Walking Corpses: Leprosy in Byzantium and the Medieval West 9780801470776

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Walking Corpses

Walking Corpses

Leprosy in Byzantium and the Medieval West

Timothy S. Miller and John W. Nesbitt

Cornell University Press Ithaca and London

Copyright © 2014 by Cornell University All rights reserved. Except for brief quotations in a review, this book, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850. First published 2014 by Cornell University Press Printed in the United States of America Library of Congress Cataloging-in-Publication Data Miller, Timothy S., 1945- author. Walking corpses : leprosy in Byzantium and the medieval West / Timothy S. Miller and John W. Nesbitt. pages cm Includes bibliographical references and index. ISBN 978- 0-8014-5135-5 (hardcover : alk. paper) 1. Leprosy–Byzantine Empire–History—To 1500. 2. Leprosy–Europe–History—To 1500. I. Nesbitt, John W., author. II. Title. RC154.3.M55 2014 616.99'8009495—dc23

2013030660

Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. For further information, visit our website at www.cornellpress.cornell.edu. Cloth printing

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9 8 7 6 5 4 3 2 1

For Vicki and Carla

Contents

List of Illustrations

ix

Preface and Acknowledgments

xi

Introduction

1

1. The Ancient World

10

2. Leprosy in the Byzantine Empire

27

3. Byzantine Medicine

48

4. Byzantine Leprosariums

72

5. Leprosy in the Latin West

96

6. Leprosariums in the Latin West

118

7. The Knights of Lazarus

139

v iii

Contents

Conclusion

155

Appendixes

163

1. Aretaios of Cappadocia, On Acute and Chronic Diseases (Books IV.13 and VIII.13)

163

2. Gregory of Nyssa’s Oration, Regarding the Words “As much as you have done for one of these, you have done for me” (Matt. 25:40)

173

3. Selection from The Funeral Oration in Praise of Saint John Chrysostom (Chapters 60.17 to 67.1)

186

List of Abbreviations

193

Notes

195

Bibliography

221

Index

239

Illustrations

Map 1. The Mediterranean World

35

Figures 1. Miniature from the Athos, Octateuch Vatopedi codex 602, illustrating Numbers 5:2: “Command the people of Israel that they put out of the camp every leper . . .” 19 2. Christ healing a leper, as described in the Gospel of Mark 1:40– 45. From the Athos, Iveron codex 5. 20 3. The martyrdom of St. Zotikos, as depicted by an eleventh-century anonymous artist. 76 4. Lead seal of the Monastery of St. Zotikos. 87 5. Saint Benedict of Nursia healing a leper—eleventh-century fresco from the church of San Crisogono in Rome. 104

Preface and Acknowledgments When the blessed one (John Chrysostom) saw many among these sick stricken [with these symptoms] abandoned along the roads in the land of the Bithynians—unburied corpses, moving cadavers, creeping bodies, rational beings who sent forth inarticulate sounds, who displayed only so much of their [natural] character that those who saw them knew that at one time they had been human beings—the saint moistened his cheeks with streams of tears, and said, “What must one do for his fellows if he would lighten such a misfortune for these brethren?” (The Funeral Oration in Praise of Saint John Chrysostom)

The title of our book, Walking Corpses, was inspired by these lines from an anonymous funeral oration, delivered in 407 in honor of the former bishop of Constantinople, John Chrysostom (see appendix 3 for the entire section of this speech dealing with leprosy). The same image of the victims of leprosy as half-dead, walking corpses appears in Gregory of Nazianzos’s powerful sermon, On the Love of the Poor, and in Gregory of Nyssa’s oration on leprosy (see appendix 2 for the full text). From these passages one can clearly perceive that leprosy, an illness that contemporary physicians identified as Elephant Disease, terrified men and women of the early Byzantine Empire. As a result of sermons such as these, however, religious leaders in Asia Minor, Constantinople, and the other lands of the Eastern Mediterranean attempted to redirect this terror in the face of leprosy and its supposed contagiousness to support a campaign to assist the victims of Elephant Disease through a network of leprosariums, institutions that provided lepers with food, housing, palliative care, and perhaps, most importantly, with a sense of community

x ii

Preface and Acknowledgments

to  replace their families and their city-states (what Greeks called the “poleis”). As we, the authors, translated these powerful sermons, we decided that the story of leprosy in the Byzantine Empire and especially the response of the medieval Greek world to the victims of this disease had not been sufficiently examined. Moreover, when we began to read the many recent books and articles on medieval leprosy and its effects on the Latin Christian world of Western Europe, we realized that no study had examined closely how Byzantine ideas about leprosy, and the leprosariums created by those ideas, had in turn shaped the attitudes and institutions of Catholic Christendom. The need for such a new approach to the study of medieval leprosy seemed even greater when we recalled that this disfiguring disease became more common in Western Europe after the First Crusade (1096–99), that is, after Western warriors had passed through the regions of the Byzantine Empire. Walking Corpses thus traces leprosy’s advance through the medieval Christian world from the Eastern capital of Constantinople and the provinces governed by this great city, first to Italy, then to France, and finally to the farthest reaches of the West and North. As our project unfolded, we needed help from many quarters. Working at Salisbury University, a regional school on Maryland’s eastern shore, Timothy Miller would have been unable to complete his part of the project without the help of Deborah Malone and Marilyn Ruddy of the interlibrary loan office of Blackwell Library who managed to obtain copies of obscure journals and old editions of Byzantine medical texts. For example, they located for our project a collection of documents from Venetian Crete (sixteenth century), published in the journal Kretika Chronika. Perusing these documents, we found the first indication that women participated alongside men in governing leprosariums in Crete and in other leper asylums in France and Italy. Also at Salisbury University, Nicholas Melczarek helped clarify for us some of the more abstruse points in Michel Foucault’s theory of exclusion, while Christopher Briand of the biology department checked our partial translation of Aretaios’s On Acute and Chronic Diseases (see appendix 1) to ensure that we had used the proper modern terms for genus and species in identifying plant names in the text. Many other colleagues at Salisbury University made contributions in informal conversations, often in corridors and at the lunch counters on campus.

