The Lost Hospitals of London: Leprosaria

5 March 2012   The Lost Hospitals of London: Leprosaria    Professor Carole Rawcliffe     Between the late eleventh century, that is just after the Norman Conquest, and 1350, a bare minimum of 300 hospitals and refuges were set up in England for the accommodation of people suffering from a disease called lepra, or leprosy. In practical terms, this means that between a quarter and a third of all medieval English hospitals were intended for presumed leprosy or lepers. The total number of leprosaria, as these places were known, was probably far larger since the great majority of such foundations were not only small, ad hoc and poorly documented, but also of relatively short duration, sometimes being endowed for the benefit of specific persons.  Many of these hospitals succumbed to the economic vicissitudes and demographic upheavals of the first half of the fourteenth century, which began with floods and famines, and ended with a cataclysm of the Black Death, but, as we will see, there were other reasons for the decline in numbers, and after 1350, fewer than two dozen new leper-houses appear to have been established to fill the gap. I say “appear to have been established” because, once again, we come up against this problem of evidence, and it is notoriously difficult to establish precisely when most of these places, even in the capital city, began to function.   We also need to bear in mind that many presumed lepers lived in informal communities or with family members, rather than in hospitals, being considered too disruptive or intransigent for institutional life, or simply wanting to retain a semblance of normality for as long as possible.     Hospitals could be surprisingly selective in the matter of admissions. Some, as we shall see, charge for entry, while others expected their inmates to adhere to a strict rule or face expulsion.     There is now no means of estimating patient numbers or of telling what proportion of individuals opted for the security of institutional care.     Fortunately, we are on safer ground in asserting that the overwhelming majority of leprosaria were urban, or more accurately suburban, in nature. The map before you clearly reflects the distribution of major centres of population in medieval England, with the concentration in the South-East, and there can be little doubt that the establishment of leper-houses went hand-in-hand with the growth of towns and cities, and it is seen by some historians as a marker of urban development, so it is not surprising there are so many around London.   The process followed a fairly standard pattern, insofar that the first wave of foundations was almost entirely sponsored by members of the royal family, aristocrats, or prominent clergy, such as Bishop Herbert de Losinga, of Norwich who died in 1119. This is his hospital of St Mary Magdalene, just outside the city, and I am showing it to you because none of London’s survive – they are lost, but the smaller ones would have looked like this. Most of these early hospitals followed a religious rule, and indeed, this is run by the Benedictine monks of the Cathedral and follows their rule.   These initiatives were enthusiastically supported by leading townsmen and women, but before long, they wanted to ape their social superiors by endowing leprosaria of their own, either on an individual or collective basis. We will explore their motives in a moment, but at this stage, it is important to note that almost all these houses were situated on major roads on the outskirts of towns and cities, sometimes, as in Norwich, at the very gates.   I will show you this map because you can see they are right, those leper-houses, those civic leper-houses, are right on the gates. You almost fall over them as you go into the city.   York conformed to the same type of layout, as also did London, the subject of my lecture today.  The city’s first leper hospital was allegedly founded by Henry I’s Queen, the saintly Matilda, who died in 1118, in Holborn, on the south side of the main western approach road into the city, right near what is now Centre Point.   This hospital was dedicated to St Giles, the patron saint of sick paupers and lepers, and had its own well-appointed chapel. Here is the seal of the hospital, showing St Giles with his episcopal staff. Matilda’s confidante and confessor was Bishop Losinga, so we can detect a very close connection here.   Disputes over the exercise of patronage were a common feature of medieval hospitals, and St Giles was no exception, claiming from an early date that the hospital was not a royal foundation but had been set up by a leprous citizen specifically for the benefit of others. The people of London initially lavished gifts of land and rent upon it, and we are incredibly lucky that St Giles is one of the very few English leprosaria whose registered deeds still survive – it is in the British Library. So, we can document these grants in unusual detail.   The mayor and aldermen also appointed the wardens, but from 1286 onwards, when the Crown began to interfere in these appointments, one controversy followed another. Edward I’s misguided decision to entrust the management of the hospital to the Order of St Lazarus in 1299 led to a gradual privatisation of resources – if one were not being polite, one might call it asset-stripping – and helps to explain why Londoners decided to vote with their feet and set up other institutions which would admit patients free of charge.   