LEPROSY.

Section I.

Nomenclature of the Disease.

Since the application of the term Leprosy to designate the disease described in Lev. xiii. and xiv., the greatest confusion has prevailed in the use of the word, and the utmost difference of opinion as to what it implies. This appears to have arisen mainly from the same Latin word, lepra, having been used in at least two distinct senses. In the one case it denotes a mere skin disease, and in the other a serious constitutional malady, having indeed important cutaneous manifestations, but implicating the whole organism, and ending invariably, it is believed, in death. When used originally to denote simply a disease of the skin, lepra was synonymous with the Greek λέπρα, the radical meaning of which is rough or scaly (λέτὲος, a husk or scale). No medical author, it is believed, either before or after the time of St. Luke ever used the Greek word λέπρα to denote anything but some rough scaly cutaneous disease.¹ The old Greek version of the Pentateuch translates the Hebrew tsara'ath צָרַעַח by λέπρα, indicating thereby that the translators considered the Levitical disease (called in the Authorised Version leprosy) to be the skin disease known by that name in Greek medicine. In modern times also, the same word has been applied to one of the forms of scaly skin disease that was called lepra vulgaris. This, however, has been abandoned, what was at one time so called being now classed as a variety of psoriasis, an ancient and very common cutaneous disease. It may indeed be said to be the most universal of all skin diseases, being found in every climate and among all races, though most common in equatorial latitudes and among the coloured races. But as Philo has remarked of λέπρα,² it is ' a multiform and complicated' disease, and when differing from its more usual aspect has received special or colloquial names.

How then, it will be asked, came the terms lepra and leprosy to be apphed to that far more serious and indeed awful disease prevalent in the Middle Ages, and still widely spread through the world, technically called elephantiasis Grœcorum, and now spoken of as ' true leprosy? ' In the present day, this formidable disease is not known as indigenous, either in our own or in some other countries, where it was for several centuries endemic, but is still fearfully prevalent in the East, in the South Seas and West Indian Isles, and in Scandinavia. It was to those who were the subjects of this disease that the terms lepra and lepers were applied, in the Middle Ages, when Wycliffe made his translation of the Bible; and to such only are they in the present day applied. A satisfactory answer to the above question is, therefore, a requisite preliminary to any discussion as to the nature and characteristics of the Mosaic disease, as well as to a right understanding of the leprosy of the New Testament.

Dr. Greenhill, in the papers already referred to, traces the origin of the use of the word lepra in the mediaeval sense, as synonymous with elephantiasis, to Constantine, a monk of Monte Casino, who died towards the end of the eleventh century.

The following is Dr. Greenhill's view of the origin of the confusion that has arisen from the misapplication of the terms:³ 'The Latin word lepra is used to signify both the leprosy of the Middle Ages and also the lepra vulgaris psoriasis of modern nosologists. We cannot explain how it came to be used in two such different senses, but we think we can trace the confusion to its fountain-head; at least we will put together a few points which, so far as we are aware, have hitherto escaped observation, and which appear to us to be not unworthy of the attention of the medical antiquary and historian. The treatise which appears among the works of Constantinus Africanus, under the title De Morborum Cognitione et Ctiratione, is known to be a translation of an Arabic work by Ibn-el-Jezzar, who lived in the tenth century. This work also exists in Greek and Hebrew, and therefore enjoys the honour (unique probably) among the older medical writings of being found in no less than four different languages.

'In this work the chapter on the Arabic judhám or true leprosy is headed Ἐλεφαυτίασις in the Greek MS., and De Elephantiasi in Constantine's printed Latin version (p. 160), but in the body of the chapter the disease is called lepra, which is probably the earliest Latin instance of the word being applied to ἐλεφαντίασις. Why he should have used two different words, and not synonymous, to designate the same disease we cannot tell.' We know also that from the close similarity of certain skin diseases, especially those coming under the category of the old Greek λέπρα, with some of the cutaneous manifestations of elephantiasis or modem true leprosy, the subjects of various skin affections were often erroneously considered to be leprous, and treated as such by confinement in leper hospitals. In this way the popular confusion would be maintained. To such an extent was this the case, that when, in the beginning of the sixteenth century, an inspection was undertaken in France and Italy of the overcrowded leper hospitals, the fact came out that, in many of them, by far the greater number, and in some instances the whole of the inmates, were found to be suffering merely from various skin diseases, and only a minority from true leprosy.⁴

In like manner, in the present day, some persons are met with in India who are deemed lepers, but are not treated as such, either from being considered to have the malady in a mild form in which the chief visible sign is a persistent skin disease, or because they really have only some analogous skin affection, such as leticoderma.

We may now then, without entering too much int( medical details, which would scarcely be acceptable to the general reader, briefly describe the two diseases which have been so unfortunately confounded the one with the other.

Section II.

Lepra of the Greeks and the Modern Psoriasis.

The first, the λέπρα of the Greek physicians (the modern psoriasis, formerly called lepra vulgaris), whence have been derived the Latin lepra and leprosus and the English leprosy, leper and leprous, is a cutaneous disease varying in its features, but the essential characteristic of which is a rough, scabrous or scaly eruption on the skin, with more or less evidence of surrounding redness or superficial inflammation. This may be limited to particular regions, though rarely seen on the face, or may extend over the greater part of the body. These scaly patches assume different forms, some being more or less circular with depressed centres. In some the surrounding edges are more or less elevated. The patches vary also in colour, some presenting a glistening mother of pearl whiteness, others various shades of a dark colour, grey or purple. These patches, though for the most part thin, scarcely rising above the surface of the skin, obtain in some varieties a thickness that elevates them a quarter of an inch or more above the surrounding skin.

In severe and protracted cases the surface of the skin becomes excoriated and exudes serum and blood, which with the scales form thick scabs.

If the parts affected are naturally covered with hair, this for the most part falls off, or becomes thin and white, or woolly. Of this disease, thus characterised in general terms, various modifications or varieties are met with, which have received particular names, and which correspond more or less closely with those employed by the Greek writers, such as λέπρα ἀλφός, λευκή, μέλας. All the species or varieties comprehended under the old Greek generic term λέπρα are in the present day, by very general consent, at least in our country;, classed under the head of psoriasis, whilst by universal consent, all the world over, the terms lepra and leprosy are now restricted to the disease called by the Greeks elephantiasis.

There is no reason whatever to believe that any of these varieties of the old Greek λέπρα (psoriasis) are contagious, nor are they ever so treated by. physicians in the present day. In the more aggravated an^l persistent forms they are indeed sufficiently repulsive in aspect to interfere with social intercourse, and when met with in the poor and uncleanly they are apt to be associated with other and infectious disorders, more especially scabies or itch. And it is tolerably certain that the itch existed in Egypt.⁵ Nor is psoriasis m any sense a dangerous disease, or attended even by any grave or very distressing symptoms, though in severe cases there may be a good deal of irritation, and from accidental causes some of the patches may pass into the condition of open sores or raw spots. Though often very persistent and rebellious to treatment, it is curable, but apt to recur. There is some reason for believing in a hereditary tendency to the disease, and certain constitutions are more liable to it than others. It can scarcely be said to interfere with the ordinary duties of life, or with mental activity, although when associated, as it often is, with other causes of impaired health there may, after a while, be loss of both flesh and strength.

There are several kinds of what are called epiphytic skin diseases, i.e. diseases which are produced by vegetable parasites or epiphytes. The appearances presented by these have some analogy with those of some of the varieties of psoriasis. They are all contagious, inasmuch as they are propagated by the transfer of the particular epiphyte from one person to another. The danger of contamination depends, however, very much on the soil, or state of skin and health of the individual, with which the epiphyte is brought into contact. The common ringworm, so troublesome in schools, is a well-known example of such disease. None of them, however, much impair the general health.