Preface and Acknowledgments

x iii

Thelonious Williams, a history major at Salisbury University, helped us solve a number of computer issues in preparing the final manuscript copy, problems that were simple for his fellow students but seemingly insurmountable to us. Moreover, Thelonious’s interest in Richard Coeur de Leon and the ducal administration of Aquitaine motivated us to take a second look at southern France and its government one hundred years later in the late thirteenth century and at the mysterious association of leprosariums around the cities of Narbonne and Toulouse. Alice-Mary Talbot, Director of Byzantine Studies Emeritus at Dumbarton Oaks Research Library and Collections, played a key role in our research by bringing to our attention the two poems by Manuel Philes (1275–1345) describing victims of Elephant Disease (i.e., leprosy). One of these poems provided interesting insights into the perceived connection between leprosy and lust. We also wish to thank John Duffy, John Nesbitt’s colleague and Dumbarton Oaks professor of Byzantine philology and literature, Harvard University, for his assistance in photocopying the leprosy chapter of Book Thirteen in Aetius of Amida’s summary of ancient Greek medicine, compiled in the sixth century. It is an indication of how much work still needs to be done in the field of Byzantine medicine that no complete Greek edition of Book Thirteen of Aetius’s work exists. With Professor Duffy’s help we obtained a copy of the Latin translation of Aetius’s discussion of leprosy in a rare 1542 edition of the text. We are especially grateful to Stamatina McGrath, adjunct professor of history at George Mason University, for her help in locating valuable sources on the care of orphans in the Byzantine Empire. Before turning our attention to lepers and leprosariums, we both studied the Great Orphanage of Constantinople, the Byzantine Empire’s premier philanthropic institution. In fact, Constantinople’s only leper asylum, the Zotikos Leprosarium, was an agency subject to the director of the orphanage. While working at Dumbarton Oaks, Stamatina found two key references to the care of orphans by provincial bishops, sources that helped connect the central orphanage of the capital to the general responsibility of Christian bishops to care for children without families, a duty that came to include the victims of leprosy. For, as we shall see, lepers suffered a fate even worse than that of orphans, since they were abandoned not only by their families but by their friends and communities as well.

x iv

Preface and Acknowledgments

We also are grateful to Peter Potter of Cornell University Press not only for finding readers who carefully reviewed our manuscript and made many valuable substantive suggestions to improve our arguments but also for his extensive efforts in helping us prepare our manuscript for publication. Our research has shown that references to Byzantine leprosariums after 1204 are rare. Dr. Adelina Angusheva-Tihanov of the University of Manchester (UK), however, alerted us to the significance of the Life of Saint Stephen Dečani (Vita Sancti Dechani), which includes a detailed description of a fourteenth-century refuge for lepers attached to the Monastery of Dečani in Serbia. As in the past, Father John Cotsonis, director of the Archbishop Iakovos Library at Hellenic College/Holy Cross Orthodox School of Theology, has again offered us his invaluable assistance in identifying a colorful and moving manuscript illumination for the Iveron Monastery on Mount Athos (codex 5), an illustration of Christ healing the leper in Mark’s Gospel (1:40– 45). With the kind permission of Abbot Nathaniel, this illustration appears on the cover of Walking Corpses. The monks of the Holy Monastery of Vatopedi have also permitted us to use an illustration from one of their Byzantine manuscripts. Finally, we wish to remember Father David Johnson, S. J., Professor Emeritus of Semitic and Egyptian Languages at the Catholic University of America. For thirty years Father Johnson had been a good friend and a helpful colleague while teaching Coptic language and papyrology at the Catholic University. In the summer of 2011 he was diagnosed with pancreatic cancer and died on Thanksgiving Day of that year. We recently discussed with him the possibility of finding additional information on leprosy and leprosariums in Byzantine Egypt, but he had already grown too weak to read. We thank him for the encouragement he gave us as we wrote this book.

Walking Corpses

Introduction

Leprosy occupies a special place in the history of contagious diseases. It is closely related to tuberculosis, yet people react far differently when they think of Margarite, the consumptive heroine of The Lady of the Camellias, coughing spasmodically, than they do when observing lepers bathing their oozing sores. The consumptive evokes pity, as Dumas intended in his romantic novel, but the image of lepers inspires fear and revulsion and in many a strong desire to flee from their presence. Medieval writers even described the victims of leprosy as the living dead. What image could inspire more terror?1 Leprosy triggers such reactions because its more extreme symptoms can be so terrifyingly visual. The most severe form of the disease, lepromatous leprosy, causes horrifying alterations in the body’s appearance. Persons with this form of the disease develop skin lesions and over time experience a loss of sensation, especially in the hands, feet, and face. After lesions and crusty nodules break out both on the face and body, the skin thickens and becomes rough and cracked. Ancient Greek physicians compared the effects of leprosy

2

Introduction

on human skin to the hide of elephants. Nasal mucosa thickens, commonly resulting in nosebleeds; ulceration and destruction of tissue follow. Since leprosy also attacks bone, it can alter the skull structure around the nose and mouth so that the face takes on a grotesque appearance. As the disease progresses, various nerves can incur damage, including those of the face, forearms, and the legs below the knees. Gradually, patients suffer a diminution of sensory and motor function and begin to walk with a staggering gait. In the end, they may experience a loss of their toes and fingers. Because the effects of leprosy resembled the rot of death, Byzantine preachers sometimes called its victims “walking corpses.”2 For people living during the Middle Ages, conscious of the divine power in every natural manifestation, the decaying flesh of leprosy was especially disturbing. Were its victims being punished or being readied for heaven? Were they saints like Job, tested in their patience, or sinners in the hands of an angry God? Were they bearing Christ’s sufferings in their own flesh, or were they in league with the devil? In view of the disfiguring effects of the disease on the human body, it is no wonder that observers were both horrified and fascinated by leprosy. Moreover, during the twelfth century the disease suddenly flared up throughout Catholic Europe, an epidemic that seared the collective psyche of Western society with a fear of contagion. Even the young Saint Francis of Assisi was terrified of lepers.3 The medieval Catholic Church responded to the leprosy epidemic of the twelfth century by constructing charitable institutions called leprosariums throughout Western Europe. Although this philanthropic response was part of a larger effort within Christendom at the time to assist a wide range of people in need—poor travelers, orphans, pregnant, and homeless women, as well as people with curable diseases—the leprosy epidemic called for its own particular measures. In addition to providing care for those debilitated by this sickness, such leprosariums also offered lepers an alternative to living in close contact with family members and neighbors, some of whom harbored fears of catching the disease. The fear engendered by lepers also cast its shadow over literature produced in Europe during the high and later Middle Ages. It was not uncommon for the suffering victims of this disease to appear as evil characters in chivalric romances. In several versions of Tristan and Isolde, lustful male lepers begged King Mark to let them ravish the beautiful Isolde as punishment for her unfaithfulness.4 In the French romance The Quest for the Grail,

Introduction

3

a once-beautiful lady castellan, now hideously disfigured by leprosy, bled Perceval’s sister to death because she needed the blood of a pure maiden to restore her health.5