By then, that is by the end of the thirteenth century, the city possessed two other leprosaria. The first in St Margaret’s Parish in Westminster, just here, on the site of what is St James Park, was allegedly founded by a group of pious citizens, and although it certainly did not pre-date the Conquest, as the Tudor antiquary John Stow believed, it was functioning by 1150, so it is pretty early. It was the only London leper-house formally to follow a religious rule, being designed for eight Augustinian canons, who were healthy, and sixteen unmarried female lepers, who were professed sisters, sworn to poverty, chastity and obedience. The sisters were certainly poor since funding was precarious, but as visitation reports reveal, they were not very obedient and they were always being told off for being a bit lippy, and there were evidently quite a few instances of what the shocked inspectors termed “carnal copulation”. Since the canons were given to fraternising with the sisters over a drink, this is perhaps hardly surprising. Visitation reports give you a wonderful picture of what really happened in these places.   The second house, known as Les Lokes, is just down here, south of the river, in Southwark, and was founded in 1227, under civic patronage, with some support from the Crown. Like many English leprosaria, it was dedicated to St Leonard, who is interestingly the patron saint of prisoners. This is not because lepers were incarcerated but because they were regarded as captives of a debilitating disease. They were often known as prisoners of God. We do not know much else about the house or its inmates, save for the fact that it was eventually placed under the management of full-time wardens, appointed by the mayor and aldermen. It was run along with a house up here, in Hackney – this was also under the management of wardens – which was up and running by about 1330 but may have been much older. So, we start out, by 1330, with these four houses, which I have itemised to you here.   To these original four leper hospitals were added smaller houses, managed by civic wardens: at Knightsbridge and at Mile End, which were both in existence by around 1475; a modest private leprosaria in Highgate, built or acquired in 1473 by one of Edward IV’s yeomen, who contracted leprosy and was given the land by the King, very generously; and an extremely obscure institution in Hammersmith, which is mentioned in a will of 1500 but nowhere else, so these are the next ones; and also, in his will of 1399, Richard II left money to a community of lepers in Bermondsey, but I think, rather than Bermondsey, he was thinking of Les Lokes, the hospital in Southwark, and I suspect that, like many Londoners, his knowledge of the terra-nova south of the river was a bit dicey! In case you think I am exaggerating, I asked my husband, who was born within the sound of Bow Bells and spent his first twenty-five years in London, precisely where Bermondsey was and he did not know, so I rest my case!   By the close of the Middle Ages, the distribution of London’s leprosaria looked like this. So, you have got one there, one there, one there, one there, and then up here, up here, and down here, so you have got a ring of them round the city, and this is like any major European city. There were at least eight houses, of varying size, wealth and ownerships, dotted around the suburbs, on the major approach roads, and please notice they are on the main roads, or very near them.   Why were these houses built? Why did they seem so necessary? Who lived in them? How were they regarded by the wider community? The answers may seem obvious to those of us who grew up on a diet of nineteenth century literature, such as Robert Louis Stevenson’s “The Black Arrow”. I took this from my childhood copy, with its terrifying image of a leper leaping out from the undergrowth to terrify two unsuspecting lads – well, one of them is a girl disguised as a boy, but we will not go into that. That is the dastardly villain who, to escape detection, has hidden himself as a leper, knowing no one dare go near him. But the reality is very different, and indeed far more interesting, and that is what I want to address in the rest of my talk.   Some of you may recognise this watercolour, which appears regularly in books on medical history and archaeology. It was painted in 1912 by Richard Tenant Cooper and depicts the residence of an unspecified medieval town, and I quote, “scrambling to get away from a leper” – that is the title. They are in such a hurry, they have even dropped the baby!      We can find it, for example, in the recent “Plague, Pox and Pestilence: Disease in History”, a glossy and profusely illustrated history of epidemics aimed at the general reader. I have got a copy – some of you may. The accompanying text observes grimly, and I quote: “The world of the medieval leper was outside the safety of walled cities and towns, a world belonging to bandits and other wild creatures.”   Such assumptions form but one resilient weed in the dense undergrowth of myth and misinformation that has sprouted up around a disease whose history has so often been misunderstood, misrepresented and sensationalised, and inevitably, the role of the leper hospital has also been consistently described in terms of isolation, confinement and exclusion.     