There are also various fungi, such as those which give rise to common mouldiness and the dry rot, which are self-propagating, and by which houses and garments are affected. There is little difficulty therefore in understanding what may be meant by leprosy in the house or raiment, though the Mosaic description may not enable us to speak with confidence as to the particular species denoted. They for the most part indicate an unwholesome state of the atmosphere where they are found. Some Jewish writers maintain that the marks of house leprosy correspond exactly in appearance with those of the person, but no appearances on inanimate objects can be said to indicate either leprosy or any other malady.

Section III.

Elephantiasis Græconim,

Elephantiasis Græconim, the designation of the other disease to which, as we have said, the term leprosy is now restricted, differs essentially from the cutaneous affections of which we have spoken, both in its nature and general characters. It is one of the most formidable and hopeless of all known maladies. In some respects it may be said to have most analogy with scrofula or syphilis. The term elephantiasis seems to have been given to it from consideration of its greatness and gravity. Aretaeus,⁶ the Greek physician, speaks of it as so much greater than the rest of diseases as the elephant is bigger than all other animals. But the term may, with equal probability, have been given to it from the thickened dense condition which the skin assumes, very like that of an elephant, and its diminished sensitiveness to impressions.⁷

Although, according to Dr. V. Carter, the true leprosy in a few rare cases supervenes suddenly, in persons of apparently sound health, its commencement is usually ill defined and its early progress slow and insidious. The earliest symptoms of ill-defined bad health may pass off and recur on several occasions, at various intervals. After a while, two distinct features are manifested, loss of sensibility of the nervous fibres supplying the skin and a congested state of the minute vessels, showing itself in the form of circular spots or blotches of irregular forms and varying extent, on the forehead, the limbs and body, the face and neck perhaps showing only a diffused redness. Even these symptoms may disappear for a time, to return only with increased intensity, the spots assuming a darker or coppery colour; stains appear on the skin, which at length becomes tumid, thickened, and rugous, something like the rind of a rough orange. The centre portions of the circular spots, in some instances, turn white, and the whole assumes the character of a white blotch. Thus there may exist at the same time, red, purplish, or white spots, some having elevated edges and of various outlines. The eyebrows, nose and ears, are the parts of the face most frequently affected; elsewhere the spots generally coincide with the distribution of the nerves. The surface of the blotches may be dry and scaly, or moistened by a greasy exudation. In the early stages there is scarcely any pain, and there may not be much throughout, unless from accidental pressure or injury of particular parts; but a certain degree of numbness or anœsthesia exists in all the affected spots, the fingers especially being numb, wasted and brown. In many even advanced cases its manifestations may be chiefly seen in the skin and mucous membrane of the mouth, the former showing a number of nodules or tuberosities of various size; in other cases, the joints of the members are dislocated and fall off. In others again the most prominent symptoms are the increased loss of sensation and diseased state of the nerves. In the tuberous variety the nodules increase in size and number with each return of the febrile symptoms, ulcerate, and after discharging for a while at length heal, unless very extensive. The mouth, nasal passages and larynx in severe cases, are similarly affected. The voice becomes hoarse and feeble or lost; the septum of the nose is destroyed, and the bones fall in. The eyelids, eyes and ears may also be affected in a like manner, the lobes of the ears sometimes enormously enlarged. But we abstain from farther description of the awful and destructive consequences of this terrible disease, by which, in many instances, almost all trace of the human form and aspect may be destroyed by mutilation and disfigurement.⁸ In the anesthetic variety, whilst the loss of common sensation is more pronounced, there are often internal burning and neuralgic pains productive of great suffering and attended by distressing and frightful dreams.

Instances are recorded where the miserable sufferers have survived the loss of more than one lamb; but though life may be protracted for even more than ten or fifteen years, the disease pursues its onward course. It is irremediable by any known human means, and of the witnesses of such appalling sights it may be said: 'Horror ubique animos, simul ipsa silentia terrent' well nigh to the exclusion of pity.

All observation of this terrible malady goes to prove that it comprises a deep-seated general dyscrasia of the system, but where and how it originates are still involved in mystery. For the present we do not enter on the questions of contagion and heredity.

Its former existence and subsequent disappearance from certain localities and countries, our own among others, have given rise to a very prevalent opinion that it springs from endemic causes, whether malarious or not. Although most prevalent in hot and damp climates, it is rife in the most opposite climes, in Norway, the East and West Indies, and in the South Seas, and although vicinity to the sea-shore has been thought to have some special influence, it is found in inland districts.

Removal from all known or suspected injurious climatic influences, as well as from all insanitary conditions, are admittedly of the first importance as remedial means, and next to these a generous and nutritious diet.

The history of leper hospitals and institutions in the Middle Ages is fraught with the deepest and varied interest. Nowhere has so full and learned an account been given of them as in the Essays of Sir J. Y. Simpson,⁹ although he had specially in view their history in Scotland, where they existed, as well as in the border counties, before the year 1200. And the disease continued to exist in the Shetland Isles till the middle of the last century.¹⁰ In Scotland the malady was termed the 'mickle ail.' or great disease, and by the old French chronicler Froissart, who visited Scotland in the time of Robert II, it is called la grosse maladie. The hospitals, however, were not for the cure of the infected, but charitable retreats, as the disease was considered incurable. Of this a curious illustration is afforded by the case of one Christian Livingstone, tried for witchcraft, against whom one of the gravest accusations was that she 'affirmit that she culd hail (cure) leprosie quhilk the maist expert men in medicine are not abil to do.'¹¹

It has been supposed that the leprosy of the Middle Ages was introduced into England by those who returned from the Crusades (1096); but there is ample evidence that it existed in the continent of Europe before the time of the Crusades, and Lanfranc, Archbishop of Canterbury in the time of William the Conqueror, founded a hospital for lepers at Canterbury, ligneas domos ad opus leprosoricm.¹² Other leper hospitals were also founded before the end of the eleventh century.

Although it was chiefly among the lower orders, the 'villeyns,' that the disease prevailed, no class of society was exempt, not even royalty. King Robert Bruce is believed to have died of it. It appears to have been more prevalent among males than among females.

Much has been said on the injurious effects of particular articles of food, such as fish, as well as on the want of others, particularly salt, and generally on modes of living and habits of life, but nothing has been definitely proved. As to all such external causes of this as well as of other diseases. Sir James Simpson has well observed, 'that the investigation of the causes of disease (ætiology) has probably more than any other department of medicine been marked by belief without evidence and assertion without facts.' Recent discoveries in pathological science would perhaps demand some modification of this severe censure, for which, however, there is still too much justification. And it is certainly very difficult to ascertain from the multifarious statements of modern observers, with any degree of confidence, what are the true sources of this fearful malady. Dr. Dudgeon gives an abstract of Chinese views of the disease in his Report on Peking, 1875. Among other names given to the disease is ' lai,' the term applied to the 'mange' in the dog. It is said to arise from three sources—climate, infection, and defective nutrition. Five different forms of the disease are met with. In one, the skin dies, indicated by loss of sensation; in the second, the flesh dies, and no pain is felt on cutting it; in the third, the blood dies and ulceration and pus are formed ; in the fourth, the tendons die and hands and feet drop off; and in the fifth, the bones die, the nose is destroyed. Along with this the eyes, lips, and nose become involved. Among the causes specified is 'the air of graves.' The hereditary and infectious nature of leprosy is noticed and terms used expressive of its malignity.¹³

That its unhappy subjects are rendered unfit for ordinary social intercourse has always been admitted, and from Christian benevolent considerations, as well as on medical grounds, they have not been allowed to appeal in vain for that sympathy, care, and alleviation which can only be afforded by segregation in duly appointed and supervised special institutions.¹⁴

Section IV.

Characteristics of the Levitical Disease.