Studying the Disease When one considers the macabre nature of leprosy and the complex reactions it provoked in medieval society, it is easy to understand why modern scholars have been drawn to the subject. An early influential book on leprosy in the Middle Ages was Saul Brody’s The Disease of the Soul (1974).6 A historian and literary critic, Brody analyzed medieval romances to illustrate how Christian Europe interpreted leprosy as a symbol of sin. Since then a wealth of scholarship has been published internationally, in both article and book form exploring nearly every facet of the disease.7 One of the more noteworthy studies appeared in 1988, Histoire des lépreux au Moyen-Âge, by the French scholar Françoise Bériac. In it Bériac examined leprosy in medieval France from many angles, taking into account medical writers, popular literature and romances, pious stories and sermons, and documents (both published and unpublished) from the archives of French leprosariums.8 A year later, François-Olivier Touati published a detailed study of leprosy and leprosariums in one ecclesiastical province, that of Sens, from the twelfth to the fourteenth century.9 More recent scholarship has built on and extended the impressive work of Bériac and Touati. We now have access to published archives of medieval leprosariums as well as geographical surveys that map the location of leprosariums in parts of France and Germany. These, along with bioarchaeological research on skeletons from leprosarium cemeteries, are changing our understanding of both the disease itself and its treatment throughout the Middle Ages.10 Despite this extensive body of research, popular perceptions of leprosy as a “disease of the soul” have been slow to change. Surprising though it may seem, Enlightenment hostility to medieval civilization has combined with late nineteenth-century concepts of contagious disease and quarantine measures to cast a long shadow over contemporary ideas concerning leprosy and how medieval society reacted to it.11 As Touati has demonstrated, the force of these preconceptions is so strong that even Michel Foucault, who strove to free the study of the past from conventional epistemological systems,

4

Introduction

fell victim to its distorting influence.12 In his introduction to Madness and Civilization, first published in English in 1967, Foucault referred to medieval leprosariums as “cities of the damned” multiplying “over the entire face of Europe.” Such a depiction had no basis in the historical record, but the image is so powerful that it alone might explain why old ideas about leprosy persist in the face of new research.13 Even reputable histories of medicine such as Roy Porter’s The Greatest Benefit to Mankind (1997) perpetuate these views. Leprosy became highly stigmatized. Authorized by ancient Levitical decrees, leper laws were strict in medieval Europe. They were forbidden all normal social contacts and became targets of shocking rites of exclusion. . . . They were segregated in special houses outside towns, lazarettos, following the injunction in Leviticus that the “unclean” should dwell beyond the camp.14

One of our main reasons for writing this book, therefore, is to address these common misperceptions that continue to linger in the popular conscience as well as in some scholarly circles about leprosy in the Middle Ages. The fact is, despite the abundance of solid research in recent years, few attempts have been made, especially in English, to synthesize our understanding of this horrific disease and how medieval society responded to it. Furthermore, it also needs to be said that much of what we know about leprosy in the Middle Ages comes from scholarship focused almost exclusively on the Western half of the Christian world, leaving Byzantium out of the picture entirely. This is despite the fact that the Greek Byzantine Empire (often called the East Roman Empire) shared a common religious tradition and inherited the same Greco-Roman culture as did Western Europe.15 There are very good reasons, however, for considering the Latin West together with the Byzantine Empire when studying the history of leprosy. The earliest recorded outbreak of the disease occurred in the eastern Mediterranean during the third century BC. In the late antiquity period, the Byzantine state and church were confronting leprosy and its effects well before the Latin West. Indeed, they were forced to reckon with the disease as early as the dedication of Constantinople in 330 and up until the final conquest of the city by the Ottoman Turks in 1453. We believe it is essential, therefore, to integrate the story of leprosy in the East and the West into a single, comprehensive account. As we will demonstrate, the ideas, attitudes,

Introduction

5

and institutions forged by the Greek Christians of the eastern Mediterranean naturally passed to the West. Here these ideas and institutions helped guide Latin Christians as they faced the same sanitary and social problems caused by leprosy in the twelfth and thirteenth centuries that Byzantine Christian leaders had confronted in the fourth and fifth centuries.16 At the same time, it is important to recognize that there were other forces that influenced how the West confronted leprosy. Although Latin Christendom shared a common classical culture and a common Christian religion with Byzantium, the Western Empire was overrun during the fifth and sixth centuries by Germanic tribes that introduced new attitudes and institutions different from those in the Eastern Empire. Our study explores the new perspectives on leprosy and leprosariums that this Germanic influence introduced into the West.17 Our research has arrived at a number of significant conclusions. First, contrary to the findings of some researchers, ethical writings from the Byzantine world and from Catholic Europe did not, as a rule, brand leprosy as punishment for sin; rather, theologians and moralists saw the disease as a mark of God’s favor on those chosen for heaven. Leprosy became for both Orthodox and Catholic Christians the “Holy Disease.” Second, the stimulus to ban lepers from society and ultimately to persecute them came not from Christian influence but from Germanic customary law. Finally, leprosariums, both in Western Europe and Byzantium, were not prisons to punish lepers but were centers of care to offer them support. Some leprosariums even provided residents the opportunity to govern their own communities under a form of written constitution. Unlike other charitable facilities such as general hospitals or orphanages, the residents of leprosariums regularly met to make decisions about their institutions’ finances and regulations. In some leprosariums residents were even allowed to impeach a prior or master for dishonesty or incompetence. More surprisingly, female lepers sometimes participated alongside their male counterparts in community meetings and assisted in managing the leper asylums. Women were even chosen to act as representatives of these institutions, and in several documented cases women served as priors of their leprosariums with authority over male residents and staff members. Ultimately, our study confirms that the general picture emerging in recent scholarship was that leprosariums, far from being prisons to punish lepers or isolate them totally from the society of the healthy, provided a protected

6

Introduction

environment. In some of these institutions, male and female lepers were able to participate in what was, in fact, an experiment in democracy under a form of constitutional government. In support of our discussion of leprosy and leprosariums in the Byzantine Empire, we include English translations of three key texts in Greek. One of these—a section of an anonymous funeral oration in honor of John Chrysostom—has never been translated into English and has only been available in a printed Greek text since 2007. The section of Aretaios of Cappadocia’s medical compendium describing leprosy was last translated into English in 1857.

