buckland by Dover, Lynn, Burton Lazars, Aylesbury, Ripon and Northampton, and there were also other early asylums at Carlisle, Preston, Shrewsbury, Ilford, Exeter and so on.

Lazar houses also provided spiritual care. Archbishop Lanfranc of Canterbury was especially active in this way, endowing a hospital at Herbaldown in the Forest of Blean in 1084. He laid down that lepers should be 'cared for by a Chaplain and skilful, patient and kindly watchers'. It is interesting to note though that a lot of these institutions were created before the Crusades. Most people imagine that the returning Crusaders alone introduced leprosy into Britain, but the evidence of leprosy being present, certainly in England, prior to the Crusades is very strong.

The Crusaders and leprosy
The Crusaders did pose a problem for the Church, though. On 15 July 1099, the Turks were driven out of Jerusalem. After three years of fighting, the First Crusade was over: the Crusaders had captured Jerusalem, but in the process, several of them had also contracted leprosy. So what was the Church to do? These men had been sent, with the Church's blessing, to engage in a holy war against the infidel Turk and they returned stricken with a disease that was generally reckoned to be a sign of God's displeasure or a punishment for sins.

The answer to the difficulty came from the Bible and, ironically, from the very passage in Isaiah which had until then caused the most suffering. The men who studied Isaiah early in the 12th century suddenly realised something that should have been obvious from the start – this was a book of prophecy. It foretold what would happen to the Christ when He came down to earth. If one translated the word leprosum literally as meaning leprous, then Isaiah had said that Jesus himself would be 'esteemed leprous'.

The 'holy' disease
This argument had obvious weaknesses, but they were not apparent to the medieval mind. They now had an excuse for believing what they wanted to believe – that leprosy could be looked upon as a 'holy' disease. The Crusaders had not been struck down by God so much as singled out by Him for His own purposes. They were 'Christ's Poor', holy men visited with leprosy in much the same way as wise men in the Middle East are said to be visited with blindness.

Once this reversal in attitude had been made, everything else followed logically, and a continent-wide movement to ease the suffering of leprosy began. Leper hospitals sprang up like mushrooms, irrespective of whether they were needed or not. It also became fashionable to engage in works of charity, to gain merit in the hereafter or to expiate sins committed; those suffering from leprosy became the objects of special concern.

This compassionate attitude probably reached its peak following the life of St Francis of Assisi (1182–1226), who attributed his conversion from a life of luxury and ease to one of service to his fellow man to a chance encounter with a starving leper. Terrified of the man, Francis nevertheless jumped down from his horse and kissed his hand. When his kiss of peace was returned, Francis was filled with joy and it was from this moment that his life changed. Henceforth the leper was regarded as an instrument of God's intervention in earthly matters. The welfare of lepers became the particular concern of the Franciscan Order; every novice in that Order having to serve some period of his novitiate in a leper hospital.

Royal examples
Royalty led the way in being seen to 'do good' for those with leprosy. The earliest indication of this is probably the behaviour of King Edward the Confessor (1042-1066). When on one occasion the royal procession from Westminster Palace to Westminster Abbey passed an infirm victim, the king, 'moved by the sight, carried the sufferer upon his own shoulders into the Abbey where he publicly prayed for his subject's restoration to health'. Later, King John (1199–1216) set the fashion by endowing hospitals and hospices for those with leprosy at Stourbridge and Shrewsbury.

Queen Matilda, wife of Henry I (1100–1135), who was responsible in 1101 for the building of the hospital of St Giles in the Fields, in Holborn, for 40 leprosy sufferers, exemplified practical concern for those with the disease. When her brother (David, King of Scotland) was serving as a youth at the English Court, the Queen called him into her chambers one evening. He found the place 'full of lepers, and the queen standing in the midst with her robe laid aside and a towel girt round her. Having filled a basin with water, she proceeded to wash the feet of the lepers and to wipe them with the towel, and then taking them in both her hands, she kissed them with devotion.'

Her brother remonstrated with her about this with the words: 'What dost thou, my lady? Certes if the king were to know this, never would he deign to kiss with his lips that mouth of thine polluted with the soil of leprous feet.' She apparently answered with a smile: 'Who does not know that the feet of an Eternal King are to be preferred to the lips of a mortal king? See, then, dearest brother, wherefore I have called thee, that thou mayest learn by my example to do so also.' Queen Eleanor of Aquitaine, wife of Henry II of England (1154–1189), also opened a 'leper house' in Caen Normandy around 1160 and founded many other hospitals in France and England.