Writing about the leprosaria of medieval London in an article published in 1967, Marjorie Honeybourne began by noting that, quote: “Segregation became the accepted treatment in England after the Norman Conquest.” She then informs her readers that, and I quote: “So terrified were other men by them that lepers became social outcasts, with no common law rights. The burial service was read over them by the Church, and they were classed with idiots, madmen, and outlaws by the State. They lost all property rights, and a long list of prohibitions was inflicted on them.” She goes on to itemise these prohibitions at some length.   In point of fact, none of these statements is true, although they are now so engrained in the popular mindset that it is extremely hard to shift them. Indeed, since I myself shared all Miss Honeybourne’s assumptions when I began to study medieval leprosy, over a decade ago, you might regard today’s lecture as a penitential exercise.   That the disease called lepra played a notable part in the medieval imagination and was accorded a degree of significance far beyond the physical threat it actually posed cannot be denied, but nor can the fact that responses to it were far more sophisticated, diverse and subject to change across time than much of the previous historiography would have us believe. Tenant’s watercolour does indeed provide an entirely accurate, and very revealing, depiction of medieval responses to leprosy, but only as they were imagined at the start of the twentieth century when the painting was commissioned by Sir Henry Wellcome. I should add, Sir Henry Wellcome paid for my research, so I am sure he feels penitential too!   It was produced at a time when leprophobia was at its height, following the 1897 Berlin international conference on leprosy, during which the disease was mistakenly, as it transpired, deemed to be highly infectious, and a mandatory system of segregation was recommended by the assembled physicians and bacteriologists.     Aghast at the imperial danger posed by what looked like an inexorable epidemic sweeping westwards from the colonies, the medical and intellectual elites of Europe and America turned to the Middle Ages for inspiration. How had these backward and superstitious people managed to defeat the apparently unstoppable monster of leprosy? The answer, to them, obviously lay in compulsory mass isolation, in remote leper-houses, a topic of consuming interest to medical specialists, who were not much given to a close reading of sources and were sometimes prone to wholesale distortion.   Just one example, and I could give many, of this cavalier approach is of particular interest in the present context and derives from a mid-fourteenth century illuminated copy of Vincent de Beauvais’ “Miroir Historial”. This was very popular in English because of course, in this period, the elite spoke French and English interchangeably so were very happy with these texts. The manuscript text explains how, as a child, the Old Testament hero, Josaphat, escapes from his father’s protective care in order to learn about human suffering. Deliberately seeking a leper and a blind man – the blind man is at the back – he goes out of the city to welcome them at the gates of Jerusalem. This image was evidence of the stringent sanitary measures employed by medieval towns. “Two lepers arrive at the city gates,” he writes “but the guard on duty makes a sign, forbidding them to enter.” So, from the welcome of Josaphat, it becomes the exclusion. Reproduced ad nauseam in books on medieval life, this illustration remains shackled to the twin themes of marginality and exclusion, and of course it is not at all.   By contrast, the average medieval man or woman, and certainly the average Londoner, was exposed constantly to images of Christ healing and consoling the leper. This is the twelfth century and I would like you to notice the iconography used to depict the leper, the spots, or measles, as they are called – they give us the term measles.   Later, fourteenth century, from the Holkham Bible Picture Book, an English text, this shows Christ very compassionately healing the leper with his bell, rung to tell people he needs alms because he has lost his voice, and another one of Christ, again from a fourteenth century English bible, touching and healing the leper.   The idea that during his passion Christ himself came to resemble a leper, in both physical appearance and in the scale of his sufferings, and was thus singularly well-equipped to offer solace to others, is movingly depicted in a fifteenth century register of donations to one Nuremberg leprosarium. I use this because, as you will know I am sure, most of the English evidence from leper-houses and other hospitals was destroyed at the Reformation, so we use Continental examples.   This is a late medieval illustration, so notice the leper is covering his mouth – I will come back to that later. This is just at the point where leprosy is deemed to be contagious, and he has got his rattle. Christ is assuring him, “I suffered and my sufferings will help you.” It is a very compassionate image, and we can find this idea of Christ depicted as the leper in the Holkham Bible Picture Book, referring directly back to St Jerome, and similarly at the crucifixion, that spotty flesh just like the leper. This concept of Christ’s quasi-leprosis was developed by Jerome and is a recurrent theme in medieval English hagiography – that is the lives of saints and devotional writing. It figures prominently in the contemporary biographies of St Hugh of Lincoln and of Henry I’s Queen, Matilda, who founded St Giles Holborn.     