INTERNATIONAL JOURNAL OF LEPROSY^ Volume 54, Number 2

Printed in the U.S.A.

INTERNATIONAL JOURNAL OF LEPROSYand Other Mycobacterial Diseases

OFFICIAL ORGAN OF THE INTERNATIONAL LEPROSY ASSOCIATION

EDITORIAL OFFICE

National Hansen's Disease CenterCarville, Louisiana 70721, USA

VOLUME 54, NUMBER 2^

JUNE 1986

EDITORIALSEditorial opinions expressed are those of the writers.

Leprosy and Social Class in the Middle Ages

The hospital emerged as a unique insti-tution during the most brilliant period ofthe Middle Ages in Western Europe (rough-ly 1050-1348). Most medieval hospitalswere not medical institutions at all, usuallycaring for pilgrims, widows, orphans, andreforming prostitutes. Among hospitals withat least quasi-medical functions, leprosariawere very prominent. In 1250, Toulouse hadat least seven well-endowed leprosaria toserve a population of 25,000 at maximum.'France (roughly corresponding territoriallyto the modern nation) had approximately2000 leprosaria in the year 1300, while En-gland had several hundred.'--4 Yet, by 1300,leprosy was clearly declining in England.Only half of the available hospital spaceswere filled and some leprosaria began to beconverted to other uses.' Estimates of theprevalence of the disease are unrealistic sincethere are inadequate data available. None-

' Mundy, J. H. Charity and social work in Toulouse,1100-1250. Traditio 22 (1966) 203-287.

Richards, P. The Medieval Leper and His NorthernHeirs. Totowa, New Jersey: Rowan and Littlefield, 1977,pp. 5-93.

3 Brody, S. N. The Desease of the Soul: Leprosy inMedieval Literature. Ithaca and London: Cornell Uni-versity Press, 1974, pp. 221-198.

4 Ell, S. R. Leprosy In: Dictyionary of Middle Ages.Strayer, J. ed. New York: Charles Scribners' Sons, 1936,vol. 7 (in press).

theless, it is clear that the institutional re-sponse to leprosy exceeded any real need.In this paper, I should like to discuss thefollowing question: Why did leprosy evokeso disproportionate an institutional re-sponse? I will argue that a perception arosesometime around 1100, and persisted at leastuntil the Black Death of 1348, that leprosywas a peculiar burden of the upper classesof society.

Before considering this question in detail,however, we must first determine what theterm lepra connoted in the High MiddleAges, how leprosaria fit into the social struc-ture of medieval Europe, and why the re-sponse to leprosy at an institutional levelimplied a commitment of the upper classes.

The diagnosis of leprosy. First, let us con-sider the disease. It has been fashionableamong historians to claim that the term lep-ra represented a loose diagnostic expres-sion, indicating a wide variety of skin dis-eases. This is the view of Brody, Bonser,Creighton, and McNeill, among others. 5-7

Bonser, W. The Medieval Backround of Anglo-Saxon England. London: Wellcome History of Med-icine Library, 1963, p. 371.

Creighton, C. A History of Epidemics in Britain.pp. New York: Barnes and Noble, 1965 (reprint of1894 edition), vol. 1, pp. 69-113.

1 McNeill, W. H. Plagues and Peoples. Garden City,New York: Anchor Press/Doubleday, 1976, p. 175.

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Much of the medical writing of the periodbefore 1100 comes from encyclopedic au-thors. Of these, Isidore of Seville (570-636)was the most influential. He did not clearlydescribe leprosy at all, but rather the dis-eases satyriasis and elephantiasis whose re-lation to leprosy is quite unclear. 8 HrabanusMaurus, ninth century abbot of Fulda, wroteof leprosy as an indicator of heresy`' follow-ing a tradition of associating leprosy withfalse religion which dated back at least toGregory of Tours'° (as opposed to unclean-ness, an association found in the Old Tes-tament), but which did little to define thedisease itself.

The translation and dissemination ofGreek and Arabic medical texts radicallyaltered the level of medical argument inWestern Europe, just as the more generaltask of translating classical works trans-formed intellectual life.