Under the impetus of this growing charitable attitude, a large number of houses for the care of lepers were founded by royal, ecclesiastical and aristocratic patronage. People of the standing of King Henry I and Queen Matilda, King John, the Earl of Chester, Archbishop Lanfranc of Canterbury and Abbot Gregory, of St Alban's Abbey, built institutions and endowed them with the income from tithes, rents and tolls under their control. Parcels of land, the rent of which was granted for the upkeep of leper houses, became known as Terra Leprosorom and marked as such on early maps. Many foundations must have come about as acts of penance, since several are dedicated to St Mary Magdalene, as at Ripon, Cardiff, Tenby and, of course, Winchester. The Hospital of St Mary Magdalene for Lepers in Canterbury, founded in 906, was one of the first 'leper' houses in England. There was also one dedicated to St Mary Magdalene near Bargates in the northern part of Christchurch, Dorset. The revenues of this foundation, which arose from small pieces of land, some cottages and garden grounds, amounted to about £30 yearly, and were applied for charitable purposes.

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Entry to and living conditions in 'leper houses'
Diagnosing leprosy to secure someone's admission to a 'leper' house or hospital was a curious business. One method was by dropping a raven's egg into a sample of the person's blood: if the egg hardened, he was supposed to be leprous!

The hospitals were small places, most having a staff of about three and accommodation for about ten lepers, but a few were larger, such as Harbledown, near Canterbury, which could accommodate 100, and Sherburn near Durham, which had room for 65. The Harbledown leper house was built in 1174 and Henry II (1154–1189), after visiting Canterbury Cathedral and spending the night in prayer at Becket's Shrine, is said to have bared his back for a scourging and undertook to pay an annual contribution of 20 marks to the house (which is still paid to the local hospital by the Crown today).

Each house had its own set of rules and regulations, but all had religious observance as part of their daily routine and in most the inmates had to take some form of religious vows on admission. In some, married couples were expected to live separate lives; in others women were expected to take the vows of becoming a nun. Most houses employed staff free of the disease, but at St Leonard's at Lancaster, the leper inmates elected their Master from among their own ranks.

Vows of obedience
Vows of obedience were imposed on the entrants, who had to conform to certain laws of behaviour and wear whatever dress was prescribed, not just because they were lepers but because they were in a manner professed brethren. This movement brought relief and comfort to many sufferers, among whom there must have been some uncertain proportion of true cases. It is interesting to note that not all inmates were as grateful to their benefactors as was expected. It is recorded, for example, that in 1315 the inmates of the Kingston leper house rose in revolt, demolished the building, and took to the roads.

The 12th-century set of regulations for inmates of a leper house laid down by Bishop Bartholomew of Exeter were quite harsh:

1. Any brother or sister, being one of the company of the said house, unless sick, shall bear divine service twice daily.
2. No brother or sister shall go beyond the bridge without the gate of the hospital without the licence of the custos or his deputy.
3. No visits are allowed between houses or lodgings of any sister or brother.
4. No guest may lie with his wife or wife to lie with her husband in one and the same bed within the precincts of the hospital.

In contrast to this, the rules of Sherburn leper house expressly permitted the inmates to receive their friends, and those visitors who came from a distance could remain for the night. It is illuminating to read in these same rules that a mutinous leper, whose obstinate disobedience yielded neither to flogging nor to a diet of bread and water, would receive the final penalty – expulsion! Similar rules were in force in other institutions, and a long account has survived of the expulsion of a 'leper' from the Ilford house because he had 'imported a woman of light character under the pretence that she was his sister'.

Rules were also laid down for the dress of the inmates. At St Julian's, in St Albans, 'The brothers are to have an upper tunic of russet with a hood cut the same so that the sleeves be closed as far as the hand.' And at Sherburn Hospital, in Durham, 'Each leper to have a yearly allowance for his clothing of three yards of woollen cloth (white or russet), six yards of linen and six of canvas.'

However, in certain areas lepers could refuse to enter a lazar house. Indeed, in 1344 it is recorded that the revenues of St Julian's in St Albans 'are too large for its needs, for in general there are no more than three inmates, sometimes two, and occasionally only one, because of the difficulty of finding lepers willing to lead a restricted life'.

The decline of leprosy
The foundation of 'leper houses' reached a peak around 1200 AD, decreasing during the 14th century and reducing to zero by the 15th. Many attempts have been made to answer the question of why leprosy died out, but no real reason has been found. While most people thought leprosy was hereditary and would die out when no descendants were left by known sufferers, environmental factors were also thought to be playing some vague role in the decline of the disease. Reduction by famine or pestilence selectively picking out those with leprosy, changes in dietary habits and improvements in housing, resulting in decreases in domestic overcrowding, have all been offered as reasons. The disappearance of leprosy in Britain is also often attributed to the enforcement of 'absolute and strict segregation', but there is much evidence to refute this. Whatever the cause, during the 14th century, the leprosy endemic began to wane, and many of the old institutions were hard put to find enough deserving inmates to justify their continued existence.

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