In both the Old and New Testaments the name leprosy is given to a number of physical conditions which were often unrelated to leprosy. These conditions were considered a punishment from God for sin. The victim was said to be in a state of tsara'ath , or defilement. This Hebrew term was later translated as lepros, from which came the word leprosy. The Old Testament gives detailed instructions in the Leviticus (13:1-23) regarding the recognition of an infectious skin lesion and a non-infectious lesion.

The disease spread from its probable area of origin in the Indus Valley in India to the Mediterranean and North African regions; all of Europe was eventually affected. The disease is much less common now. It is estimated that less than 5 percent of the world population is susceptible. The disease is found more frequently in countries where nutrition is poor. Approximately 5500 known cases of leprosy exist in the United States, and nearly 200 new cases are reported annually. In the western hemisphere, about 336,000 cases are registered; worldwide figures indicate about 5.25 million registered cases and about 10 million estimated sufferers. Leprosy is perhaps the least infectious of all the contagious diseases. At present, newly diagnosed patients are seldom isolated.

Leprosy is classified, according to symptoms and histopathology (abnormalities of tissue cells affected by the disease), as lepromatous, a generalized form; tuberculoid, a localized form; or dimorphous (borderline), a form between tuberculoid and lepromatous. Strong resistance to the disease is shown by the development of the tuberculoid form. Lack of resistance to the organism results in the lepromatous form, in which the disease attacks not only the peripheral nerves but also the skin, the extremities, the mucous membranes, and the eyes.

The earliest symptom is often anesthesia (loss of sensation) in a patch of skin. In the lepromatous form, large areas of the skin may become infiltrated. The mucous membranes of the nose, mouth, and throat may be invaded by large numbers of the organism. Because of damage to the nerves, muscles may become paralyzed. The loss of sensation that accompanies the destruction of nerves may result in unnoticed injuries. These may result in secondary infections, the replacement of healthy tissue with scar tissue, and the destruction or absorption of bone. The classic disfigurements of leprosy, such as loss of extremities from bone damage or the so-called leonine facies, a lionlike appearance with thick nodulous skin, are signs of advanced disease, now preventable with early treatment. The use of chaulmoogra oil was for many years the established treatment for leprosy.

The origins of leprosy in Malta is unknown. It has been suggested that the first cases of the disease in the Islands were possibly introduced from the east and south Mediterranean region by the Arabs during the two centuries of Saracen domination which started in the ninth century A.D. This hypothesis was based on the fact that the Maltese word for leprosy is djem or gdim, the origin of which is the Arabic word for the disease djudsam . The recent suggestion that the Islands may have been depopulated during this period suggests a later introduction. It is more probable that the disease was introduced with the advent of the Knights of St John of Jerusalem to the islands in 1530. The ceding of Malta to the Order markedly augmented the population by the arrival of the knights, soldiers, attendants, and refugees from Rhodes. Leprosy was apparently quite prevalent in Rhodes, so much so that the Order of St John during its stay there found it necessary to issue segregatory regulations to attempt limit the spread of disease. The earliest recorded case of leprosy in Malta was that of a Dominican friar who died in the Rabat convent on the 30th April 1630.

The second half of the seventeenth century saw an increasing preoccupation with the disease. In 1659, the Council of the order expressed its concern about the fate of lepers on the Islands, while a 1679 Commission appointed to assess the management of the Sacra Infirmeria suggested that while local lepers should be given financial aid and treated in their own homes, foreign lepers should only be admitted to the falanga reserved for contagious disease. Academic interest was first shown in 1687 when Dr. Giuseppe Zammit read a paper before a medical assembly wherein he described five cases of leprosy. A number of isolated cases were reported during the eighteenth and early nineteenth centuries, while the disease was academically discussed in a dermatological book written by Dr. Giuseppe DeMarco in 1762, and the discussions of the Accademia Medica Maltese which functioned until 1837. By 1847 Malta was included among the seats of leprosy, though it was not apparently commonly encountered. The latter half of the nineteenth century saw a marked increase in the number of affected cases probably resulting from increasing contact with North Africa through returning migrants, refugees and increased shipping. The stationing of a large detachment of Indian Troops at Imriehel in 1878 may also have been contributory since the earliest statistics of origin of leprosy cases showed that the majority of local lepers came from villages in the vicinity.