By the 12th century, Western Europeanmedical writers and the Arabic sources theytook to be authorative offered descriptionsof a disease, lepra, which clearly includedleprosy. While no single sign or symptomof the disease is pathognomonic, certaincombinations of signs and symptoms are.Autoamputation of the digits with nasaldestruction, facial coarsening and vocalchanges, for example, occur in no other dis-ease. Certainly in considering a variety ofcommentators on leprosy, such as GilbertusAnglicus, Theodoric of Cervia, John ofGaddysdyn, Guy de Chauliac and the au-thor upon whom they drew most heavily,Avicenna, it is clear that leprosy as we knowit was being described. Let us examine, fora moment, a portion of the description ofleprosy left by Theodoric of Cervia'': ".the face becomes puffy, the hairs of the eye-brows and eyelids thin out . . . nodules arefelt in the skin . . . the voice wavers, tendingto lower . . . if patients are pricked in theankle bone and are unaware, they feel little,similarly on the leg." Every symptom men-

8 Isidore of Seville. Allegoriam quaedam SacraeScripturae. Patrilogia latina, 83:127.

Hrabanus Maurus. Dc univcrso. Patrilogia latina,111:501-503.

'° Gregory of Tours. Historia francorum. Monu-menta Germaniae historica, RSM, I, 1:93.

" Theodoric of Cervia. The Surgery of Theodoric.Campbell, E. and Colton, J., trans. New York: Apple-ton Century Crofts, 1955-1960, vol. 2, pp. 167-182.

tioned is a well-recognized feature of lep-rosy. Yet, Theodoric describes several typesof leprosy, each with supposedly character-istic symptoms. Many of these relate to thesupposed imbalance of humors producingthe disease. It is clear that some of whatTheodoric describes occurs in leprosy, butnot all. The question remains: Was leprosythe only disease connoted by the term lepra?

The examination of skeletons of personswho died in medieval leprosaria permits anaffirmative answer to this question. An ex-amination of 202 such skeletons from themedieval leprosarium at Naestved, Den-mark, permitted a positive diagnosis of lep-rosy in 155 or 77%, work duplicated by twoindependent researchers.' 2, 13 In this case,skeletons from an ordinary cemetery a shortdistance away with one exception among633 cases, and that one from a time beforeleprosy patients had to be buried in separatecemeteries, showed no such changes, arguingagainst the possibility that these were theresult of weathering. 2 Seven of eight skele-tons from South Acre in Norfolk showedevidence of leprosy." An extensive study ofthe leprosarium at Aachen showed leprouschanges in over 80% of the skeletons ex-amined. 15 ' 16 All of these remains date fromthe 13th through the 16th centuries. Nomedical literature has appeared to disputethat such osseous changes as those describedresult only from leprosy.

In general, osseous changes would not beexpected in anything like this proportionamong modern leprosy patients. Suchchanges are largely the result of long-stand-ing lepromatous leprosy, so that nearly allof the patients dying in medieval leprosariahad lepromatous leprosy. This argues thatmedieval diagnosis of leprosy was conser-vative, tending to select out the most ex-treme cases.

12 Moller-Christensen, V. Bone Changes in Leprosy.Copenhagen: Munksgaard, 1961.

13 Andersen, J. E. Studies in the medieval diagnosisof leprosy in Denmark, M.D. thesis, Copenhagen, 1969.

14 Bayliss, J. Domus leprosae—community care inmedieval England. Nurs. Times 75 (1979) 62-67.

Schmitz-Cliever, E. Zur Osteo-archaologie dermittel-alterlichen lepra. Med. Hist. J. 6 (1971) 249-263 and 8 (1973) 182-200.

16 Schmitz-Cliever, E. Das mittelalterliche leprosar-ium Melatan Bei Aachen. Clio Medica 7 (1972) 13-34.

302^ International Journal of Leprosy^ 1986

One may argue that some of these personsacquired the disease in the leprosarium; thatis, they were initially misdiagnosed but latercontracted the disease. Possibly this did oc-cur, but modern understanding of leprosyargues strongly against such a phenomenonplaying a major role. A high proportion ofindividuals exposed to leprosy contract thedisease in some form, but the vast majorityof cases are subclinical and only a few per-sons exposed in this way could be expectedto show overt leprosy, 12-1 " and only a fur-ther few of those could anticipate osseouschanges. It is sometimes argued that the or-ganism itself has changed,' but there is noevidence of any kind to support this con-tention. Indeed, there has recently beenstrong medical objection to such notions onthe ground that the clinical expression ofleprosy is entirely host-dependent. 2"