This brief and necessarily imperfect sketch of the diseases which we have attempted to describe, will probably have enabled the reader to form a sufficiently correct notion of their respective features. We may therefore proceed to enquire what are the characteristics of the disease or diseases spoken of in the Authorised Version of our Scriptures as leprosy, the most detailed description of which we have given us in Lev. xiii. and xiv.

'When a man shall have in the skin of his flesh a rising, a scab, or bright spot, and it be in the skin of his flesh like the plague of leprosy; then he shall be brought unto Aaron the priest, or unto one of his sons the priests:

'And the priest shall look on the plague in the skin of the flesh: and when the hair in the plague is turned white, and the plague in sight be deeper than the skin of his flesh, it is a plague of leprosy: and the priest shall look on him, and pronounce him unclean.

'If the bright spot be white in the skin of his flesh, and in sight be not deeper than the skin, and the hair thereof be not turned white; then the priest shall shut up him that hath the plague seven days:

'And the priest shall look on him the seventh day: and, behold, if the plague in his sight be at a stay, and the plague spread not in the skin; then the priest shall shut him up seven days more:

'And the priest shall look on him again the seventh day: and, behold, if the plague be somewhat dark, and the plague spread not in the skin, the priest shall pronounce him clean: it is but a scab: and he shall wash his clothes, and be clean.

'But if the scab spread much abroad in the skin, after that he hath been seen of the priest for his cleansing, he shall be seen of the priest again:

'And if the priest see that, behold, the scab spreadeth in the skin, then the priest shall pronounce him unclean: it is a leprosy.' — Lev. xiii. 2-8, et seq., A. V.

Here the first difficulty with which we are encountered is manifestly philological: What is the true meaning of the Hebrew words used to describe the diseases, and what are the modern equivalent medical terms? We are, no doubt, greatly assisted in this enquiry by translations of the Hebrew texts made at a time when medical science had considerably advanced, and when medical terms were used in a definite recognised sense. And though in some cases these terms may have since acquired a different meaning, there is not often much difficulty in determining what the Greek and other ancient medical writers meant by the terms they employed. In answer to the first question, I am fortunate in being able to give the following, with which I have been favoured by so competent an authority as my friend Dr. S. G., Green: 'Leper and leprosy are always denoted in the Old Testament by words derived from one root (צָרַע, tsara), the primitive meaning of which appears to be to sting, hence to smite, the root-element in the word expressing narrowness— hence sharpness, and so affliction and distress generally. The word is used alike for the leprosy of Moses (Ex. iv. 6), of Miriam (Num. xii. 10), also for leprosy of a house (Lev. xiv. 44), and of a garment (Lev. xiv. 55)' It was evidently a cutaneous disease, at least in one of its manifestations "white as snow," and in house or garment a white surface, e. g. "mouldiness."

'The following are the terms used to denote the appearances or signs of this tsara'ath:

Dr. Mason Good,¹⁶ and after him Dr. Belcher¹⁷ and Others, consider that Moses described three varieties of leprosy, and used berat or bahéreth, 'bright spot,' as a generic term, two of these, the berat kehah and the berat l'bhanah, being the severer, or malignant forms, and bohaq a more innocent. All these he identifies with the three Greek varieties of λέπρα, and the three varieties of the vitiligo of Celsus,¹⁸ which are described by corresponding Greek terms, viz. λέπρα ἀλφός, λέπρα μέλας, and λέπρα λευκή, all of which Dr. Good classes under the head of his leprosis, or lepriasis, or the modern psoriasis. Other cutaneous blemishes, or blains, Good considers to be mentioned by Moses, as requiring to be carefully watched, being liable to terminate in the malignant form of leprosy. It must, however, be stated that other writers have not been able to satisfy themselves that the Levitical descriptions are sufficient to identify the signs with those which mark the three varieties of the Greek λέπρα. This probably arises principally from differences in the interpretation of the terms employed to distinguish the different cutaneous changes. Thus 'a rising' in Lev. xiii. 2 has been supposed to denote the thickened rough elevations of skin in elephantiasis; and much stress has been laid on this, as strongly supporting the opinion of those who hold that the Levitical disease was elephantiasis. But the word is held by competent scholars to denote any pimple or vesicle arising on the skin, and to be co-extensive with what the Greek physicians termed φλύκταινα. It must also be remembered that in psoriasis there is often considerable elevation and thickening of the cuticle.

The word translated scab in ver. 2 is, according to Mason Good, the dry sahafati of the Arabians, derived from the same root, and which the Greeks translated by psoriasis. It would therefore indicate a dry scall or scale, words derived from the Saxon sceala, a rough surface. This Saxon sceala, Dr. Belcher says, comprised two varieties, dry and moist, as did also the Arabic sahafati. Mason Good says that the description 'dry' in ver. 30 does not occur in the original, which is נֶתֶק, the root of which Dr. Green says denotes tearing off. Dr. Good therefore takes this to be a variety of humid scall, and to 'correspond to impetigo, which forms a thick crust of exuded matter on the beard, which cannot be removed by shaving, nor without violence or tearing. The word used by the LXX to translate נֶתֶק is θραῦσμα, or crust.

That the descriptions of the various forms of skin disease were intended, not to denote differences in their nature or pathology, but to enable the priests to discriminate between the clean and unclean forms, is manifest. They were intended purely for practical use. But that the three forms of scaly eruption to which the terms bohaq and bahéreth are applied, do correspond very closely if not indisputably with the three varieties of the vitiligo of Celsus and of the λέπρα of the Greeks can scarcely be denied. Thus we have bohaq as representing λέπρα ἀλφός, bahéreth kehah = λέπρα μέλας, and bahéreth l'bhanah = λέπρα λευκή.

It has been said that the appearances described to guide the Jewish priests relate only to the early stages of the disease, and cannot therefore be expected to comprise any of the advanced signs characteristic of elephantiasis. But a long list of medical writers of the Middle Ages might be given who clearly describe the phenomena of elephantiasis, and among these some who give minute accounts of the various symptoms which the physician ought to look for when examining suspected persons, and point out the mode in which he should proceed before venturing to consign a suspected person to the seclusion of a leper hospital, and thus doom him for ever to be a despised 'child of St. Lazarus.' Now the indications laid down for the guidance of the Jewish priests comprise scarcely any, if any, of those insisted on by these medieval writers, although such indications are carefully divided by these writers into (1) occult premonitory signs ('signa occulta principio'), which, though far more decisive than those given by Moses, are not to be held sufficient to adjudge the patient for separation, but only as requiring that he should be carefully watched; (2) infallible signs, which, though they are such as are not even hinted at by Moses, require immediate separation from the people ('quibus apparentibus patiens est a populo sequestrandus'); (3) signs of the last stage and breaking up ('naufragium') of the disease, and which comprise those fearful signs of deformity and mutilation which characterise the most advanced cases.¹⁹

Guy de Chauliac, a physician at Lyons and Avignon, in the fourteenth century, in like manner speaks of the equivocal and the unequivocal signs denoting all the species of leprosy, but neither does he give any mere cutaneous appearances as decisive of the disease.²⁰ It has been affirmed that the blanching of the hair on the patches is decisive of anaesthetic leprosy, but this it certainly is not. Dr. Chaplin, formerly Physician to the Leper Hospital at Jerusalem, says, 'In the interest of scientific truth,' 'that white hairs are not a characteristic of anaesthetic leprosy. I speak from knowledge, having, as Physician to a Lepers' Asylum, closely observed that disease during sixteen years.'

