LEPROSY 469 Middle Ages exists in a picture at Munich by Holbein, j painted at Augsburg in 1516; St Elizabeth gives bread and wine to a prostrate group of lepers, including a bearded man whose face is covered with large round reddish knobs, an old woman whose arm is covered with brown blotches, the leg swathed in bandages through which matter oozes, the bare knee also marked with discoloured spots, and on the head a white rag or plaster, and, thirdly, a young man whose neck and face (especially round the somewhat hairless eyebrows) are spotted with brown patches of various size. It is conjectured by Yirchow that the painter had made studies of lepers from the leper-houses then existing at Augsburg. These external characters of mediaeval leprosy agree with the descriptions of it by the ancients, and with the pictures of modern leprosy given by Dauielssen and Boeck for Norway, by various authors for sporadic European cases, by Anderson for Malacca, by Carter for India, by Wolff for Madeira, and by Hillis for British Guiana. There has been some confusion in the technical naming of the disease ; it is called Elephantiasis (Leontiasis, Satyriasis) by the Greek writers, and Lepra by the Arabians. The latter term has been generally adopted in modern books, but in England the name of Lepra is applied (after Willan) to an entirely different disease of the skin. History. Egypt was regarded by the ancients (positively by Lucretius) as the country whence leprosy came. It was probably endemic among the Hebrews when they migrated from Egypt. The minute diagnostic indications given in Lev. xiii. appear to relate to true leprosy and to other diseases that might be mistaken for it, and the frequently recurring word Sara ath (translated "leprosy") is best taken in a generic sense ; those cases in which progress would show itself at so short intervals as seven days, and those case? for which the ceremonial of cleansing was pro vided, could hardly have been cases of leprosy, a disease always incurable, and with stages reckoned rather by months or years than by weeks. Herodotus knew of leprosy as existing in Persia. The earlier Greek and Latin writers speak of it as a foreign disease, but it became estab lished in Greece and Italy in the 1st century B.C. ; Pliny implies that it was introduced by the army of Pompey returning from Syria. The disease soon appeared in the Roman colonies of Spain, Gaul, and Britain. The Lom bard king Rothar (7th century) made laws regulating the marriage of lepers, and similar laws were made by Pippin and Charlemagne. Leper-houses existed at Verdun, Metz, and Maestricht in the 7th century, at St Gall in the 8th, and at Canterbury in the llth. It was amidst the stir and movement of the crusades that leprosy grew to be epidemic in western Europe ; it attacked the people in great numbers and in all ranks (including members of royal families). Leper-houses (mostly religious and dedicated to St Lazarus, but in northern Europe more secular and dedicated to St George) were founded in every considerable town ; the total number of these in Europe was loosely estimated by Matthew Paris at 19,000, the number in France is independently estimated at 2000, and (according to Sir J. Y. Simpson) there were 95 houses of the first class in England (of these 7 at Norwich and 5 at Lynn), and several in Ireland and Scotland. The isolation of lepers was strictly enforced by law and popular senti ment. They wore a special costume, usually a long grey gown with hood drawn over the face, and carried a wooden clapper to give warning of their approach. They were forbidden to entjr inns, churches, mills, or bakehouses, to touch healthy persons or eat with them, to wash in the streams, or to walk in narrow footpaths. Their outcast state was signified by the German name (Aussatz) ; the Chronicle of Limburg (under the year 1374) speaks of a famous monkish poet, whose songs all Germany was sing ing, as one " der ward von den Lenten, aussdtzig, iind war nicht rein." The disease began to decline (first in Italy) in the 15th century, and had mostly disappeared in the 17th. A leper-house was founded in Edinburgh (at Greenside) as late as 1591, and it was not till 1741 (others give 1798) that the last known leper died in Shetland. Present Geographical Distribution. Survivals of the great mediaeval outbreak are found on the west coast of Norway (about two thousand lepers ; leper hospital at Bergen founded 1277, now added to), in the Baltic pro vinces of Russia (leper hospitals founded at Riga in 1220 and Revel 1237, not now in use), on the Riviera (a small and diminishing number), on the Sicilian coasts, aud in certain coast provinces of Spain and Portugal (leper hospital at Lisbon since the 13th century). Sporadic cases of home origin have also been described for Hungary and Roumania ; the cases occurring in England and France are in persons who have been born or have lived in the East or West Indies. The disease is met with also in Iceland, along the Caspian and delta of the Volga, along the Black Sea, and in islands of the Levant (especially Scio and Crete). It is common all over the East from Syria to Japan and Kamchatka, in Egypt and North African states, in West Africa from the Senegal to the Congo, in Cape Colony, Madagascar, Mauritius, Isle de Bourbon, St Helena, Madeira, Canaries and Azores, Brazil, Central America, the West Indies, Mexico, New Brunswick (small isolated French colony), and especially in the Hawaiian Islands. Leprosy has been found among Chinese immi grants in the United States as far east as Chicago, and in Queensland. Leper hospitals (with inmates numbering from two hundred downwards) are kept up in several of the West Indian colonies, at Tracadie (New Brunswick), at Cape Town, in Mauritius, at Malacca and Singapore, at Colombo, at Madras, Cochin, and Bangalore, at Bombay and Rajkot, and at Calcutta, Benares, and Agra. There are also leper hospitals at Bergen (3), Molde, and Trondhjem, at San Remo, at Oporto, Coimbra, and Lisbon, at Terceira (Azores), Las Palmas (Grand Canary) since 15th century, and Funchal (Madeira) since about 1500, at Pernambuco, Bahia, and Rio, at Honolulu, at Macao (for two hundred years) and Canton, in Java (several) and in Amboyna, at Scio (since 1445), Scutari, Damascus, and Jerusalem. A ruined convent at Ramleh accommodates thirty lepers or more, and a mosque at Nablus is occupied by about seventy. In several of the above instances the leper hospital is built upon an outlying island. Leper villages occur in China and Japan, and in Persia. Leper communities exist in Crete, but the largest of them is now mostly occupied by a non-leprous population. Throughout the East, including British India, the hospital accommodation for lepers is only casual, and isolation is not carried out to the same extent as during the prevalence of the disease in Europe. Definition, Characters, Pathology, and Causation. Leprosy is an incurable constitutional disease, marked externally by discoloured patches and nodules on the skin, and deeply implicating the structure and function of the peripheral nervous system. Like the infection?, it has a prodromal stage, which is uncertain in its character, and is measured rather by months or years than by days or weeks ; the chief premonitory symptoms are unaccount able lassitude and mental depression, pains in the limbs and joints, febrile periods (cold and hot fits), loss of appetite, and nausea. That stage is followed by the " periodically eruptive stage," during which blotches on the skin come and go ; sooner or later these crythematous congestions and exudations leave either permanent spots, brown or blanched, which are often without feeling, or they leave nodules. The disease diverges into two main