Leprosy was not a diagnosis to be takenlightly. As early as 757, the Frankish lawpermitted leprosy as grounds for divorce.Alexander III specifically forbade divorceon the basis of leprosy in 1180, but a yearearlier the Lateran Council decreed that lep-rosy patients could not share church, ceme-tery, or even social life with the non-afflict-ed. By 1220, it was a civil crime for a leprosypatient to live among the healthy. Further,the diagnosis occasioned a religious rite inwhich the leprosy patient was cut off fromthe rest of Christian society. Leprosy pa-tients were legally dead in some parts ofMedieval Europe. 2 • 21-23 Medical writerstended, at least by the 14th century, to rec-ommend a conservative approach to diag-nosis. Gaddysdyn stated that only one whose

17 Godal, T. Immunological detection of sub-clinicalinfection in leprosy. Lepr. India 47 (1975) 30-41.

" Myrvang, B. Immune responses to Mycobacte-rium leprae in man. J. Oslo City Hosp. 25 (1975) 3-24.

" Job, C. K. Leprosy—the source of infection andits mode of transmission. Lepr. Rev. 52 Suppl. (1981)69-76.

Harboe, M. Mycobacterium leprae and host re-sponse. Lepr. Rev. 52 Suppl. (1981) 1-14.

2 ' Jeanselme, E. Comment ('Europe au moyen agese protegea contre la lepre. Bull. Soc. Fr. Hist. Med.25 (1931) 1-155.

22 Delaunay, P. Histoire de la medicine: de la con-dition des lepreux au Moyen Age. Hippocrate 2 (1934)456-460.

23 Cougoul, J. E. La Lepre dans lAncienne France.Bordeaux: Delmas, 1943.

face had been destroyed by the diseaseshould be declared a leprosy patient.' 4 Guyde Chauliac, probably the most importantlate medieval commentator on leprosy, ad-vised that doubtful cases be observed overtime, so that the disease could declare itselfunequivocally.' For all of these reasons, onlyfrank lepromatous leprosy was likely to bediagnosed as leprosy at all, precisely inkeeping with the results of the leprosariastudies.

The medieval hospital as institution andsocial expression. Medieval hospitals werepious benefactions of individuals or fami-lies. Even royal foundations, such as St.Giles, founded by Queen Matilda early inthe 12th century, 24 were acts of individuals,with no concept of the state involved. In-deed, the medieval period is conspicuousfor its lack of a concept of the state or ofgovernment existing apart from the personof the ruler.

Thus, hospitals functioned as private in-stitutions of charity. Charity, in turn, wasdefined as the love of God with all one'sheart and soul and the love of neighbor asof self. The hospital's role was not that ofmedicine but that of hospitality. Only seenas a personal expression of piety and pri-marily non-medical does the medieval hos-pital come into focus.

The "flowering" of medieval civilizationwas based on a narrow agricultural surpluswhich permitted both a sharp rise in pop-ulation and the concentration of wealth inthe hands of a tiny elite. With few excep-tions, high medieval institutions were theconstructs of the highest levels of society,the nobility, the rich ecclesiastics, and thewealthy burghers. Leprosaria were such aconstruct.

Whatever else they may have disagreedover, these disparate fragments of the upperclasses were united in contempt for thepeasantry. As Duby has recently written, 25

when the depradations of warring noblesfurther impoverished the peasantry, outragewas expressed at the resultant loss to thelandowner. Involuntary poverty was a mat-

24 ^E. J. Medieval Medicus: A Social HistoryofAnglo-Norman Medicine. Baltimore: Johns HopkinsUniversity Press, 1981, pp. 82- 107.

25 Duby, G. William Marshall, Flower of Chivalry.New York: Pantheon, 1985, pp. 33,123-153.

54,2^ Editorials^ 303

TABLE 1. Early medieval references to leprosy and their associated imagery.

Type of reference to leprosyType of document^Number

Worldliness^Heresy "Epidemio-logical"' None'

Chronicles 16 4 9 1Saints' lives 20 5 12 0Biblical commentary 24 6 13 1 5

Total 60 15 34 9

This refers to any comment on who is most likely to acquire leprosy. One such work is quoted in the text;the other refers to the lasciviaes.

6 Leprosy mentioned, or a person identified as having leprosy, but no comment made on its significance.

ter for contempt. In general, the upper classeslooked after their own interests. The inter-ests of the poor merited some lip service butlittle action. Hospitals looking after widowsand orphans were institutions which couldand did serve high families fallen on hardtimes. Prostitution was a risk of a womanwithout adequate dowry.-26 Pilgrims ofwhatever origin were revered but, again, theserf who went to a distant shrine was theexception, while high nobles were expectedto undertake some pious journey. 25

Thus, leprosaria imply a commitment ofthe upper classes and it would be atypicalif the goal was not in their favor. One mayreason quite logically that the goal was free-dom from contamination, but an exami-nation of the literary imagery surroundingleprosy suggests an alternative explanation,namely, that the upper classes saw them-selves at particular risk for the disease.