What Is Leprosy? Galen of Pergamon, born in Western Asia Minor in 130 AD, became the most renowned physician of the Greco-Roman world. He enriched the medical observations attributed to the fifth-century (BC) Hippocrates with his own anatomical research and personal experiences with patients. Galen also integrated the findings of earlier Hellenistic scientists into his many studies to produce a masterly corpus of medical wisdom. Any modern physician or biologist who holds ancient Greek medicine in contempt as a collection of unfounded theories and folk remedies should read Galen’s remarkably detailed and accurate description of the muscles, bones, nerves, and tendons in the human hand.18 Galen’s writings not only won him the respect of his contemporaries, including the emperor Marcus Aurelius, but also the homage of succeeding generations. He came to dominate subsequent Greek medicine so that doctors throughout the thousand years of Byzantium rarely questioned his opinions, and in the Arabic world physicians revered him as one of the founders of medical science. Influenced by the treatises of Islamic medicine, Western physicians also considered Galen an infallible expert on the human body and its illnesses. To medieval health professionals around the shores of the Mediterranean, Galen’s medical works spoke with an authority almost equal to that of the Bible or the Qur’an. Galen, like other ancient writers, referred to leprosy as “elephantiasis,” or “Elephant Disease.” If we were to ask Galen what caused the disease, he

Introduction

7

would have responded clearly and with great confidence that it arose from an excess of black bile in the body. Galen made just such a reply to his friend, the philosopher Glaucon.19 Black bile, or melancholia, was one of the four humors—blood, phlegm, yellow bile, and black bile. According to the dominant Greek medical theory, which Galen forcefully supported in his treatises, men and women remained healthy when their bodies maintained the correct balance of these humors. An excess or a dearth of any one of these fluids resulted in illness. If, for instance, the body had too much black bile and did not manage to eliminate the surfeit, leprosy was the most serious of several possible effects from such an imbalance. Although by the sixteenth century European physicians and scientists had begun to challenge how Galen described the human body and its illnesses, no one succeeded in replacing his explanation for leprosy until 1873, when the Norwegian scientist Gerhard Armauer Hansen identified Mycobacterium leprae as the bacteriological agent that caused leprosy. Hansen had been conducting research on leprosy because the number of cases of the illness had been increasing in Scandinavia during the nineteenth century. Hansen was convinced that Mycobacterium leprae could easily spread from one victim to another, thus he recommended that victims voluntarily avoid contact with others—a recommendation that subsequently helped reduce the number of people with leprosy in Norway within a few years of Hansen’s discovery. As a result of Hansen’s achievement, modern science has renamed leprosy “Hansen’s disease.”20 Modern science has also identified two different manifestations of Hansen’s disease: lepromatous leprosy and tuberculoid leprosy. There exists only one strain of Mycobacterium leprae, but the human body responds to the bacterium in several different ways. In fact, most people have a natural immunity to leprosy. This explains why the disease has never affected more than 10 percent of a population at any particular time and place and has not had the devastating demographic effects of bubonic plague and smallpox. This also accounts for the fact that not all ancient or medieval observers of leprosy were convinced that the disease was highly contagious. Among people susceptible to the disease, some have limited resistance and develop tuberculoid leprosy, which causes skin lesions, swellings, and even some nerve damage and which, in turn, can lead to the loss of fingers and toes. If the body has no ability to resist the bacterium, the patient eventually

8

Introduction

comes down with the dreaded lepromatous form of Hansen’s disease, which if left untreated produces the horrifying effects on the human body described earlier.21 Modern experts on infectious diseases have identified the bacterium that causes leprosy; they can also explain the different manifestations of the illness. More important, since the early 1980s modern medical therapies can stop the spread of Mycobacterium leprae in the victim’s body, although they cannot repair any damage already done to tissues, nerves, and bone. Despite these advances in knowledge, medical science has not been able to solve the riddle of leprosy epidemics—why the disease remains in a population, at first attacking only a few victims, but then suddenly becomes aggressive and infects many more people. The epidemic of the European High Middle Ages, therefore, is still a mystery, as is the apparent epidemic that struck the Eastern provinces of the Roman Empire in the fourth century AD. Although Hansen and his contemporaries were convinced that the disease caused by Mycobacterium leprae was the same illness that people in medieval Europe called “leprosy” and Galen and later Byzantine physicians named “Elephant Disease,” modern scholars are not so sure—for several reasons. First, many skin infections have symptoms that can easily be confused with Hansen’s disease. Second, Mycobacterium leprae, like other bacteria, may have changed its structure over the centuries while, at the same time, humans were likely developing new defenses against this pathogen. Both of these mutations surely affected the observed symptoms.22 Third, the ancient and medieval sources employ a confusing bundle of names for the disease. When leprosy first appeared in the Mediterranean, Greek physicians called it kakochymia and, later, leontiasis and satyriasis, before settling on the name elephantiasis, or Elephant Disease. Modern studies have shown that Hansen’s disease, in its lepromatous form, not only attacks tissue but corrodes the bone around the oral and nasal cavities and leaves distinctive marks on toe and finger bones. It is possible, therefore, to examine skeletal remains and positively identify individuals who died with an advanced stage of Hansen’s disease.23 Indeed, paleopathologists have studied forty skeletons from a leper cemetery at Aachen, 358 skeletons from a Danish institution, and smaller numbers from leprosariums in England. Between 70 and 80 percent of these skeletons display clear signs of Hansen’s disease.24 However, the leprosarium cemeteries excavated so far represent a very small percentage of the total number of such burial sites.

Introduction

9

Until we have a far greater body of supporting skeletal evidence, therefore, it is wise not to assume that all incidents of Elephant Disease were in fact Hansen’s disease. With this in mind, throughout the book we will only use the term Hansen’s disease in its modern, scientific context. When discussing the disease in its premodern context, we will use leprosy, Elephant Disease, and elephantiasis, which more closely represent the terms contemporaries would have used to identify what they were witnessing. It is important to note, however, that modern physicians use elephantiasis to identify an entirely different disease. For more on the evolution of the usage of this term, see pages 17–22. Our study tracing the movement of Elephant Disease from the Eastern Mediterranean basin to Western Europe compares the reactions of people from different places and centuries to what they believed was the same incurable disease of leprosy. By juxtaposing institutions and ideas from the Greek-speaking world of Byzantium with those of the Latin and Germanic world in the West, remarkable similarities become visible. Some of these similarities resulted from reactions to the same threat to public health; others resulted from deliberate imitation. Although there are risks in a study that spans so many years and casts it gaze over such a wide expanse of territory, this wide perspective provides significant new insights into the history of leprosy in Europe and the institutions designed to assist its victims. To understand leprosy and its impact on medieval society, first it is necessary to go back in time to the initial major outbreak of the disease in the ancient Mediterranean. We will review the earliest Latin, Greek, and Hebrew words used to identify this strange new scourge. We will consider Jewish reaction to leprosy and how this response shaped early Christian attitudes toward this illness. From there, we will turn to the first incidents of the disease in the Byzantine world.