Some of you may know one particular anecdote. Like her mother before her, she made a practice of welcoming lepers into her rooms at Westminster, where she washed their sores and kissed them in reverence for Christ. This is a lovely sanitised image, which I am very fond of. Her brother, David, standing there looking pretty cross, was appalled by what to him seemed a frankly disgusting activity, and he remonstrated with her, demanding to know what her husband, King Henry, would say if he realised that lips which had kissed rotting flesh were now kissing him, and she replied to him, or she said to him, “Since I have just been kissing Christ, frankly, I could not care less!” which is very interesting anecdote and reinforces that idea of Christ as leper.   If few Londoners went so far as to embrace the leprists, they were nonetheless mindful of their responsibilities to care for them as well as possible. How could anyone aspire to salvation while rejecting those to whom the son of God had extended his hand? Even after ideas about contagion had taken hold among the jittery residents of last-medieval London, this message lost none of its force. “Grudge not to visit the sick,” warned one fifteenth century preacher, urging his congregation to follow the example of Christ, “for it is written in the gospel that he touched bare lepers and they were made whole, wherefore the servant should not distain to do what his lord did.”      Notice again - this is an early sixteenth century engraving – that you have the leper’s nose covered here and are outside the city wall. I will come back to that in a moment.   We might also note the assumption that, because they were demonstrably undergoing their purgatory on Earth, in terms of the intensity of their physical suffering, lepers, or at least those who accepted their trials with patience, would ascend directly to heaven and thus enjoy privileged access to the ear of God.    The surgeon, Guy de Chauliac, he is French but his textbook is used in English, in both French and English versions, was immensely influential in England. Guy de Chauliac advised surgeons when they gave a positive diagnosis that you should explain to your patient that, with good counselling words, he says, that they are going straight to heaven and will not have to suffer purgatory, and so you make the diagnosis easier. Who better then to intercede on one’s behalf?  In the larger hospitals at least, it was understood that, in return for their spiritual and physical care, the patients would pray on a regular basis for the salvation of their benefactors. That the latter were in effect purchasing paradise is spelt out in many of the grants of land, rents and property made to St Giles Holborn, and in the wills of pious citizens, such as Richard Whittington, who left money to the city’s leprosaria.   This point is made rather clearly in this image, which I showed last year but I think is extremely eloquent. Here, you have people who are in the fires of purgatory. This is this intermediate stage before you go to heaven, where all your residual sins are burnt away. But through alms deeds, it says, alms deeds, and mass and prayer, here, you are winched up in this celestial elevator to heaven, where the lepers are, and there is God, up there. So you can expedite your time in the fire, and this is very interesting because, clearly, the people who give to leprosaria had got their eye on this idea.   We unfortunately do not know what regulations the staff and patients of St Giles Holborn were expected to follow, but a lawsuit of 1391 reveals that the chapel was well enough stocked with vestments, plate and service books to mount the full opus dei – that is the seven canonical hours, as well as elaborate requiem masses and that sort of thing for patrons. It also owned an obit book, which has now been lost, but we do have one, just one, survives, for the leper hospital of St Mary Magdalene at Gaywood outside King’s Lynn. It is the only mortilegium to survive for any English hospital of any kind. They were all destroyed at the Reformation. You have here the names of all the donors who have money, and they would be prayed for at special services, and the mortilegium would have been on the altar at the mass and would be held up to the assembled patients.   A similar round of services was followed at St James Westminster, although the female patients, who came from higher status families and probably felt less gratitude towards their benefactors, were reluctant to get up early for matins and had constantly to be reminded of their responsibilities.   So I think if we look at this map, what we can see here is a spiritual cordon of prayer around the city, just as the walls of London, which are here, represent the physical defences. Hospitalised lepers and the wider community were thus closely bound by ties of mutual obligation, although the principal onus lay upon the healthy members of the urban body to provide for those who were sick. Men and women who ignored the sufferings of Christ’s earthly representatives were left in no doubt of the grim fate that awaited them after death.   