The first mention of leprosy is in Exodus iv. 6, where, as a sign given to Moses to satisfy the people that he had been sent by God, he was directed to put his hand into his bosom, and on withdrawing it ' behold, his hand was leprous as snow,' and after repeating the act, and again plucking out his hand, ' behold, it was turned again as his other flesh.' ²¹

The sign thus given was no doubt miraculous; but is it necessary to assume that the appearance presented by the hand of Moses indicated either an incurable or infectious disease, in order to convince the people that it was miraculous, as the commentators suppose? The sign was that of a skin disease well known to the people as gradually and slowly manifesting itself, and of a more or less persistent character, as well as difficult of cure. The sudden invasion of such a disease in fully developed form, and its equally sudden disappearance, were quite sufficient to prove its miraculous occurrence; and there is certainly nothing to lead us to think that it was anything more than a local affection implicating the hand.

The next particular example that we have is the case of Miriam (Num. xii. 10). The pillar of the cloud in which the Lord came down and stood in the door of the tabernacle having departed from off the tabernacle, 'behold, Miriam became leprous, white as snow,' and Aaron looked upon Miriam, and, behold, she was leprous.'²² Here it is observable that the same terms are used to characterise the leprosy as in the case of Moses, whose hand became 'leprous as snow.' In both cases the snowy whiteness is the only characteristic that is given us, and in the case of Miriam, as in that of Moses, the sudden manifestation of the disease in the skin in a form that admitted of no question was proof of its miraculous origin. But the Divine interposition for the cure of Miriam, though doubtless also miraculous, does not appear to have been immediate, as in the case of Moses, it would rather seem that she remained leprous for seven days; probably in order that the judgment of God for her sin might be made manifest to the people. The prayer of Moses that she might be ' healed,' not merely cleansed, was at all events answered after her seven days' seclusion from the camp. No mention is made of any cleansing. But the words of Aaron demand especial attention. 'And Aaron said unto Moses [Revised Version]. Oh, my lord, lay not, I pray thee, sin upon us, for that we have done foolishly, and for that we have sinned. Let her not. I pray, be as one dead, of whom the flesh is half consumed when he cometh out of his mother's womb.' It is difficult to understand exactly what is meant by these last words. Do they mean, Let her not be as good as dead, like one whose flesh is diseased and corrupted at birth, and who manifestly cannot live? If so, this is almost the only passage which can be cited in support of the theory that the Mosaic leprosy presents any analogy to the modern leprosy, or elephantiasis. Or do the words simply imply that Aaron, seeing how pronounced was the disease, felt that she never would be cured by ordinary means, and so during the rest of her life would be shut out from the congregation, and civilly dead?²³ That she was rendered ceremonially unclean is manifest from what follows, and therefore a period of seclusion was enjoined. More on this difficult passage cannot well be said, except that in this instance the disease was inflicted as a judgment of God for sin, whilst in the case of Moses what appears to have been the same variety of disease was inflicted simply as a sign. Had Miriam presented any of the signs of elephantiasis beyond the cutaneous appearance so as to excite Aaron's despairing cry, would it not have been mentioned?

The next cases are those of Naaman and Gehazi. No description of the aspect of Naaman's case is given; it is simply stated that 'he was a leper.' (2 Kings v. 1.) But he was not therefore the subject of an incurable disease in the estimation of the little Israelitish maid, who said unto her mistress, 'Would God my lord were with the prophet that is in Samaria, for he would recover him of his leprosy.' Of Gehazi it is said, 'The leprosy of Naaman shall cleave unto thee, and unto thy seed for ever. And he went out from the presence of the prophet a leper as white as snow.' (2 Kings v. 27.) His, therefore, is a third case of what has been called white leprosy. But neither in the case of Naaman nor of Gehazi is there any evidence that the disease was contagious, and thus rendered them unclean. On the contrary, Naaman is represented as living at the court and discharging his duties as general in the army, and Gehazi as still serving as the attendant of Elisha and holding intercourse with the king after he had become the subject of a leprosy that was to cling to him and his seed for ever, but which did not impair his health so as to incapacitate him for service.²⁴

In the case of Uzziah (2 Chr. xxvi. 19-21)'the character of the leprosy miraculously inflicted for sin is not described; it is merely stated that it appeared first on his forehead. But that it was of the severe type and rendered him unclean must be inferred, because he ' was a leper unto the day of his death, and dwelt in a several house, being a leper; for he was cut off from the house of the Lord.'²⁵

The remaining instance given in the Old Testament is that of the four lepers at the gate of Samaria, 2 Kings vii. 3, of whose leprosy we know nothing, but infer that it rendered them unclean, and compelled them to dwell alone without the gates, though evidently it did not incapacitate them for bodily exertion.

Section V.

Sanitary and Ceremonial Regulations.

Having thus sought to gather all the light that we can from the particular cases recorded in the Old Testament, we proceed to examine the descriptions and regulations respecting the disease or diseases mentioned in Lev. xiii. and xiv.

In these chapters it must, we think, be evident even to the ordinary reader, and certainly to the physician, that more than one disease is treated of. Certain symptoms are described, on seeing which, and after watching their course, the priest declares the patient to be clean or unclean, as the case may be; and that this decision does not turn merely on the slight and limited character or on the extent and severity of the outward signs is clear, For, strange as it appears, in chap. xiii. i2, 13 (R. V.) we are told that if the 'leprosy" cover all the skin of him that hath the plague from his head even to his feet, as far as appeareth to the priest, then the priest shall look; and, behold, if the leprosy have covered all his flesh, he shall pronounce him clean that hath the plague: it is all turned white: he is clean.' Here again the appearance is that of the white leprosy, which, however, is styled the plague.

Whilst tsara' ath (צְרַעַת) is the word always used in the Hebrew to denote what in the A. V. is called leprosy and the plague of leprosy, it evidently was employed as a generic term, other words being employed to denote, if not varieties, at all events particular aspects of the disease. Not only Dr. Mason Good, as we have seen, but also Dr. Adams,²⁶ Dr. Greenhill, and others have bestowed much learned pains in endeavouring to identify these varieties with corresponding diseases of the Greek, Arabian and Latin writers. But though it is not in most cases difficult to see the correspondence between diseases with which physicians in the present day are familiar and those described by Greek and other ancient writers, we cannot speak with more confidence than we have already spoken as to the classical names or position that should be assigned to some of the descriptions given by the Mosaic writer as varieties of tsara' ath or other analogous diseases. It may, however, without fear of contradiction be affirmed that scarcely any physician of the present day can see in the various features of the Levitical disease anything but varieties of cutaneous disease of some kind. The use of the word λέπρα, as we have remarked, seems sufficient proof that the LXX considered the Hebrew word to correspond with the Greek word which the Latins called lepra. The Latin writer Celsus, whilst using another word, vitiligo, describes with great accuracy and clearness the several varieties of the Greek λέπρα, which correspond more or less closely with the Mosaic descriptions. But to none of these does Celsus attribute any contagious property, though he does call them foul (fœda). And he distinctly states that they are not dangerous, which could certainly not be said of elephantiasis or modern leprosy.²⁷

In what then does the distinction between clean and unclean consist, on which the Levitical laws were based? If we suppose that uncleanness ever implied contagiousness, which, in many cases, we are sure that it did not, the only conclusion to which we can come with any confidence is, that in certain kinds of צְרַעַת there was a contagious element, perhaps unknown to the writer, which might be some form of epiphyte, or an acarus, as in the case of the itch. Such a complication of an otherwise non-contagious disease would, of course, call for sanitary regulations, and render necessary the seclusion of the affected. But, if apart from such considerations any of the species described were in their nature infectious or contagious, we are ignorant of any analogous diseases, either ancient or modern. Nor is there evidence that any of the species presented, apart from the cutaneous signs, any of the essential characters of such a disease as elephantiasis.