Chapter 1

The Ancient World

At some date in the early decades of the third century BC, Greek physicians at Alexandria were beginning to see cases of the malady they called “Elephant Disease.” After Alexander the Great’s conquests, this city had become the heart of Greek intellectual life and a major center for medical science. It is likely that these physicians had identified the most serious form of the disease, lepromatous leprosy. If they had also encountered instances of tuberculoid leprosy, they probably did not call it “Elephant Disease” because its symptoms were much less dramatic than lepromatous leprosy, and it was more likely to have been diagnosed as any number of other skin diseases (as sometimes happens even today). Many scholars believe that Elephant Disease entered Egypt from India, its appearance along the Nile being the unintended result of settling Macedonian soldiers in Egypt who had fought in India under Alexander the Great. This is a reasonable hypothesis because Indian literary sources have clearly shown that Elephant Disease was well established in South Asia before Alexander’s invasion, and thus those Macedonian soldiers suscepti-

The Ancient World

11

ble to its pathogen could have easily contracted the disease while fighting there.1 It is also possible that the spread of the illness received a renewed impetus under King Ptolemy II Philadelphus (283– 46 BC) when Greek merchants engaged in trading ventures between Egypt and India by way of the Red Sea. Living in close contact with the Indian population, these traders could also have contracted leprosy and served as vectors when they returned to sell their merchandise in various Egyptian entrepôts.2 Modern scientific research has confirmed that leprosy had reached Egypt by the time of the Ptolemaic kings (after 305 BC). Paleopathologists examined skeletons, discovered in the Dakhleh Oasis, and have confirmed that four of these show the effects of lepromatous Hansen’s disease. These skeletons belonged to Europeans, either Greeks or Macedonians, not to native Egyptians, and they were dated to the second century BC. The results of this bioarchaeological research prove that Mycobacterium leprae had arrived in the Mediterranean basin sometime after Alexander’s Eastern conquests.3

Ancient Physicians and Elephant Disease The scientific evidence provided by these skeletal studies thus confirms the statement found in a medical treatise by the Greek physician Rufus of Ephesus. Writing in the first century AD, Rufus observed that Elephant Disease had reached the Mediterranean basin in the decades after Alexander’s conquests. The first physician to mention what Rufus himself called “elephantiasis” was Straton, a student of Erasistratus, the famous physician and anatomist who had practiced medicine and conducted dissections of the human body under King Ptolemy I (305–281). Straton had identified the disease as kakochymia (literally, a bad mixture), a name referring to the unbalanced mixture of humors.4 According to Rufus, subsequent medical experts abandoned Straton’s terminology. Some physicians began to describe the first stages of Elephant Disease as leontiasis because the patient’s face took on the appearance of a lion, with sagging cheeks and eyebrows and with thickening lips. The patient also began to give off a bad odor, like a lion. Other doctors identified the second stage of the disease as satyriasis because the patient’s cheeks reddened, the

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eyebrows became puffy, and the victim was seized by a desire for sexual gratification, like a satyr. In its more advanced stage the illness produced black protuberances on the legs, face, and body. Some of these tubercles developed oozing ulcers. In severe cases, the fingers and toes fell off. According to Rufus, physicians called this final stage of the disease “elephantiasis.”5 In his poem “On the Nature of Things,” the Roman philosopher Lucretius (first century BC) had expressly stated that Elephant Disease originated in Egypt: “The sickness is called the elephant which arose along the canals of the Nile and nowhere else.”6 In the Apotelesmatika, a work ascribed to the Egyptian writer Manetho of the third century BC but written much later during the Roman Principate, the unknown author observed that those who suffered from elephantiasis came to have “the skin of elephants of measureless age.”7 Echoing the statement of Lucretius, Pliny the Elder (23–79 AD) stated that elephantiasis “is native to Egypt.” He observed that the disease initially manifested itself on the patient’s face, but this stage was followed by an outbreak of scabrous encrustations of diverse sizes and colors on various parts of the body. In time the sores turned black, and the toes began to swell. Pliny alluded to the spread of elephantiasis in Italy, but he maintained that the contagion had been unknown there before the time of Pompey the Great (died 48 BC). Pliny added that the disease did not remain a problem for long in Italy and vanished from the peninsula.8 Writing a few decades later, in the Greek peninsula, Plutarch (ca. 46– 120 AD) also took up the question of the chronology of Elephant Disease in a passage of his Table Talk, which was devoted to the possibility that new diseases suddenly appeared. During an animated after-dinner discussion, a Greek physician named Philo averred that knowledge of elephantiasis was relatively recent because no physician of ancient times had mentioned it. Since Philo was a resident of Hyampolis in Phocis, a town in central Greece, we may conclude that his comments referred to his native city and that he believed that elephantiasis had arrived there only recently. Plutarch countered Philo’s statement about Elephant Disease by noting that in a work by a philosopher named Athenodorus, the author had stated that the illness had first been noted in the time of the Bithynian physician Asclepiades, a doctor who had practiced medicine in Rome in the first century BC.9 Plutarch’s observation on elephantiasis thus confirms Pliny’s statement that the disease arrived in Rome during the life of Pompey.

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In the second century AD the renowned Galen of Pergamon identified Alexandria as the place where Elephant Disease was widespread. Galen observed that large numbers of Alexandrians suffered from Elephant Disease because of their diet and the hot climate. He described the Alexandrian diet as consisting of gruel and lentils, snails, brine-preserved foods, and donkey meat, all foods that generated black bile. The effect of this diet, according to Galen, was to produce, in conjunction with the heat of the region, a thick, melancholic humor that entered the blood and eventually rose toward the skin.10 Galen recommended bloodletting as a treatment for Elephant Disease, followed by the administration of purgatives, both procedures designed to eliminate the excessive quantity of black bile in the body. As for topical salves, Galen recommended an ointment made from berry juice, but because it tended to be greasy, he suggested as substitutes a salve prepared with zinc oxide and another salve made from calcite. With regard to diet, Galen favored hefty draughts of a liquid made from peeled barley or of whey from milk. Patients were encouraged to eat vegetables such as orache (a leafy plant) and round gourds when in season, as well as fish and fowl. Galen especially recommended, however, the consumption of viper meat. The great physician was in essence recommending a kind of sympathetic magic; just as the skin of vipers sloughed off, so too would the scales and tubercles of leprosy fall away if one consumed the snake meat. Galen included detailed instructions on how to prepare the viper delicacy. First, the head and tail of the snake had to be removed along with all the inner organs and the skin. The flesh was then washed in water and prepared by boiling the meat until soft in a mixture of water, olive oil, leeks, and dill. Galen also advised that patients drink a potion of snake meat boiled with salt and a little dill. This same mixture could be applied directly to sores.11 We encounter a cure of a different sort in an Egyptian papyrus document of the second century AD. In this case we are dealing with what is undeniably magic, not medical science. The text suggested that a patient with leprosy carry a verse from the Iliad written “on a clean sheet of paper” and “tied with the hair of a mule.” The verse had to be Iliad 4.141: “as when some woman colors ivory with purple dye.” Why the papyrus text specified this verse is unclear, but it probably refers to how Elephant Disease gave the skin of its victims a dark hue.12