This is the parable of Dives and Lazarus. I am sorry, it is a little bit dark. Here is the leper, Dives, and this is a parable told by Christ, arriving with his rattle at the door of the rich man, Dives, who sets the dogs on him, so poor old Lazarus dives in the ditch, but his soul is taken expressly up to heaven by two ministering angels. He subsequently intervenes with God and begs him to rescue Dives from hell, but no chance, so Dives is left to burn forever in eternity. We get a hint of his fate in these red robes. He is also extremely choleric – he looks as if he is going off pop anyway, does he not?   Although, as we shall see in a moment, there were sound pragmatic reasons for the situation of leper-houses at city gates, we should not forget the impact of this parable, which guaranteed leprosaria a prominent place in the symbolic medieval townscape. The study of urban topography, which plays such a notable part in the work of today’s hospital historians, was however of scant interest to the nineteenth century advocates of forcible isolation. Nor, since they were for the most part progressive Protestants or staunch rationalists, did they devote much thought to the great corpus of medieval theological writing on leprosy, which of course historians now study avidly today.   Well, you may be asking, if fear of infection was not initially an issue and lepers enjoyed special status as the recipients of charity, why could they not live inside the walls like everyone else? As an answer to this, we leave the New Testament and go back to the Old Testament. The numerous ritual prohibitions listed in the Book of Leviticus included the injunction that suspect victims of the condition called tsara’ath or tsaara-at should be inspected by a priest and, if necessary, obliged to dwell outside the camp until they recovered.   Now, time does not permit me to explore the series of mistranslations and misunderstandings, whereby a Hebrew word that embraced many different dermatological disorders, including cirrhosis, scabies, cancer of the skin, and eczema, was gradually and specifically transformed into Hansen’s Disease, as real leprosy is known today. Suffice to say that the process was a very long and complex one that effectively undermines the viability of much retrospective diagnosis.  Indeed, lepra, the Latin word deemed to approximate most closely to tsara-ath, was chosen by earlier translators because it too was an umbrella term for lots of different diseases. So, in early medieval England, lepra is an amalgam of lots of skin diseases.   Medieval men and women for whom the bible constituted the infallible word of God believed that, in accordance with Mosaic Law, anyone with an advanced case of what they considered to be lepra – that is a serious skin problem – should in theory live apart. Such a ruling was enshrined in the customs of London from at least the 1280s onwards. But this did not condemn them to oblivion or exclusion from the Christian community, and nor did it prevent them from entering major urban centres to purchase food, beg for alms or visit pilgrim centres. On the contrary, the provision of proper physical and spiritual services for leprosy was enshrined from 1179 onwards in canon law, and I should warn you at this point that those of you who are a bit squeamish with skeletal evidence should shut your eyes now because I am going to show you some bones.   However, some of the inhabitants of these suburban leper hospitals were victims of what we today call Hansen’s Disease, so there are, if you like, real leprosy and the other leprosy. This is evident from the work of archaeologists and paleopathologists. Skeletal evidence – and this shows lepromatis leprosy, which is the most aggressive form, which is relatively abundant, confirms that Hansen’s Disease was endemic, if not ubiquitous, in pre-modern England. These individuals were the victims of this lepromatis strain of leprosy, the most virulent and lethal strain of the disease, which produces the unmistakeable deformities still unfortunately familiar to us today from the Third World. Leprosy has become a forgotten disease, and I hope people will not forget it because it is still with us. The symptoms can readily be identified in the human skeleton, as we can see from the feet. This shows the nervous damage, which means people cannot feel – they have no sensation in their extremities, which become infected and they lose toes and fingers. In the face, which results in damage to the nasal cartilage, to the jaw, loss of teeth, and the polluted breath to which late-medieval sources refer, and this kind of imagery very clearly depicts a victim of Hansen’s Disease, saying, in English, “Some good, my gentle master, for God’s sake,” ringing her bell because she has no voice – it has become hoarse.   Although the arrival of a steadily-growing mass of medical literature from the Muslim centres of learning in Spain and the Middle East led to the introduction of more precise and superficially familiar diagnostic criteria from the late twelfth century onwards, they took quite a while to spread from the pages of specialist literature, and even longer, as we will see, to impinge upon the English populace at large. As a result, a wide range of dermatological conditions might be termed leprous and it is this lack of diagnostic precision, rather than epidemic of leprosy as we understand it, that helps to account for the striking number of leprosaria that sprang up in England between 1100 and 1300. This is, after all, an age before antibiotics – a lot of people have skin problems.     