There is nowhere any mention or even hint of the characteristic anaesthesia, or loss of sensation, indicating nerve disease, although the examination of the local signs by the priest was evidently of the most careful and minute description. Nor is there anywhere either I in the Old or New Testament any passage to show that ' a leper had been recognised by any of those hideous signs of deformity or mutilation denoting a pronounced case of mediaeval leprosy. Even if we admit that the Levitical descriptions are confined to the early manifestations of the disease, yet inasmuch as distinct statements are given respecting lepers that were abroad and not secluded, one would have expected some other signs besides those presented by the skin to have been noticed, as modern travellers have done. Neither does it seem probable that none of those who were secluded were ever seen from a distance and recognised by such disfigurement as would have excited horror. Nor is anything said of any service or care being afforded to those who were unable to take care of themselves. Again, of those who were excluded from the congregation-on account of their uncleanness, we have no ground for assuming that the disease was ever fatal, as no such instance is given; or even that they were in all cases irremediably diseased and never cleansed, whether miraculously, or by ordinary means employed during their period of seclusion. On the contrary, the minute rules for cleansing show that they were sometimes cured. If in all cases the disease was inflicted for sin — of which there is no evidence — we might perhaps have supposed that the infliction was irremediable by ordinary means, but not therefore mortal.

On the other hand, if, apart from all sanitary or medical considerations, we are to view the disease in a ceremonial or symbolical aspect alone, it is difficult to understand either why it should be described at such length, or why certain species should render the sufferer unclean, and others not. Why, for example, should one in whom the leprosy covered all the skin of his fleshy and who had the plague from his head even to his feet, be pronounced clean? (Lev. xiii. 12.) That no argument in support of contagion can be drawn simply from the sentence of expulsion from the camp is evident from Num. v. 2-4, and elsewhere, for lepers and non-lepers are equally excluded on the ground of uncleanness. In fact, the laws of seclusion were as rigorously applied to the uncleanness induced by touching a dead body, as well as in other cases where no question of contagion can exist. The same terms are used when speaking of inanimate objects as when speaking of persons, so that Jewish writers have supposed that the same appearances were presented by the spot or eruption in both cases. On the other hand, it must be admitted that from early periods elephantiasis is believed to have existed in Egypt (but whether in the time of Moses we are not certain), and therefore we might assume that the Jews would be likely to be affected. But modern observers who have seen most of true leprosy state that it is not very common among Jews. Thus Dr. V. Carter says that during a period of seventeen years, out of a very large number of cases in Bombay, he had seen only four cases and but one death among Jews.²⁸ The so-called endemic leprosy of Egypt, whatever it was, does not appear to have been known to the older Greek physicians as an Egyptian disease, and the true leprosy or elephantiasis was unknown in the Roman empire till the last century before Christ. ^

The references made by Brugsch in his Histoire d'Egypte to a medical papyrus discovered at Memphis and containing a number of receipts for the cure of disease, 'du genre de la lèpre,' composed during the reign of Rameses II, B.C. 1350, and also to a passage the date of which he throws back to B.C. 4200, do not shed any real light on the question. The collection of receipts given in the latter document are for curing the exanthemata. The way in which Celsus treats the subject of elephantiasis warrants the behef that he, who was not a physician, had never seen the disease, and would explain his omission of the characteristic feature of anaesthesia. He makes no mention of Egypt.²⁹

Section VI.

Leprosy of the New Testament.

In the New Testament twelve cases only of leprosy are mentioned, and ten of these must be considered together under one head. 1. The case of these ten is mentioned only by St. Luke, xvii. 12-19, from whom we might have expected some medical details; but none such are given; the men are simply said to be lepers. But that their disease was of the unclean type we infer, not merely because they stood afar off while lifting up their cry for mercy, but because they were directed to go and show themselves to the priests. It is also deserving of notice that the terms cleansing and healing seem to be used as synonymous, for as they went they were cleansed, before seeing the priests; and one of them, being a Samaritan, when he saw that he was healed, turned back to give thanks, glorifying God, and gave occasion to the question of Christ, ' Were there not ten cleansed, but where are the nine?' and to His command to the Samaritan, 'Go thy way: thy faith hath made thee whole;' without repeating the injunction to show himself to the priest.³⁰ 2. In the case of the single leper that is mentioned in all the three Synoptic Gospels, he is stated to have been in one of the cities with the multitude following the Saviour, and yet is by St. Luke said to be full of leprosy. In this case again the term cleansing is used for healing, though the man was enjoined to go and offer for his cleansing according to the law. That St. Luke means by the words 'full of leprosy'³¹ that the man was the subject of the severest or inveterate form of disease, and not that he was merely covered with the skin disease, is evident, because in the latter case he would not by the Levitical law have been required to present himself to the priest for cleansing, 3. The remaining case, that of Simon the leper, has given rise to much discussion as to how the sitting at meat in the house of a leper could be consistent with Jewish law and custom. Some have sought to solve the difficulty by supposing that Simon was designated 'the leper' merely from having once been leprous for a long time, and known as such. But the more probable explanation seems to be that his leprosy was of the clean type described in Lev. xiii. 12, 13.

From these cases recorded in the New Testament can any inference be drawn adverse to the view that we have taken of the disease described in the Old Testament? Is there anywhere any indication whatever of the sufferers presenting any of the fearful signs of elephantiasis which travellers have noted? In His reply to John's disciples, Christ, recounting His miracles of healing, speaks only of the lepers being 'cleansed,' and in answering the petition of the single leper He said, 'I will, be thou clean,' which seems to convey the impression that removal of ceremonial uncleanness was of more importance than the cure of the disease.

We must again lay stress on the fact that at the time when St. Luke wrote, medical science throughout the East was undoubtedly Greek, though Galen, the great medical authority, was not born till A.D. 130. It seems therefore scarcely credible that St. Luke, himself a physician, should have used the Greek word λέπρα to denote anything but the malady known to physicians by that name, which certainly was a cutaneous disease, but presenting a variety of aspects. Hippocrates (B.C. 460) makes no mention of elephantiasis, but treats of the Greek λέπρα under the plural term λέπραι, indicating thereby that there were varieties, or, as Philo says, that the disease was multiformis.

Section VII.

Contagion and Heredity,

Contagion. — Although it would be out of place in the present work to enter on all the difficult and complicated questions that arise in connexion with the etiology and spread of true leprosy, a few words on these subjects seem required in further elucidation of the view that we have been led to take of the Levitical disease. If we should agree with those who maintain that modern leprosy is not contagious in the ordinary sense, or communicable | through contact in ordinary or even intimate social intercourse, it yet might be granted that there is now some reason for believing that by inoculation, or introduction into the system in some other way, as by food or water, an infectious agent may be the means of contaminating the system, and thus be the vera causa of disease which might only be developed after a greater or less lapse of time. This latter view would be consistent with the admitted fact, that in but few instances has sufficient evidence been advanced in its support. On the other hand, an overwhelming amount of evidence exists against the spread of the disease by contagion in its ordinary sense, which is quite inconsistent with what we know of other contagious diseases, such as smallpox, which rapidly spread when communicated through the medium of a single infected person. For it is notorious that lepers may be found living for years in populous districts, where never more than a very insignificant proportion ever become affected. Nay, even of leper families a small proportion only may suffer. Such facts also militate strongly against the importance that has been attached to peculiarities of locality, habits and food, notwithstanding the statements that leprosy is almost unknown among the nomadic races.