Literary imagery: Leprosy as heresy toleprosy as worldliness. Medieval exegesisand even popular literature equated variousdiseases with moral states. Disease was afigure, as distinct from a symbol, of the mor-al state. A symbol signifies something else,while a figure has the quality it signifies.David as king is a figure of Christ in thathe symbolizes the Heavenly King, but isalso a divinely appointed king himself. Thus,a disease might symbolize a moral state, butthe sufferer was also felt to be in that moralstate. With this in mind, let us consider astriking change in literary imagery that oc-curred around 1100.

Tables 1 and 2 summarize references ofvarious types to leprosy. Note that in the

26 Kirshner, J. Pursuing honor while avoiding sin:the Monte delle dolt of Florence. Studi Senesi 89 (1977):177-258.

Early Middle Ages, when the diagnosis ofleprosy was uncertain, leprosy was equatedwith heresy. Once the diagnosis became re-liably that of the disease we know as lepro-matous leprosy, the imagery shifted toworldliness, especially pride, avarice, glut-tony, sexual license and neglect of spiritualvalues. While no sample of medieval textscan be called random, these references werecollected while researching two general ar-ticles on images of disease and the physicianin the Middle Ages. These articles were notconcerned primarily with leprosy. 27 ' 28 Thus,they are to that extent impartial. Further,one must note that certain literary genresrose and declined during the transition fromEarly to High Middle Ages. Hagiographydeclined sharply in the High Middle Ages,while the Early Middle Ages had little ver-nacular literature. Yet, even within the samegenre, imagery changed. Note that in bibli-cal commentaries, the early medieval sam-ple shows leprosy associated with heresymore than twice as often as with worldli-ness, while the larger high medieval sampleequates leprosy with worldliness over fourtimes as often as with heresy, despite thetremendous tendency to copy exegeticalworks from earlier periods word for word.

Consider the transformation of a singlestory, the legendary (and clearly fictional)leprosy of Constantine. In the original ver-sion of unknown authorship, Constantinethe Emperor is afflicted by leprosy and begsa cure from Pope Sylvester II. In return forthe cure, Constantine grants the papacy

" Ell, S. R. Concepts of disease and the physician inthe Early Middle Ages. Janus 65 (1978) 153-165.

28 Ell, S. R. The two medicines: some ecclesiasticalconcepts of disease and the physician in the High Mid-dle Ages. Janus 68 (1981) 15-25.

304^ International Journal of Leprosy^ 1986

TABLE 2. High and late medieval references to leprosy and their associated imagery.

Type of reference to leprosyType of document Number

Worldliness Heresy "Epidemio-logical" None

Chronicles 20 7 0 0 13Saints' lives 8 5 0 1Biblical commentary 32 26 6 0 0Courtly literature 30 23 0 0 7Medical tracts 10 3 0 6 1

Total 100 64 8 6 22

temporal dominion in Western Europe. Thisis the fictional basis of the forged but famousDonation of Constantine, 29 one of the key-stones of papal claims to worldly dominion.In the hands of Gregory of Tours in the 6thcentury, this story is reworded around thebaptism of Clovis. The former pagan is de-scribed as a "new Constantine," sheddingthe "disgusting macules" of leprosy at theceremony)" It is unclear if Gregory actuallythought Clovis had leprosy, but his languageis so graphic as to leave considerable doubt.In any case, heresy (paganism was not de-marcated from heresy in this period—theIslamic religion was considered a heresy) iscentral to the imagery of leprosy. As citedabove, influential writers, such as Isidore ofSeville and Hrabanus Maurus, specificallyequated leprosy with heresy.