If we look, for example, at one case – this is Elias the Leper Monk of Reading, who is described in the Miracles of Thomas Beckett, whose abbot forbad him to go to Beckett’s shrine, which was just started in the 1170s, but ordered him to come to London where the best physicians were to be had. The physicians there said they could do nothing for him, so, surreptitiously on his way home, he snuck into Beckett’s shrine and was cured, and it is clear from the account of his symptoms that he was a victim of cirrhosis.     This confusion between different diseases is easy to understand because, up until the fourteenth century, people almost invariably focused upon facial symptoms, which is hardly surprising given that bodies were otherwise so heavily covered. This is a picture of a female leper at the shrine of St William of York, probably suffering from eczema or another skin disease. Notice, these people come and go to shrines very easily – nobody prevents them or gets in their way.     Interestingly, up to the fourteenth century, in legal terms, a leper was expected to live apart once his or her appearance became insupportable – that was the definition, and this is a very subjective matter. Up to the mid-fourteenth century, the decision to remove a suspect was reached through a process of gradual consensus on the part of family, friends and neighbours, rather than much in the way of medical opinion or official intervention.   Even then, since Leviticus imposed a ritual rather than a sanitary prohibition, the question of proximity to boundaries, walls or ditches simply did not matter. As long as you were outside the camp, it was not of much account where precisely you were. So, far from being remote and isolated, leper-houses were sited right next to gates or on the immediate approaches to towns and cities. In a heartening reversal of the fate of Lazarus, they conveyed to passing travellers an unambiguous example of the generosity of the rich towards the sick poor, while also constituting a rather less altruistic but highly effective advertisement of urban growth, independence and prosperity. Try to imagine, if you can, you are a Londoner coming into the twelfth century capital and you see this wonderful chapel at St Giles in Holborn, which was so impressive that Matthew Parris did a pen drawing of it in his Chronica Majora, and here it is…   These leper hospitals were dominant landmarks. People noted them, and they would often stop and give alms to them. This is why the proximity of public thoroughfares is so vital. Medieval travel could be extremely dangerous, and chapels such as this offered men and women the opportunity to invoke divine protection and the prayers of the inmates when they set out, and to thank God when they arrived back, placing an appropriate gift in the alms box as they did so. We know the box at St James Westminster was locked with three separate keys for added security.    We should note too that other hospitals for the sick poor, such as St Mary Spital, a big London general hospital outside Bishopsgate, friaries, such as those here, and baronial residences shared this type of extramural relocation, not least because they too needed sufficient space to accommodate and support a sizeable community.     Copious supplies of pure water in wells, streams and rivers were essential for laundry, waste disposal, brewing, cooking, gardening, animal husbandry, and the creation of fish ponds. English hospitals aimed to achieve at least a modicum of self-sufficiency, and these leprosaria were no exception. Indeed, interestingly I think, light gardening duties were deemed to be therapeutic for the more mobile patients, who were encouraged to take gentle exercise as a means of dispelling the melancholic humours then associated with the disease.   St Giles, here, occupied an eight acre site and owned a further sixteen acres up here across the road, before the Reformation - these are all given by generous citizens in return for prayers – and, in 1391, owned a sizeable number of pigs, cattle, poultry and agricultural equipment. So, these are running as sort of almost private farms.   By this date, the Mayor and Corporation had gone to law to force the Master of St Giles to honour his obligation to make available places for at least fourteen leprous citizens of London, who were to be supported free of charge, according to the terms of the original foundation charter. Their legal battle, which began in 1354, just four years after the Black Death, marks a significant shift in attitudes to leprosy. It is only at this point that we begin to approach what those nineteenth century leprologists and bacteriologists actually believed. This shift was driven by the dissemination of medical knowledge across the social spectrum, as ideas that had previously been the preserve of an academic elite gained far wider currency.     The Canon of Avicenna – Avicenna, the great Muslim physician, who died in 1037 - was introduced to the West gradually from the twelfth century onwards, but really only begins to circulate in any numbers in the fourteenth century. It contains a lengthy section on diagnosis and the treatment of lepra as Hansen’s Disease – it is much, much more specific.   