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Aretaios Aretaios of Cappadocia, according to some experts a contemporary of Galen’s, wrote the most complete description of Elephant Disease by an ancient Greek or Roman physician. In his treatise called On Acute and Chronic Diseases, Aretaios included two separate sections on leprosy: one to describe the disease and another to suggest treatments.13 Aretaios himself has baffled modern historians of medicine for many reasons.14 First, he wrote in an archaic Ionic Greek in imitation of Hippocrates. We have no other examples of such an effort. Second, his text shows clearly that he had conducted postmortem autopsies to identify lesions and other effects of specific diseases on the body’s internal organs. We have no other examples of such pathological anatomical studies until Christian times, when physicians in Constantinople cut open the buboes of plague victims during the reign of Justinian (541– 42).15 Third, Aretaios mentioned no other physicians in his text, references that might have provided some clue as to when Aretaios lived. Finally, no other physician referred to Aretaios before the reign of the emperor Constantine. Historians of medicine have been arguing for more than one hundred years about when Aretaios wrote. Some have suggested that he lived as late as the fourth century; others have maintained that he was active before Galen’s birth (130 AD) because Aretaios espoused a strong pneumatist physiology. In other words, he believed in the primacy of pneuma—a lifegiving substance present throughout the universe. Its proper movement and mixture inside the human body guaranteed health. Aretaios’s physiology closely paralleled that of the pneumatist Archigenes who had written medical texts during the reign of Trajan (98–117). Because physicians after Galen appear to have abandoned pneumatist ideas, medical historians have hesitated to assign Aretaios to the third or fourth centuries.16 Aretaios opened his study on leprosy symptoms with a detailed description of an elephant—its color, size, and body structure, as well as its eating and drinking habits. He digressed on the subject of elephants to show why Greek physicians often called leprosy the “Elephant” or “elephantiasis.” According to Aretaios, physicians used these terms because leprosy gave the patient a black hue like an elephant and because it was the strongest of diseases (i.e., incurable) just as the elephant was the strongest among the beasts. Aretaios’s elephant section, however, is so long (more than a third of the

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whole section on leprosy symptoms) and so detailed that he surely had some other purpose in mind.17 Greek physicians such as Rufus of Ephesus recognized that Elephant Disease had arrived in the Mediterranean region during Hellenistic times. This had led some ancient medical writers to speculate that new diseases arose from “seeds” that were released at a precise point in time into the human environment from under the earth or perhaps from other worlds. As we saw earlier, Plutarch recorded a debate among learned colleagues concerning the origins of new diseases such as Elephant Disease, a debate that took place circa 100 AD. Influenced by the ideas of the philosopher Democritus, Philon, the physician from Hyampolis, proposed the idea that new diseases originated because of corpuscles that had entered our world from outside it. Plutarch, however, dismissed this theory as a form of mythologizing and argued instead for the traditional Hippocratic concept of disease as an imbalance caused by bad diet and immoderate lifestyles. Plutarch suggested that under the peaceful Roman Empire it had become possible to import exotic foods from faraway regions. These foods, combined with new habits of life, might easily produce novel imbalances that in turn generated previously unrecorded diseases. One did not need to invent alien creatures inhabiting other worlds to find a rational origin for Elephant Disease.18 Let us return to Aretaios’s description of the elephant. Is it possible that Aretaios introduced the essay on elephants and their peculiar way of life to suggest that leprosy resembled an elephant in that it too was an exotic species, an entity in itself that existed apart from the imbalance it caused in any particular human body? Besides the curious metaphor of the elephant, Aretaios hinted at the possibility of disease seeds when he discussed how leprosy was transmitted from person to person. Aretaios emphasized that Elephant Disease was contagious. It passed from victim to victim just as rapidly as did a disease called loimos. Thucydides had used this term to describe the highly contagious illness that struck Athens in the early years of the Peloponnesian War.19 Aretaios explained that people were afraid to live with lepers because “a rapid infection occurs through exhalation to spread the disease.”20 Here Aretaios referred to the medical theory that a sick person with leprosy exhaled corrupted air—air tainted with a harmful pollution (miasma). When a healthy person came too close to a leper, that person would breathe in the polluted air that then entered the lungs, where it was transformed into corrupted pneuma and distributed throughout the body

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by the arteries. This harmful miasma also could enter the body through the pores of the skin. Corrupted by this air from outside, the pneuma might radically cool the body’s innate heat, a process that led to leprosy and eventually to death. As a pneumatist, Aretaios made no reference to an excess of black bile as the cause of Elephant Disease, as Galen had.21 In another reference to the contagious nature of leprosy, however, Aretaios mentioned two possible methods by which Elephant Disease spread from one person to another. One of these was through the air—the process described earlier, and supported by many Greek physicians. Aretaios, however, referred to a second method of contagion. He stated that “the disease seems to come from the air or from something from those [things] outside.”22 Aretaios’s Greek in this passage is vague because he used two general pronouns. One might, however, construe his sentence to refer to the air (an accepted medical theory of contagion) and to the new corpuscles (something from outside) described in Plutarch’s Table Talk, alien animals resembling the exotic elephant. After finishing his elephant analogy, Aretaios described how people had refused to live with their own relatives if these people contracted leprosy. Healthy family members would take the sick to deserted places— deserts or mountains—and abandon them there. Some of these people continued to help their exiled relatives by bringing them provisions, but others abandoned their leprous family members in the hope that these relatives would soon perish.23 Aretaios’s discussion of Elephant Disease is best known for its detailed description of lepromatous leprosy in its final stages. If the malady grows stronger, [the patients] develop ulcerous tubercles, and the ulcers on the cheeks, chin, fingers, and knees become malodorous and will not heal. Other ulcers break out on top of others, while still different ulcers are closed up on top of others. Sometimes, at this point, some of the members of the patients—the nose, the feet, the genitals, and all parts of the hands—begin to die to the point of falling off. The malady does not kill a person to release the patient thereafter from a disgraceful life and horrible sufferings, but rather his limbs are severed by the disease.24

In the aforementioned passage, Aretaios seems to be describing patients in the last stages of the modern Hansen’s disease. (For an English translation of Aretaios’s full discussion of leprosy, see appendix 1 in this book.)