OCCUPATION OF IDENTIFIED LEPERS DURING PERIOD 1900-1929

                              MALES      FEMALES    
      OCCUPATION                                 
Agricultural labourers          81          22      
Day labourers                   47           -       
Hawkers/shop-keepers            18           4       
Stone masons                    18           -       
Fishermen                       16           -       
Carters/cabmen                  16           -       
Coalheavers                     15           -       
Servants/housemaids              6          12      
Plasterers                       4           -       
Carpenters/blacksmiths           4           -       
Soldiers/seamen                  4           -       
Students/clerks                  4           -       
Priests/nuns                     2           1       
Washerwomen/seamstresses         -           7       
Housewives                       -          27      
Lacemakers/spinners/weavers      -          15      
Beggars                          4           2       
Other/unspecified               25          18       

As a result of the committee's report, the Council of Government issued the Lepers Ordinance entitled An Ordinance for checking the spread of the disease commonly known as Leprosy. The ordinance provided for the compulsory notification under pain of legal penalties of every cases of leprosy immediately it was recognized. Cases confirmed by the Leprosy Board, composed of five doctors, were to be immediately segregated in a Leprosarium for as long as they were deemed a public danger. An ad hoc Leprosarium was constructed near the Poor House, the male section being occupied in 1990, while females were admitted after 1912.

Concurrently with the opening of the Leper Asylum, special regulations were issued to ensure and maintain complete segregation from the outside community. The severe restrictions imposed by these regulations were greatly resented by the lepers so that the first five or six years were marked by incessant complaints, frequent disturbances, escapes from the Asylum, and attacks on the personnel. The first disturbance occurred in May 1900 - only five months after the first patientts were received. Fifty-four male lepers overpowered their attendants and found their way out of the Asylum. Another disturbance occurred in September 1900. Order was restored on both occasions after intervention by the police. In view of these repeat disturbances, a detachment of police were retained in the Asylum to maintain order. This detachment was removed in 1903 when the hospital attendants were given executive police powers. The lepers settled to a normal life in the hospital by 19067, though complaints continued to crop up. While the 1893 Ordinance did not allow the lepers to leave the Asylum except to visit sick family members or to emigrate abroad, individuals were granted special leave of absence for a few hours for domestic, legal or financial transaction which required their presence. By 1901 inmates were being allowed to go out accompanied two at a time for walks in the country. This was extended in 1902 to a drive in a cart, cab (after 1910) or bus (after 1930).

In 1916 as a result of complaints regarding the food and clothing supplies, the Governor appointed a Board to inquire into the discipline of the Leper Asylum, and to recommend efficient measures for its proper maintenance, and to ascertain whether the inmates had any substantial grounds of complaint, and to suggest the means of removing any grievances that were well founded. The board reported that the grievances were generally unfounded and were the result of the restrictive circumstances. It also opinionated the low degree of communicability of leprosy. A second Committee was appointed in 1918 to study de novo the question of the seclusion of lepers enforced by the law. This Committee maintained that compulsory segregation was still necessary, but emphasized that patients should have the right to all the necessary comforts and the best therapeutic treatment. As a result of this report, an amended Lepers Ordinance was published in 1919, while the hospital regulation were revised. The new regulations required internment of the leper only seven days after confirmation, and allowed for the eventual discharge of the patient when the disease process was considered arrested and there remained no further risk to the public.

As a result also of the 1919 Committee's recommendations, a number of innovations were instituted to alleviate the lepers' situation in the Asylum. The patients were given the facility to be usefully employed for domestic work and maintenance in the Institution, while the surrounding grounds were given over for poultry farming and cultivation by the inmates. The increasing useful activity was well received by the inmates. Furthermore a common-room with indoor games and reading material was made available, while entertainment was regularly provided. The realization and acceptance that leprosy had a very low infectivity rate allowed the introduction after 1929 of family visits by the inmates accompanied by an attendant.

Further amendments to the Lepers Ordinance were made in 1929 to enable the examination of contacts of diagnosed cases, while a new leprosarium was opened at Fort Chambray in Gozo in 1937. In the same period the Lepers Hospital, previously managed in conjunction with the Poor House, was given an autonomous management; while the hospitals name were eventually changed to St. Bartholomew Hospital (Malta) and Sacred Heart Hospital (Gozo) to remove the stigmata associated with the disease. The low infectivity of the disease was eventually accepted and the segregation policy was removed in 1953 when compulsory internment was abolished except under special circumstances. The decrease in the number of patients allowed for the eventual transfer of St Bartholomew Hospital to Gharghur. The number of known lepers in the Maltese Islands in 1957 was 151 (a rate of 0.64 per 1000 population).