If, however, we adopt the view that leprosy is another instance of disease induced by the presence of a particular microbe or bacillus, as in so many other diseases now the subject of absorbing interest to both the professional and the non-professional public, we may account for most of the facts adduced in support of the various theories; especially if we admit that there is reason to believe that such microbes, or self-propagating infecting agents, vary greatly in the rapidity with which they permeate the body. For all observers allow that as a rule true leprosy is a disease of very slow development — though it is difficult to grant to the incubative stage of a disease thus induced a period of sometimes two or even eight years, which Danielsson and Boeck assume.³² In the Middle Ages it is certain that the belief in the contagion of the true leprosy was very general, both among physicians and the common people; but it is also true that, as medical science advanced and the diagnosis of disease became more definite and reliable, this opinion lost ground and was at length abandoned. On this change of popular belief, Brunelli, an Italian physician, aptly remarks:' l'opinione era contagiosa e non la malattia.' Hirsch, as the result of his exhaustive study of the disease, says, 'My conviction is that there is not a single fact which tells decisively and indisputably for the conveyance of the disease by contagion.' Is there any single fact in the Levitical record to prove that the same cannot be said of tsarda' ath so far as regards persons? and is not Brunelli's saying applicable here also? Has not the belief in the contagious character of the Levitical disease originated mainly from two sources — (1) from viewing the terms clean and unclean as synonymous with contagious and non-contagious; (2) from assuming that the mediaeval leprosy was essentially the unclean form of tsara' ath, translated ki-npa by the LXX and leprosy in the A. V., and adopting the prevalent mediaeval belief as to the contagiousness of elephantiasis? From the Mishna it would appear that the Jews did not view even the unclean as contagious, for they allowed an unclean leprous bridegroom to remain with his bride during the nuptial week. Certainly the very general adoption by theologians of leprosy as a type of sin is more likely to have arisen from the analogy presented by the deepseated, all-pervading, corrupting and mortal character of mediaeval leprosy,³³ than from anything that is said in the Bible. If, however, none of the forms of tsara' ath possessed any such characters, even allowing that some of them were contagious or infecting, there appears no sufficient ground for believing that tsara' ath was intended in any special way to typify sin and its consequences, whilst there can be no difficulty in seeing why it should have occasionally been inflicted as a punishment for sin, and made a reason for exclusion from the congregation. For it was a disease of which a person carried about him visible marks of a repulsive character, and perhaps indicative of uncleanly habits. Augustine says that when lepers were restored to health they were mundati, not sanati, because leprosy is an ailment affecting merely the colour, not the health or the soundness of the senses and the limbs.

The complication of elephantiasis with scabies is not uncommon in Norway, and this, in the opinion of some, has given rise to the belief that the disease in that country is contagious. In like manner the association of scabies with psoriasis (vitiligo of Celsus) is mentioned by several Greek authors, and gave rise to the statement of Justin³⁴ that the Hebrews were expelled from Egypt on account of their 'itch,' though this is admitted to be a slander. In Syria scabies is, in the present day, a much more acute disease than it generally is in European climes, and more rapidly assumes a pustular form, and so gives rise to ulceration.

Heredity. — The subject of heredity is one that is in all cases surrounded with difficulties. There may, however, be said to be pretty general unanimity of opinion in favour of the transmission of true leprosy by way of inheritance. This too was the view entertained by the Arabian and mediaeval physicians. But direct transmission from parent to offspring of actual disease or malformations of particular parts, or peculiarities of organization, is one thing, and the transmission of a particular diathesis or disposition to contract particular diseases, which other persons do not possess, is another thing. That true leprosy is transmitted by this hereditary predisposition if not by congenital seeds of the disease, seems probable. There is but little difference of opinion on the subject, though some observers incline more strongly than others to the belief that there is something more than mere hereditary predisposition, or proclivity to its development in favouring circumstances. Hence the very general adoption of the principle of segregation and the prevention of intermarriages with the healthy.

Is there anything in the history of the Jews, from the time of the Exodus to the present day, to show that they are specially liable either to contract or transmit either true leprosy or the various forms of tsara' ath? A negative answer must, we believe, be given to this question, although there is reason to think that certain races, particularly the negro race, are specially predisposed to elephantiasis. We have cited Dr. V. Carter's experience in India as regards the Jews, but we must not forget the influence of climate and locality in developing the disease de novo, of which, however, we have little real knowledge. In certain places, as in Jamaica, the Jews form a large proportion of the sufferers, and it was of the disease there seen and in America that Reill says, 'Lepra Judaica omnino diversa est a lepra Americana.' If racial influences are in any way powerful in the transmission of disease, we might certainly have looked for far more evidence than exists of hereditary tendency to elephantiasis among the Jews, had that been the Levitical disease, especially when we consider that notwithstanding their dispersion they have continued a people apart. And had they any special tendency to contract the disease, it is remarkable that, so far as the writer knows, no case in our times has been introduced by the Jews into this country, to which they come from all the various lands where true leprosy exists, whereas isolated cases have occurred among British officers and others who have resided where leprosy is endemic.³⁵

As the result of a prolonged and independent investigation of this much disputed subject, the writer is compelled to admit that he cannot hope to have cleared up all the difficulties with which it is surrounded, whilst on the principal point he has satisfied himself that there is no sufficient evidence that elephantiasis is denoted by any of the diseases described under the head of tsara' ath, even if that fearful malady existed in Egypt at the period of the Exodus. Throughout the sacred volume there is no distinctly marked case of elephantiasis described under the name of leprosy, nor any which physicians would have so considered, had not צָרַעַת and λέπρα been translated leprosy at a time when the prevalent mediaeval disease was so called. In the main the writer agrees with the conclusions at which his learned friend Dr. Greenhill has arrived: ' That the disease was, in the words of Philo, "multiform and changeful," modified by various complications, and comprising several species more or less distinct; that some of these varieties were associated with a contagious element, and others non-contagious, and that all the contagious species rendered the patients ceremonially unclean; that it was not a special or miraculous disease, existing only in those times and countries, but an ordinary malady, used occasionally by God for miraculous purposes; that it was not incurable by human means, though troublesome and obstinate; that it was not hereditary, though a disease of common occurrence among the Jews.' In further confirmation of the view here taken we may quote the words of Dr. Stapfer, who entirely coincides in the opinion we have formed of the Levitical leprosy, and says that in our Lord's time lepers were excluded from the temple, but not from the synagogue. They had, however, separate seats assigned to them, and were required to enter first and leave the last. They were never considered as 'possessed.'³⁶ Then he says as follows: 'Il est reconnu aujourd'hui que ces précautions étaient fort exagérées; la maladie connue sous le nom de lèpre n'est nullement contagieuse. Elle pent seulement être héréditaire. Se présentait-elle sous une forme contagieuse chez les Juifs de la Palestine ? C'est possible, mais il y avait certainement beaucoup d'ignorance et de préjugés dans le dégoût et l'horreur qu'inspirait un lepreux.' . . . 'Non seulement elle (là lèpre) est guérissable mais elle pent disparaître sans que le malade suive aucun traitement. C'est une affection superficielle de la peau, fort peu douloureuse et qui n'empêche pas la santé générale d'être ordinairement bonne. Chez les Juifs on distinguait une première guérison que l'on appelait "purification du lépreux." Les écailles qui avaient paru sur la peau, et y avaient formé des disques blancs ou grisâtres, se détachaient et tombaient. Le malade était dit "purifié" ou "nettoyé." Sa guerison n'était pas encore certaine, mais le principe prétendu contagieux avait disparu ; le danger était passé; il rentrait dans la vie commune. Son premier devoir était d'offrir trois sacrifices : le premier était dit d'expiation, et le second de culpabilité; le troisième était un holocauste.'³⁷ The New Testament, the writings of Josephus, and the Talmuds are the only sources of information consulted by Dr. Stapfer, and in his opinion the only ones to be relied on.

Keeping in view the very inadequate evidence of the existence of elephantiasis in Egypt, in Moses' time, apart from what it is sought to derive from the Biblical account of the Levitical disease, we would recommend those who may doubt the correctness of our conclusions to peruse any of the elaborate descriptions of true leprosy in such works as those of Carter and Daniellson, and then, without giving heed to names, carefully peruse the Levitical descriptions, or even merely read attentively such brief sketches of the two diseases as we have given in a previous page, and decide with which the Mosaic account most nearly corresponds.

