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Leprosy

The bacillus responsible for leprosy was not discovered until 1874, one of the first bacterial pathogens to be described. In preceding centuries the early stages of leprosy had often been confused with other skin diseases, but the advanced stages of leprosy—characterized by loss of nerve conduction and bodily disfigurement—occurred frequently enough to ensure continuous alarm about physical signs that might foretell the gradual and, for all practical purposes, irreversible wasting of the body by leprous infection. Leprosy was dreaded first of all because it was frequently assumed to be incurable and eventually fatal. Second, it was thought to be contagious—somehow. The strict rules established over the millennia to quarantine lepers reveals that people commonly believed they could be infected by touching a leper or coming into contact with his or her breath.

Medical care often falls into the simple sequence of diagnosis, then treatment. For leprosy the sequence was diagnosis, then separation. Leviticus, the third book of Moses, contains detailed rules for the diagnosis of leprosy. Once the diagnosis is made, the following is commanded by the Lord:

The leper who has the disease shall wear torn clothes and let the hair of his head hang loose, and he shall cover his upper lip and cry, "Unclean, unclean." He shall remain unclean as long as he has the disease; he is unclean; he shall dwell alone in a habitation outside the camp
(Lev. 13:45-46, RSV)

We often associate leprosy with Europe's Middle Ages, and indeed leprosy was a widespread problem then. It is estimated that thousands of individual or group asylums called leprosaria existed in the thirteenth


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century.[2] The Christian church had reaffirmed the Mosaic concern with diagnosis and separation. The Third Lateran Council (1179) mandated living provisions for lepers, and elaborate rituals were decreed for the ceremony of separation. The common image of the medieval leper is of a forlorn individual coldly isolated and seeking sustenance through begging. It was not uncommon to believe that the loathsome disease was God's punishment for sin, particularly venereal transgressions. This linkage of leprosy with sexual promiscuity, with promiscuity seen either as a cause or a consequence of the disease, is interesting in light of our present attitudes toward AIDS.

But medieval society also took a larger and more humane view of leprosy. The church, the chief instrument for dealing with disease and sin during this era, devised religious ceremonies that enlisted the leper's cooperation in his or her isolation. The ritual centered on the leper and presented separation from society as a mutually wise decision. Sometimes the leper was encouraged to regard the disease as the sufferings of purgatory here on earth; leprosy was a sign that the leper would pass directly into heaven without the intervening punishment other mortals must endure in order to attain a purified form. Buttressing this concept were the Crusaders returning to Europe with leprosy apparently acquired in the Holy Land. A link between sin and the disease in these cases was unthinkable.

The ritual varied from one diocese to another and over time—for leprosy was a problem that, unlike its victims, would not go away. Fundamentally, the ritual was a service for the dead, because lepers, in effect, were declared dead to their society and the communion of the healthy. A priest would conduct the leper to church where the leper would hear mass kneeling under a black cloth suspended over his head. After mass he would be led again by the priest preceded by a crossbearer to another site in the church where comforting passages from the Bible would be read. As the leper left the church, he was sprinkled by the priest with holy water. The whole procedure was similar to that of conducting a dead body to the church, the saying of a requiem mass, and the passage from the church to the cemetery. Indeed, some rituals specified that dirt be scattered over the head of the leper or onto his feet; in some dioceses, the leper would stand in a freshly dug grave. When at last the leper had concluded his role in these elaborate ceremonies, he separated himself from society, while the priest admonished him:

I forbid you ever to enter the church or monastery, fair, mill, marketplace, or company of persons. I forbid you ever to leave your house without your


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leper's costume, in order that one may recognize you and that you never go barefoot. I forbid you to wash your hands or anything about you in the stream or in the fountain and to ever drink; and if you wish water to drink, fetch it in your cask or porringer. I forbid you to touch anything you bargain for or buy, until it is yours. I forbid you to enter a tavern. If you want wine, whether you buy it or someone gives it to you, have it put in your cask. I forbid you to live with any woman other than your own. I forbid you, if you go on the road and you meet some person who speaks to you, to fail to put yourself downwind before you answer. I forbid you to go in a narrow lane, so that should you meet any person, he should not be able to catch the affliction from you. I forbid you, if you go along any thoroughfare, to ever touch a well or the cord unless you have put on your gloves. I forbid you ever to touch children or to give them anything. I forbid you to eat or drink from any dishes other than your own. I forbid you drinking or eating in company, unless with lepers.[3]

The priest might follow these uncompromising orders with a comforting message. At Reims the ritual included this expression:

This separation is only corporeal; as for the spirit, which is uppermost, you will always be as much as you ever were and will have part and portion of all the prayers of our mother Holy Church, as if every day you were a spectator at the divine service with others. And concerning your small necessities, people of means will provide them, and God will never forsake you. Only take care and have patience. God be with you.[4]

Lepers took a prominent role in the diagnosis of leprosy. One or more lepers might be on the committee responsible for these fateful examinations. Within the asylums lepers took care of one another. Religious orders sometimes cared for the sick and for the farm sometimes associated with the lepers' enclosure, but such a formal mixture of lepers with the healthy was limited.

In the course of the long period during which lepers were feared and segregated, it became apparent that not only was it difficult to control lepers who remained unpersuaded that they should be isolated but also that the placement of large numbers of lepers in quarantined farms required a degree of social organization and resources lacking in many parts of Europe. Prodded by the widespread fear of leprosy, however, church and state institutions perpetuated the practice of quarantine. Although the quarantine ideally was softened by religious rituals as described above, such benign practices were balanced by other instances of brutality in some places and by extermination programs carried out by Henry II of England and Philip V of France. Eventually, leprosy became a metaphor for heresy, moral turpitude, and unnatural and exces-


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sive lust. Leprosy resisted one wave of attempted cure after another—alchemy, miracle, penance, whatever stirred hope—while disfigured people suffering its late stages continued to evoke dread, thereby promoting quarantine.

Leprosy can be contrasted with diseases whose courses are dangerous but brief, such as plague, yellow fever, and cholera. The isolation of ships coming from lands where plague was present was the classic example of quarantine. During the Black Death of the fourteenth century, when a sizable fraction of Europe's population perished through a rapidly spreading, quickly fatal infection, attempts were made both to establish quarantine, on the one hand, for habitations still spared or, on the other, to isolate the sick. Physicians and others with a need to visit the diseased wore apparel that entirely enclosed the body: gloves, shoes, headgear, and a gown with a cache under the nose for holding strong-smelling herbs to purify the air breathed in. Clearly, quarantine and such elaborate apparel carry an assumption that diseases are contagious; the means of contagion, however, remained unclear. The breath, putrefying organic matter, even the patient's gaze was suspected. With no certainty about what was the target of control, the citizenry's anxiety could quickly shift from one possibility to another, even to groups of people, as when Jews were suspected of poisoning wells and deliberately spreading plague. Frustration over their society's failure to halt a terrifying contagion led to destructive, irrational outbursts.


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