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Stigma has been defined by Goffmanl as an attribute that is deeply discrediting, and the stigmatized individual is one who is not accepted and not accorded the respect and regard of his peers; one who is disqualified from fu \1 social acceptances. Goffman uses the term 'd iscreditable individual' for the person who assumes his differentness is neither known about by those present nor immediately perceivable by them, and he goes on to describe three main groups of stigmatized individuals. Firstly, those with physical deformities, particularly of the face. Additional examples are scars on the wrists of those who have attempted suicide, and the injection marks on the arms of drug addicts. Secondly, those with blemishes of character, inferred by a history of mental disorder, epilepsy, imprisonment, drug addiction, alcoholism, homosexuality, unemployment, suicidal attempt, and radical political behaviour. Thirdly, those with tribal stigma of race, nation, social class, and religion. Leprosy stigma Applying Goffman's definitions to leprosy, we can see that a\1 of his three groups of stigmatized individuals are encompassed by the one disease: in the group with physical deformities we have the face of the neglected lepromatous patient, the facial plaque of the nonlepromatous patient (especially if in reaction), facial palsy, claw hand deformity or fo otdrop (both of which may identify the leprosy sufferer in an endemic country), or the hypopigmented macules which are so conspicuous on a dark skin. In the group with blemished character we have segregation in a leprosarium, or a history of such segregation. For Christian and Je wish communities we can add the use of the word 'l eprosy' in the Bible as a punishment for sin. In the group with tribal stigma we have the immigrant worker in, say, a country of Western Europe, who has been fo und to have leprosy; not only is he a fo reigner but he is likely to have a pigmented skin and to belong to the working class, factors which render him 'i nferior'. He may even not be a Christian. The 'tribal' factor in countries where leprosy is endemic is poverty, for society looks upon leprosy as a disease of poverty.

This is the first report of renal transplantation in a patient with lepromatous leprosy although renal failure is an important cause of death in these patients (Brusco and Masanti, 1963;Desikan and Job, 1968;Hart and Rees, 1967).The deficiency of cell-mediated immune response in patients with lepromatous leprosy results in a prolongation of survival of allogenic skin grafts (Heart -and Rees, 1967;Turk, 1970;Han et al., 1971 He was now treated initially with dansone at a dose of 1 mg dailv and the prednisolone was increased to cover the lepra reaction. After initial improvement he developed a further reaction and his therapy was changed to clofazimine. On a dose of 300 mg daily his skin lesions regressed ranidly although he developed a bright red pigmentation of his skin.He remained well until December 1970, when he was readmitted with deterioration of renal function coincident with a further lepra reaction. His creatinine clearance was 5-2 ml/min and a renal biopsy showed the appearances of a chronic rejection process. He was re-established on outpatient haemodialysis. Three months later he developed pneumonia with a cavity in the apex of the lower lobe of the left lung. This was assumed to be tuberculous and he was treated with antituberculosis therapy. He had a severe lepra reaction with rifampicin, but this improved by changing to isoniazid and PAS. However, he then developed a cholestatic jaundice and died a week later, four years nine months after renal transplantation.At necropsy changes affecting many tissues and organs were found. There was a papular rash mainly on the trunk and upper limbs. Some papules contained large clusters of vacuolated cells (lepra cells) in the dermis around vessels and nerves but in none of these cells were any acid-fast bacilli found. Macroscopically many organs were a lilac pink colour which was more noticeable after fixation in a formalin-saline solution. This discoloration, although affecting the stomach, duodenum, and particularly the entire ileum, was conspicuously absent in the greater part of the jejunum. Klebsiella aerogenes was cultured from the lower lobe of the left lung which was uniformly consolidated. No organisms were isolated from a cavity at the apex of this lobe in which there was caseation. Cytomegalovirus was grown from lung tissue and inclusion bodies typical of this virus were seen both in the lungs and submandibular salivary gland. The heart was enlarged (435 g) due mainly to left ventricular hypertrophy and was partly covered by a fibrinous pericarditis. The liver was engorged and many lobules included centrilobular cholestasis. The biliary tract was patent and normal. An abscess from which no micro-organisms were identified replaced the distal third of the body of the pancreas. Both testes had lost their septate pattern and included ill-defined areas of firm grey fibrous tissue. Their tubules were necrotic and the epididymes thickened.Both the patient's own kidneys were equally small with finely and evenly granular surfaces. Microscopically in both kidn...

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