It is also at this time that the judicium, or professional examination, for leprosy is introduced, adhering to between 40 or 50 specific symptoms which are itemised and which have to be ticked off respectively, and if you get a certain number of ticks, then you are deemed leprous. Again, these symptoms are very similar to what we associate with Hansen’s Disease, including a blood test here – examination of the whole body, not just the face, and of the urine. It gives you some idea of how patronising people are to medieval medicine. One nineteenth century author said that the leper’s wig is being washed here. His blood is being tested.   Furthermore, a conviction that plague – and of course plague breaks out here in 1348 – was spread by miasmatic or corrupt air prompted nervousness about the polluted breath and presence of lepers, and we begin to detect this on any scale for the first time. Given that the invention of the microscope lay far into the future and that the population of London fell by at least half during the later fourteenth century as a result of successive epidemics, the rationale behind this response is easy to understand. Fear of infection, in a society preoccupied by the threat of pestilence, meant that Londoners were especially conscious of the need to maintain adequate provision for those whose presence now seemed to threaten public safety, and it is this point that leprosy becomes a morbis contagiosis or a communicable disease, and only then.   Even so, both Edward III and Edward IV, who had access to the very best medical advice, were occasionally prompted to chide the Mayor and aldermen for their laxity with the regard to the freedom accorded to known suspects. In 1346, for example, just before the Black Death, Edward III took them to task for allowing lepers to frequent brothels, taverns and bathhouses in the city and to wander around the street, thereby allegedly affecting others. Perhaps mindful of this reprimand, in 1372, just after another epidemic, the Mayor issued orders for the removal of one John Maine, who persistently frequently public places, in defiance of orders that he should leave the city for a hospital. The fact that he was a baker may have increased anxiety, for he is the only named leper to face expulsion from medieval London. So, even now, the citizens are, to be colloquial, fairly laidback about the risks. They are not as insistent upon it as the Crown might have liked.   We can get a good idea of the discrepancy between theory and practice from an exasperated letter addressed by Edward IV to the rulers of London in 1472, just after another outbreak of plague and the discovery of a case of leprosy in the royal household. Despite the fact, he said, that several devout and well-disposed people had endowed hospitals outside the city to the pleasure of God and for the habitation and dwelling of people infected with the disease, many such people remained at large, wandering about, and he goes on to tell the Corporation off because these lepers were “…vagrant and wandering, contrary to the will and intent of the edifiers and builders of the same, as well about in this city and suburbs of the same, mixing and meddling daily with other people who be of clean disposition or complexion and not infected with the said sickness, which, if it should be suffered, should cause great hurt, jeopardy and peril to persons of clean complexion, for it is certainly understood that the said sickness daily grows and increases by such meddling and communication, more than it is done in days past.” So we can see here this sea-change in attitude.   That the Corporation took the supervision of its leper-houses in Hackney and Southwark more seriously than Edward’s order implies is apparent from its readiness to exempt the wardens from all other civic responsibilities, considering their “meritorious labour, their onerous occupation and the expenses and losses by them daily incurred”. Yet it seems clear that, even a century after the Black Death, the inmates of London’s leprosaria enjoyed a striking degree of freedom to wander about, and they were still the recipients of generous legacies from their fellow citizens, who were mindful that it could strike at any moment.   That Londoners had taken to heart the parable of Dives and Lazarus and had closely integrated their leprosaria into urban life is I think beyond question. In its early days at least, St Giles Holborn was liberally endowed with rents, tenements and market stalls, in the very heart of the city, and other houses also attracted a groundswell of support from members of the merchant elite, who not only hoped to secure a rapid transit through the fires of purgatory but also regarded hospitals as a powerful manifestation of collective authority and collaborative action. We can, I would argue, see here an expression of urban pride, a self-conscious desire for independence and a wish to demonstrate the ability of the urban body to succour and protect all its members, however sick and needy.  Such hospitals were what might today be termed a projection of the brand image or corporate message. As towns, most notably London, expanded in the twelfth and thirteenth centuries, charitable enterprises acquired a political agenda, serving to advertise success, wealth, and the presence of a community that was demonstrably capable of self-government. Collective involvement in such enterprises, moreover, gave ordinary men and women of limited means a sense of public proprietorship, and of course a share in all those attendant spiritual benefits. The leper may have lived outside the camp, but unlike Lazarus, he or she remained a figure of central importance within it.         © Carole Rawcliffe, 2012