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The Hebrew Bible and Leprosy From the time of Rufus of Ephesus to the writing of Aretaios’s On Acute and Chronic Diseases, professional physicians came to agree on “elephantiasis” and “Elephant Disease” as the scientific terms for leprosy. Even the poet and philosopher Lucretius used a variant of elephantiasis in his poetry. From the works of Galen and Aretaios, Elephant Disease passed into Byzantine medical texts and remained the standard scientific name for this disfiguring illness until the end of the Eastern Roman Empire in 1453. The English word “leprosy” obviously does not derive from elephantiasis or Elephant Disease. In fact, according to modern medical classification, elephantiasis is used to identify an entirely different illness, a condition that usually causes the patient’s leg or legs to swell up to more than twice the normal size. Microscopic parasites are responsible for this disease.25 Where, then, do we get the term “leprosy,” and how has it come to identify Elephant Disease? Like elephantiasis, the word “leprosy” derives from ancient Greek, as do many terms used in Western medical science. The term leprosy comes from lepra, which means a scale like that of a snake or a flake of human skin. In the Hippocratic Corpus (mostly written during the fifth and fourth centuries BC), the physicians used the term lepra to refer to several benign skin diseases, not one of them showing any similarity to Elephant Disease. In describing some illnesses, the Hippocratic Corpus often provides enough accurate information for modern historians of medicine to identify precisely what disease the ancient physicians were discussing. With regard to lepra, however, the Hippocratic writers did not record precise details. As a result, we cannot determine exactly what skin ailment the Greek authors were attempting to identify. Was it scabies, psoriasis, vitiligo (a disease attacking skin pigment), or some other rash?26 In a nonmedical text of the early third century (BC), Theophrastus used the term lepra to ridicule a person whose personal hygiene was deficient. Could the word here simply mean a case of acne or something more serious such as ringworm?27 Throughout the ancient period, Greek physicians clearly distinguished elephantiasis (Elephant Disease) from lepra, an annoying but not lifethreatening skin ailment. Byzantine physicians continued to distinguish these two very different diseases throughout the Middle Ages. As late as the

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fourteenth century, John Zacharias (the aktouarios) stated clearly that lepra was much less serious than elephantiasis. Its major effects on its victims were an annoying itch and an unsightly flaking of the skin from which it derived its name.28 How, then, did the word “lepra” come to have any association with Elephant Disease? At the end of the third century (BC), at the very time Elephant Disease was coming to the attention of Greek physicians working in Egypt, Jewish rabbis at Alexandria were translating the Hebrew Bible into Greek. Chapters 13 and 14 of the book of Leviticus described in great detail a contagious skin disease called “tsa’arath” in Hebrew. According to Leviticus 13, the priests of Israel were to examine with great care a person suspected of having tsa’arath. In cases of doubt, the priests were to reexamine the suspected person after a period of isolation lasting seven days. If, indeed, a person was said to have tsa’arath, that man or woman was to live outside the camp of Israel and to wear distinctive clothing. Leviticus 14 described rituals to purify those people who happened to recover from tsa’arath so that they could reenter society. Modern scholars have debated what disease tsa’arath was. Most are certain that it was not Elephant Disease, first, because there is no mention of the fearsome symptoms of true leprosy, and, second, the disease sometimes went away, whereas Elephant Disease never did, at least without divine intervention.29 In selecting a Greek word to translate the term tsa’arath, the rabbis of Alexandria chose lepra, a term for some sort of itching condition that caused the skin to fall off in small flakes. In the authorized Greek version of the Hebrew Bible, the Septuagint, the translators consistently employed the term lepra not only for the term tsa’arath of Leviticus but in every other context in which this skin ailment was mentioned.30 Leviticus 13 and 14 banned the victims of lepra (we shall call them “lepers”) from the camp of Israel because they were ritually impure. A leper defiled the people of God so that they could not participate in the sacred rituals of the Tabernacle. Moreover, it is clear from the instructions to the priests that the author of Leviticus considered lepra contagious, since it spread so rapidly on the skin of its victims. Whatever the illness was, the Hebrew leaders were certainly afraid of it. Thus the “lepers” were excluded from the camp both for religious and for sanitary reasons. Although no injunction of Leviticus 13 ever implied that lepra was a punishment for sin, other passages of the Septuagint translation of the Old

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1. God tells Moses in Numbers 5:2, “Command the people of Israel that they put out of the camp every leper, and every one having a discharge, and every one that is unclean through contact with the dead.” From the Athos, Octateuch Vatopedi codex 602 (fol. 108r).

Testament do portray this disease as a chastisement from God. When Aaron and Miriam were angry with Moses for having married the Kushite woman, God struck Miriam with lepra as punishment for her mean-spiritedness (Numbers 12:10–15). After the prophet Elisha cured the Syrian general Naaman of lepra, the prophet’s servant Gehazi took silver from the Syrian commander against Elisha’s orders. God punished Gehazi’s greed and disobedience by giving him lepra (II Kings 5:20–27). King Uzziah of Judah violated the Temple by offering incense to the Lord at the altar of incense, a sacred ritual reserved for the priests alone, the descendants of Aaron. As a result of this sacrilege, God punished Uzziah by giving him lepra. Because of his illness, King Uzziah was forced to withdraw

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from the palace and to live in isolation in obedience to the rules of Leviticus. His son, Jothan, assumed the duties of governing Judah until Uzziah’s death (II Chronicles 26:16–23). In light of these examples, rabbinical opinion came to view lepra as punishment for sin, although commentators did not agree about which sins usually brought down lepra on their perpetrators. The Septuagint Old Testament is not the only religious text to mention lepra. The Gospel writers of the New Testament referred to the same disease several times in contexts that indicate that they understood the term lepra to mean the Hebrew term tsa’arath. In Luke’s Gospel (17:14–19), Jesus met ten “lepers” living outside the town, as Leviticus 13 required. Jesus told them to go “show themselves to the priests,” again in accordance with the law of Leviticus, which stated that only priests could declare a victim of tsa’arath to be truly cured. On the way to show themselves to the priests,

2. Christ healing a leper, as described in the Gospel of Mark 1:40– 45. From the Athos, Iveron codex 5 (fol. 142r), a thirteenth-century Gospel book. We wish to thank the Iveron Monastery for permission to reproduce this image.

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the lepers found themselves miraculously healed. At the beginning of his ministry (Luke 4:27), Jesus mentioned the lepra of Naaman, cleansed by the command of the Prophet Elisha. These and other New Testament passages (Matthew 8:1– 4; Mark 1:40– 45) demonstrate that the writers of the synoptic Gospels considered the lepers of Jesus’s time to have suffered from the tsa’arath of the Old Testament. Although it is clear that Matthew, Mark, and Luke considered lepra tsa’arath, they never described the symptoms of the lepers whom Jesus met. Thus we do not know whether they were suffering from the Hippocratic lepra or the ravages of elephantiasis, which was definitely present in the Middle East by the time of Jesus’s ministry. For our discussion of leprosy in the Middle Ages, however, it is not important what disease these firstcentury Palestinians had actually contracted. What influenced later Christian attitudes toward Elephant Disease both in the Byzantine Empire and in Latin Christendom is what disease subsequent generations thought that Jesus had cured. A sixth-century hymn of Romanos the Melode proves that by the reign of the great emperor Justinian I (527– 65), Christians in the East unambiguously considered the lepers whom Jesus cleansed to have suffered from Elephant Disease. Romanos composed the hymn in question to be sung during the liturgy for the Wednesday of the third week during the Easter season when the Gospel stories were read that described Jesus’s miraculous healing of the lepers. In the hymn text, Romanos emphasized how this illness fed on the flesh of its victims, a description reflecting the rotting flesh of Elephant Disease. This disease deformed it victims and crippled their limbs. Here Romanos had not in mind a fast-spreading rash that itched and caused the surface skin to fall off in flakes but the horrible effects of lepromatous leprosy. The “leper” in Romanos’s song had become a true medieval leper, the victim of the disfiguring disease described by Aretaios.31 We cannot determine exactly when Christian writers first began to connect the lepra of the holy scriptures with Elephant Disease. In his funeral oration for his friend, Basil of Caesarea, given in 379, Gregory of Nazianzos called Elephant Disease “lepra” in one passage, although he referred to it in the rest of his speech as the “Holy Disease,” as we shall see in the next chapter.32 From the fourth century on, then, religious writers began to equate the term lepra with the term elephantiasis; by the sixth century, Romanos’s hymn proves that this had become the standard word for the malady. Among