When one enters the literature of the HighMiddle Ages, there is an abrupt shift. Theleprosy of Constantine in Dante's Infernois the punishment for his worldly pride, nothis pagan past. 3°

Nowhere is the change in imagery morestriking than in the new vernacular litera-ture of which the Divine Comedy is the mas-terpiece. To be sure, significant amounts ofvernacular literature were new to the HighMiddle Ages, but they were intended forcourtly and educated audiences. Perhaps themost singular such work with regard to lep-rosy is Der Arme Heinrich (c. 1200), dis-cussed at some length by Brody. 3 The hero,Heinrich, is a knight possessed of the chiv-alrous virtues, noble birth and wealth. Yet,

29 Tierney, B. The Crisis of Church and State. En-glewood Cliffs, New Jersey: Spectrum Books, 1964, pp.18-21.

30 Dante. Inferno. Canto 27, lines 94-97.

he is wertlich, worldly, and for this he ispunished with leprosy. His only chance forcure lies in the possibility of a chaste girlsacrificing her life for him. A pure peasantgirl, reasoning that death before she is taint-ed by lust or other sin will surely lead tosalvation, offers herself. Perceiving truth atlast, Heinrich prevents the girl's sacrifice,thereby renouncing the world himself (con-sidering the legal status of leprosy patients),and is cured. 31 The parallel imagery of theknight noble in the eyes of the world, impureto God, and the peasant girl, contemptibleto the world yet pleasing to God, is re-markable. As already commented, the peas-antry, if mentioned in medieval literatureat all, almost invariably evoked derision.Yet the noble "leper"/pure peasant motifenjoyed considerable popularity.

Medieval courtly literature —and reallife—abounds with tales of noble "lepers."No true epidemiology of leprosy in the Mid-dle Ages seems possible, but in light of thesharp reversal of imagery surrounding thedisease at the time when it came clearly tobe recognized as the disease we know today,it is difficult to dispute that the upper classesfelt themselves at peculiar risk.

They may have had reason to feel so. Cer-tain pious practices might well have putthem at unusual risk. Queen Matilda (c.1110), wife of Henry I of England, broughtleprosy patients into her chambers, washedtheir feet, kissed their sores, and fed them.Her brother David (later King of Scotland)roundly cursed her for this practice on oneoccasion, but later took up the practice him-

3 ' Hartmann von Aue. Der Arnie Ileinroch. 4th ed.,Gierach, E. and Knight Bostock, J., eds. Oxford: Black-well, 1965.

54, 2^ Editorials^ 305

self. William of Malmesbury, who recountsthis story clearly, admired such actions. 24 ' 32

Henry I himself made leprosy the "royaldisease" of England in a sort of thauma-turgic prestige contest with the King ofFrance. 24 One of the major contributors toMatilda's leprosarium, Saint Giles, wasRobert Fitz Ralph, himself a victim of lep-rosy. 24

Examples of behavior like that of Matildasuggest again a preoccupation with leprosyon the part of some nobles. At the sametime, they suggest that avoidance of thetemptations of the world might free one ofgenuine risk, whether of the disease itself orof sin is unclear. In any case, it is clear thathigh nobles had a direct experience with thedisease through pious acts and thereby, per-haps, an increased risk of infection. Thepopular image of the wandering leprosy pa-tient ringing his warning bell and of villagersscattering in fear is markedly at variancewith the scene in the apartments of theQueen of England.

Conclusion. On the basis of the best evi-dence at hand, namely the skeletal remainsof those thought to have had the disease,leprosy was accurately diagnosed in the

32 William of Malmesbury. Willehni Alalmeshiren-sis Monachi de Regum Anglorum. Stubbs, W., ed. Lon-don: Rolls Series 90, 1887-1889, vol. 2, p. 494.

Middle Ages, and corresponded basically tolepromatous leprosy. However tempting itmay be to proclaim medieval ignorance ofthe disease, there is physical evidence thatpersons diagnosed as suffering from leprosyin fact did.

At the same time that this diagnosis be-came reliable, a striking change in literaryimagery occurred. Leprosy ceased to be thefigure of heresy and became that of world-liness. The noble "leper," sometimes con-trasted to the pure peasant, became a pop-ular literary motif, and one at variance withessentially all other literary imagery relatingthe orders of society. Nobles poured landsand funds into leprosaria, out of proportionto actual need. Far from fleeing contact,some pious nobles sought out direct contactwith the afflicted and probably did increasetheir risk of infection. Whatever the realepidemiology of leprosy in medieval Eu-rope, it is inescapably apparent that the per-ceived burden of leprosy fell on the upperclasses and that the literary, social and in-stitutional response to the disease reflectedthat perception.

—Stephen R. Ell, M.D., Ph.D.Department of RadiologyUniversity of Chicago

Hospitals and Clinics5841 South MarylandChicago, Illinois 60637, U.S.A.