There is certainly nothing improbable in the supposition, considering the condition of the Jews in Egypt, that they were liable to forms of skin disease, peculiar to the land and their social status, which are unknown to us. It is only quite recently that we have come to know the disease called 'wool-sorters' disease.³⁸ And all who are familiar with cutaneous affections are quite aware that the same disease is apt to vary considerably in its outward signs. Seeing the difficulty there is in understanding the grounds for the ceremonial laws of uncleanness in other cases, it is not surprising if we are unable to explain satisfactorily why one form of disease should have rendered a person unclean whilst another form did not. But if we consider such ceremonial laws to have been enacted primarily from sanitary considerations, it is easy to appreciate their value, and also to discern their symbolical meaning and the spiritual instruction thus imparted.

Before leaving the subject of leprosy we feel bound to call attention to the humane and Christian efforts that are being made on behalf of the unhappy lepers of the present day. Whatever view may be taken of their disease, it must be admitted that it is essentially immedicable, it is still τὸ πάθος οὐκ ἰάσιμον,³⁹ that its victims are the subjects of unspeakable suffering and misery, and that almost the only hope presented to us for preventing its spread or exterminating the evil is by segregation and effectually excluding it from the camp and the congregation. Of the benefits to be derived from segregation both to the lepers themselves and to the community at large there cannot be any doubt, whilst we have evidence sufficient that the sufferers are amenable to Christian influence^ and are not beyond the reach of the Gospel of our Lord and Saviour. We would especially commend to the notice of Christian philanthropists the efforts made by the ' Mission to Lepers in India.' The asylums at Almora, Dara. and elsewhere in India, are entirely supported by this society, and have under care above 100 lepers, at the cost of only about £6 per annum for each adult. This accommodation is not, however, by any means sufficient for the districts where the disease prevails.⁴⁰ In Norway, where it is still very prevalent, leper hospitals and other less efficient methods of segregation have been proved to be the most efficacious means for diminishing the number of the sufferers. In the Sandwich Islands, where the disease has spread with fearful rapidity, it has been found absolutely necessary to adopt the same means. It is in these islands that the latest observations have been made respecting the presence of specific spores or bacilli in the diseased tissues of the infected; but here too it is found that change of residence to a non-leprous district is one of the most effectual means of exterminating the plague. What are the true etiological relations between microbes and the several diseases with which they are associated we have, however, yet to learn.⁴¹

1) See on this whole subject Dr. Greenhill in the Bible Educator, vol. iv. p. 76 et seq., 1876.

2) De Poster. Caini, § 13, torn. i. p. 234, ed. Mangey.

3) British and Foreign Med. Chir. Review, vol. 54, p. 117.

4) Hirsch, Handbook of Geographical and Historical Pathology, vol. iv. p. 8 Syd. Soc. Ed. This admixture is not surprising, for in the sixteenth centur lepra, as the Latin synonym of the Greek, was the word used by medica writers to designate the common skin disease. Thus Mercurialis, De Morbi, Ctitaneis, etc., Venetiis, 1585, chap. v. De Lepra, correctly describes the disease in accordance with Greek authorities whom he quotes. One part of his description deseves notice as bearing on the sense to be attached to the description, Lev. xiii. 14-16: 'Lepra aspera est ad contactum, pruritui inducit quandoquidem cutis sola affecta est, et idco excoriata ipsa cute car subiecta sana apparct'. Oribasius, commenting on the confusion existing in his day, says, 'Vulgus medicorum, Arabas in hoc secuti, lepram cum elephantiasi confundunt, imo lepram pro elephantiasi accipiunt.'

5) Deut. xxviii. 27, A.V., 'The Lord shall smite thee with the botch boil, R.V.) of Egypt (ἕλκει Αἰγυπτίῳ; Hebrew, בִּשְׁתִין מִצְדֵיִם), and with the emerods (εἰς τὴν ἕδραν; Hebrew, וּבַעְפּׂלִים, and with the scab (scurvy, R.V.) (ψὼρᾳ ἀγρίᾳ; Hebrew, וּבַנָּדָנ), and with the itch (κνήφτν; Hebrew, וּבֶחֶוֶס); whereof thou canst not be healed.' It is difficult to surmise what the botch or boil of Egypt may have been, though some have sought to identify it with elephantiasis. But ψώρᾳ ᾀγρῖᾳ,“ which our versions have rendered 'scab' or 'scurvy,' admit, it has been said, of being rendered, aggravated or malignant psoriasis, though ψώρᾳ is undoubtedly the Greek medical word for itch. Why in the R.V. it should be called scurvy, a totally distinct 1 disease, does not appear. Κνήφτι, which both our versions render ' itch,' may I very well mean some other cutaneous disease attended by itching and 1 irritation, e.g. prurigo. Emerods are pretty generally understood to mean hoemorrhoidal tumours.

In verse 35 of the same chapter, 'And the Lord shall smite thee in the knees and in the legs with a sore botch (boil, R.V.), (Hebrew, נִֺאְׁחִין דָע; ἕλκει πονηρῷ), that cannot be healed, from the sole of thy foot unto the top 0f thy head,' the sore botch or boil is probably the same as the botch of Egypt in ver. 27.

6) Morb. Chron. ii. 13.

7) Curiously enough, whilst the Lepra Arabum is the Elephantiasis Græconim, or true leprosy, the Elephantiasis Arabum is a totally distinct disease, known in the present day as the 'Barbadoes Leg.' This is characterised by hypertrophic enlargement of the legs and certain parts of the integuments, associated with a dropsical condition, and is believed to be of malarious origin. This form of elephantiasis, the E. Arabum, exists in the West Indies and South Sea Islands, and is not infrequently met with, but has never at any time been called leprosy. The term elephantiasis seems to have been applied to this from the similarity to the leg of the elephant, which the leg and skin of those affected present.

8) In a Roman Catholic Manual for Curates it is said that to some lepers the Sacrament cannot be given, because 'Non possunt Corpus Dominicum sic recipere et tractare in ore suo quin rejicerent ipsum, sic multi quibus reciderunt labia et dentes et sunt totaliter corrosi usque ad guttur.' Manipulus Curatorum. Bremen, 1577. Thomson, The Land and the Book, p. 653, says: 'Sauntering down the Jaffa road, on my approach to the Holy City, in a kind of dreamy maze. . . I was startled out of my reverie by the sudden apparition of a crowd of beggars "sans eyes, sans nose, sans hair, sans everything." They held up towards me their handless arms, unearthly sounds gurgled through throats without palates.'

9) Edin. Med, and Surg, Journal, vols. 56 and 57.

10) Few persons probably are aware of the extent to which leprosy prevailed in the Middle Ages, or of the number of leper hospitals that existed in Europe. Mezeray says., in his History of Philip II, that in the twelfth century, 'Il n'y avoit ny ville ny bourgade qui ne fust obligée de bâtir un hospital pour retirer les lepres.' Histoirc de France, torn., ii. p. i68. 1645. Muratori gives a similar account of the extent of the disease in Italy: 'In Italia vix ulla erat civitas quae non aliquem locum, leprosis destinatum haberet.' Antiq. Ital. Medii Ævi, tom. iii. p. 53.

11) Pitcaim's Criminal Trials in Scotland, vol. ii. p. 29. The following is a specimen of one of Christian Livingstone's means of cure, in the words of the libel: ' She took a reid cock, slew it, baked a bannock with the blude of it & gaf the samyn to the leper to eat.' As a further specimen of the many sure and certain cures, the following is given by Michael Scott, the Fifeshire philosopher: 'It ought to be known,' he says, ' that the blood of dogs and of infants two years old or under, when diffused through a bath of heated water, dispels the leprosy without a doubt' ('absque dubio liberat lepram '. De Secretis Naturœ, p. 241. Amsterdam, 1790.

