LEPROSY (Lepra Arctbum, Elephantiasis Graecorum, Aitssatz, Spedalskhed), the greatest disease of mediaeval Christendom, is identified, on the one hand, with a disease endemic from the earliest historical times (1500 B.C.) in the delta and valley of the Nile, and on the other hand with a disease now common in Asia, Africa, South America, the West Indies, and certain isolated localities of Europe. An authentic representation of the leprosy of the Middle Ages exists in a picture at Munich by Holbein, 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 Virchow 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 Danielssen 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 cases 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 11th. 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 enter 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 Leuten aussätzig, und 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 1711 (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, and 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), Moide, 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 1145), 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 infections, 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 erythematous 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 varieties, the spotted (Lepra maculosa) and the nodular (Lepra tuberculosa). The two kinds are found side by side in the same population, and sometimes in the same person. The maculae arise in the place of former recurrent spots, and are often raised indurations; when the pigmentation deepens, the disease is L. maculosa nigra; when the spots become blanched, it is L. maculosa alba or white leprosy. Anaesthesia, which very generally goes with the leprous process, is especially marked in the blanched spots, hence the name L. anxsthelica. Anaesthetic spots are apt to have bullae forming on them (pemphigus leprosus), their periodical eruption being attended with fever. The nodules (characteristic of the other form) generally arise also in the situation of old blotches; they are at first small scattered points, but they grow and coalesce to the size of lentils, hazel nuts, or walnuts. While the maculae of leprosy may occur in any part, the nodules are most apt to form on the face (brows, eyelids, ears, wings of the nose, lips, cheeks), causing thickening of all the features (Leontiasis, Satyriasis); but they often occur on the hands and feet, and sometimes over the whole body. The nodules, from being exposed to the weather and to injuries, often ulcerate, and the ulcers, like those of syphilis and lupus, tend to spread. Maculae, especially on the limbs, are liable to slighter ulcerations followed by incrustation. Deep ulceration and necrosis occur at the joints of the fingers and toes, which may drop off joint by joint, leaving a well-healed stump (L. mutilans). Certain mucous membranes thicken, become nodulated, and ulcerate, viz., the conjunctiva cornese (causing pannus lep>rosus), and the lining of the mouth, nose, throat, and larynx (causing hoarseness). The external groups of lymphatic glands enlarge ; leprous affections of the viscera also are described. The peripheral nerves are the subject of thickenings and degenerations like those in the skin. The new-formed tissue in all situations is granulation-like, as in syphilis and lupus; and leprosy, with those two diseases, is treated of by Virchow under the head of granuloma. By some the nervous lesions (including an alleged affection of the spinal cord) are taken to be primary, while the changes in the skin and other parts (with anaesthesia) are held to be secondary and due to disordered innervation. Leprosy has been claimed as one of the diseases caused by parasites, on several occasions by old writers in the gross sense, and recently by observers who have found innumerable minute bacillus-rods within the cells of the leprous new growth. The essential cause of leprosy is unknown. It probably arose in the Delta and valley of the Nile in prehistoric times, and under similar climatic and telluric conditions in other (chiefly inter-tropical) countries; and the most memorable fact in its history is its rise and subsidence as an epidemic disease in Europe. It is now endemic (chiefly but not exclusively) among peoples who inhabit the sea-coast or the estuaries of rivers, who live much on fish (often putrid), and who inter-marry closely. The old opinion that leprosy is contagious is now generally discredited.

Literature.—For history and geographical distribution, see Hirsch, Ranclbuch tier historisch-geographischen Pathologie, 1st ed., Erlangen, 1860 (with exhaustive literature). For pathology, Virchow, Die krankhaften Geschioulste, Berlin, 1863-67, vol. ii. For clinical histories, E. Liveing, Elephantiasis Grsecorum or True Leprosy, London, 1873, chap. iv. For mediaeval leprosy—in Germany, Virchow, in Virchow''s Archiv, five articles, vols, xviii.-xx., 1860-61; in the Netherlands, Israels, in Ncolerl. Tijdschr. voor Geneeskunde, vol. i., 1857 ; in Britain, J. Y. Simpson, Edin. Med. and Surg. Journ., three articles, vols. lxvi. and lxvii., 1846-47. Treatises on modern leprosy in particular localities : Danielssen and Boeck (Norway), Traite de la Spedalskhed, with atlasof twenty-four coloured plates, Paris, 1848 ; A. F. Anderson, Leprosy as met with in the Straits Settlements, coloured photographs with explanatory notes, London, 1872 ; H. Vandyke Carter (Bombay), On Leprosy and Ele-phantiasis, with coloured plates, London, 1874 ; Hillis, Leprosy in British Guiana, an account of West Indian leprosy, with twenty-two coloured plates, London, 1882. See also the dermatological works of Hebra, Erasmus Wilson, Bazin, and Hutchinson. An important early work is that of P. G. Hensler, Vom abendlandischen Aussatze im Mittelalter, Hamburg, 1790. (C. C.)