That the miraculous powers attributed to the relics of saints were employed will readily be assumed. Fosbroke (British Monachism, &c., p, xv) mentions a fountain near Moissac, the waters of which were so medicated by the relics of a saint contained in the neighbouring monastery that crowds of lepers resorted to them, bathed, and were immediately cured. But the waters were not of sufficient virtue to prevent the disease being communicated to the monks, or to save them when attacked. The fountain therefore, according to the confession of the abbot, was shut up in consequence of some of the monks having died of the disease which their famed waters could infallibly remove.

12) Antiquities of Canterbury, vol. i. p. 42, and vol. ii. p. 169. There are other historical evidences that the disease existed both in Great Britain and the Continent before the Crusade exodus.

13) Surgeon-Gen. Gordon's Reports, 1884, p. 150.

14) The celebrated tractate of Count Xavier de Maistre, entitled Le Lépreux de la Cité d' Aoste, gives a most graphic and pathetic account of his interview with a leper confined in an ancient tower in the suburbs of Aosta in 1797, and cannot be perused without the greatest interest, whether by medical or non-medical readers. See also Sir J. Simpson, Edin. Med. and Surg. Journal, vols. 56 and 57, 'Antiquarian Notices of Leprosy and Leper Hospitals in Scotland and England,' replete with learned and historical data.

15) This is the term employed to denote the disease of Job ii. 7, and that of Hezekiah 2 Kings xx. 7 ; Isaiah xxxviii. 21.

16) Study of Medicine. Some of his conclusions have not satisfied all critics.

17) Dublin Journal of Medical Science. 1864.

18) De Med., lib. v. in fine.

19) Bemhard Gordon, a physician of Montpellier 1309, as quoted by Simpson in Edin. Med. and Surg. Journal.

20) Quoted by Simpson. The unequivocal signs ('signa univoca') which he gives are — '(1) rotundity of the ears and eyes; (2) thickening and tuberosity of the eyebrows, with falling off of their hair; (3) dilatation and disfiguration of the nostrils externally, with stricture of them within and foetidity of the lips; (4) voice raucous and nasal; (5) foetidity of the breath and of the whole person; (6) fixed and horrible satyr-like aspect.'

21) The Septuagint says merely 'as snow' (ὡσεὶ χιών); the Revised Version, 'leprous, white as snow.'

22) The Septuagint here has λεπρῶσα. ὡσεὶ χιών.

23) We have abundant evidence that in the Middle Ages any one who was adjudged a leper was separated from intercourse with mankind, 'ab hominum conversatione separandus.'

24) Josephus speaks of leprosy in a man as ' a misfortane in the colour of his skin.' 'There are lepers in many nations who are yet in honour, and not only free from reproach and avoidance, but who have been great captains of armies and been entrusted with high offices in the commonwealth, and have had the privilege of entering into holy places and temples.' Antiq. iii. c. xi, sect. 4.

25) The first cutaneous manifestation ot elephantiasis is frequently on the forehead; hence Uzziah's case is thought to support the opinion that this was really the nature of his leprosy.

26) Paulus Ægineta, Syden. Soc. Trans.

27) Celsus, De Medicina, lib. v. cap. 28, sect. 19: 'De vitiliginis speciebus, id est, de alpho et melane et leuke,' i. e. the different species of what is called now psoriasis, and of which he says, 'quamvis per se nullum periculum adfert, tamen et foeda est.' It is observable that elephantiasis is not treated of in this book v, comprising cutaneous diseases, but in his third book, cap. 25, along with such diseases as jaundice and apoplexy. Vitiligo is the term used also by Arnobius (fourth century) to denote the Greek λέπρα (Adv. Gentes, lib. i. p. 337, ed. Paris, 1836).

28) In Tangier in the present day the two diseases are found, the leprosy Hebrœorum prevailing chiefly among the Jewish residents, and presenting exactly the symptoms described in Leviticus. On the other hand, in Syria elephantiasis is unknown among the Jews.' Belcher on Our Lord's Miracles.

29) He begins his chapter thus: 'Ignotus autem paene in Italia, frequentissimus in quibusdam regionibus, is morbus est quem ἐλεφαντίασιν Græci vocant: isque longis annumeratur. Quo totum corpus afficitur ita, ut ossa quoque vitiari dicantur.' De Med. lib. iii. cap. xxv.

30) Maundrell, one of the early travellers in Palestine, after mentioning other cases of leprosy that helmet with, says: 'At Sichem, near Naplos, there were not less than ten lepers — the same number that was cleansed by our Saviour not far from the same place — that came a-begging to us at one time. Their manner is to come with small buckets in their hands to receive the alms of the charitable, their touch being still held infectious or at least unclean. Their whole distemper was so noisome that it might well pass for the utmost corruption of the human body on this side the grave.'Journey from Aleppo to Jerusalem, A.D. 1697.

31) Luke v. 12, πλήρης λέπρας.

32) The following instance has been given in illustration ot the doctrine of infection through inoculation, and also of the prolonged period of incubation. Dr. Hillebrand narrates a case in Borneo, where a boy of European parentage was accustomed to play with a leprous child of colour. The native boy thrust a knife into the anaesthetic part of his body, which act was immediately imitated by the white lad, with the same knife. The white lad was soon after sent to Holland, where he grew to maturity, and nineteen years later (!) developed the disease, returning to Borneo a confirmed leper. (Reports furnished to the Hawaiian Government, Honolulu, i886.;i A case has also been recently recorded by Dr. T. G. Gairdner, in which a child appears to have been infected with leprosy through inoculation with virus taken from a leprous vaccinifer. Brit. Med. Journal, June 1 1, 1887, p. 1269.

33) I have not been able to ascertain the exact date when this very widespread notion originated. Dr. Greenhill, however, informs me that the idea has been general from very early Christian times, [and therefore when λέπρα meant psoriasis]. Vide notes at the end.

34) Hist. xxxvi. 2.

35) We cannot refrain from making reference to the case of the heroic Father Damien, which has excited so much painful sympathy. This young Belgian Roman Catholic priest, after his ordination in 1873, volunteered his services in the leper settlement at Malakoi, one of the Sandwich Islands. When he arrived there the lepers numbered 800, of whom between 400 and 500 were Romanists, and were dying from 8 to 12 per week. After ministering to these for 13 years (!), in every possible capacity, spiritual and temporal, as doctor, cook, carpenter, and even grave-digger, he has himself fallen a victim to the disease, and has resigned himself with the most touching Christian submission to all its well-known consequences, saying daily to God, 'Fiat voluntas Tua.'

36) Negaim, ch. xiii. hal. xii.

37) La Palestine au temps de Jésus Christ, par Edm. Stapfer; Paris, 1885, 3rd ed., pp. 245 et seq.

38) See note at the end of the volume.

39) So called by Cyrill. Alex, in Cramer's Caten. Græc. Pair, in Nov. Test. vol. ii. p. 43.

40) From statistics in regard to lepers, in the Report rendered to the Hawaiian Government, it appears that in a total population of 210,767,504 in various countries there were in 1885 124,924 lepers, or 5.9 in every 10,000 of the population. In consequence of a communication from the Under Secretary of State for the Colonies in 1862, an enquiry was instituted by a Committee of the Royal College of Physicians (of which the writer was a member) into the whole subject of leprosy, with especial reference to the question of contagion and the establishment of Leper Asylums. Evidence was obtained from all our colonies and an elaborate Report made to the Government. From this Report a mass of authentic and valuable information may be obtained. The evidence that it affords is decidedly against the contagiousness of the disease. By a rather singular coincidence the writer is again acting on a similar committee in consequence of another communication from the Government on the question of the advisability of establishing Leper Asylums and enforcing the principle of segregation. So great is the spread of the disease in many of our colonies, and so persistent is the popular belief in contagion and the necessity for enforced separation of the sufferers, that Government is urged to legislate on the subject and make it penal for a certified leper to be abroad,

41) See further works on Leprosy at the end of the volume.