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medical writers, on the other hand, lepra was never confused with elephantiasis, true Elephant Disease. As a result of this problem in interpreting Greek sources, we have exercised caution when citing any texts that use the term lepra to be sure that they indeed refer to the crippling and ultimately fatal condition described by Aretaios. In the West, physicians writing in Latin initially followed Greek practice and also called leprosy “elephantiasis,” or “Elephant Disease.” The fifthcentury physician from North Africa, Caelius Aurelianus, wrote a detailed description of true leprosy and called it “elephantiasis.”33 As late as the eleventh century, Constantine the African translated the Arab term for Elephant Disease, judham, as elephantiasis.34 By the twelfth century, on the other hand, Gerald of Cremona translated the term judham in the famous Canon of Avicenna as lepra, a word that Gerald had taken from common Latin usage.35 In her study of leprosy in medieval France, Françoise Bériac has shown that as early as the fifth century authors writing in Latin began to replace the term elephantiasis with lepra in nonmedical contexts when referring to Elephant Disease. Moreover, medical experts felt free to adopt the popular word lepra as a perfectly acceptable synonym for the term elephantiasis after they had introduced the term morphea to indicate what Greek medical writers had traditionally called lepra.36 As a result, Western medical sources of the High Middle Ages (1000–1300) are easier to interpret. In medieval Latin, “lepra” unambiguously means “Elephant Disease.” Latin medical and nonmedical texts, however, continued to use the Greek term elephantiasis on occasion.

Christian Philanthropy According to the Evangelist Matthew, after Jesus had finished his Sermon on the Mount, he met a leper who asked the Lord for healing. Jesus stretched out his hand, touched the leper, and said “Be cleansed.” The man was immediately healed, but Jesus then reminded him of the Mosaic Law of Leviticus: the former leper must show himself to the priest (Matthew 8:1– 4). Immediately after healing the leper, Jesus met a centurion whose slave was dying. The Roman soldier had such faith in Jesus’s supernatural powers that

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he only asked the Lord to say a word of healing because the centurion was confident that Jesus’s words alone could restore the slave to health. Jesus was amazed at the gentile’s faith (Matthew 8:5–13). By juxtaposing these two miracle tales, the Evangelist wished to show that the command to love one’s neighbor and to assist that person in his or her distress extended outside the normal circle of the Jews. It included the lepers who had been forced to live “outside the camp,” the gentiles, and even the officers of a despised army of occupation. Early Christians understood the importance of charity in Jesus’s message, but it is not clear that they comprehended the radical implications of moving outside the traditional recipients of Jewish philanthropy. For example, in the letter of James, the author mentioned the care of orphans and widows as the hallmarks of a person with a pure Christian faith, but the Old Testament had repeatedly stressed that the God of Abraham extended his protection to orphans and widows (Jam 1:27). Psalm 16 declared that God was the father of orphans. The early Christian practice of charity toward orphans and widows closely followed Jewish precedents. Circa 100, Ignatius, the bishop of Antioch, warned the Christians at Smyrna in Asia Minor to avoid contact with Gnostic heretics. He accused the Gnostics of failing to practice the virtue of love. They did not show concern for widows and orphans, for the oppressed, or for those who were hungry. Again, Ignatius did not venture beyond the traditional Jewish acts of love to those in need.37 About the same time that Ignatius penned his warning to Smyrna, the anonymous author of an apocalyptic text called The Shepherd of Hermas described an active charitable program sponsored by the Church of Rome. The Shepherd mentioned a female official of the Roman Church named Grapte who bore the responsibility of supervising a school of some sort for orphans and widows.38 By the mid-second century, the bishop at Rome had taken over the ultimate responsibility for the Roman Church’s philanthropic operations. According to Justin Martyr, each Sunday wealthier Roman Christians offered supplies and money to the bishop that he was to distribute to those in need. Justin again listed orphans and widows as especially worthy recipients of charity, and then those in need because of sickness, and then prisoners, strangers, and travelers. Those in need because of sickness might

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have included lepers, but neither Justin nor any other Christian writer mentioned victims of any particular illness whether identified as lepra or elephantiasis.39 A document called the Apostolic Constitutions was compiled somewhere in Syria around 380 AD as a guide for Christian bishops in the smaller cities around Antioch. The text dictated instructions on baptism, the celebration of the Eucharist, and the ordination of bishops, presbyters, and deacons, as well as on many aspects of proper Christian conduct. It even included rules on how Christian women should comport themselves in the public baths. Among these many themes, Book IV of the Apostolic Constitutions addressed the methods of practicing charity.40 Although the Apostolic Constitutions was compiled in the late fourth century, a careful examination of the text proves that much of Book IV reflected conditions in Christian communities of the late second and early third centuries. First, significant portions of Book IV were copied from an earlier Christian rule book known as the Teachings of the Apostles (Didascalia Apostolorum), drawn up in the early third century.41 Moreover, one of the works of charity recommended for the bishop in Book IV is to collect money for the ransom of Christians condemned to death or to fight as gladiators.42 The period of the persecution of the Church had ended in the East with Constantine’s victory over the rival emperor Licinius in 323. Thus this section of Book IV clearly dates from the time before Constantine made Christianity a legal religion. Like the other Christian texts describing acts of charity, Book IV of the Apostolic Constitutions focused its attention on nurturing orphans. Local bishops were to maintain a school to teach male orphans a trade so that they could eventually support themselves and their families. The bishop was also to find good Christian husbands for the orphan girls. Book IV provides solid evidence that orphanages were the first organized charitable activities supported by bishops and their communities of believers.43 Book IV also referred to the bishop’s obligation to shelter the homeless, feed the hungry, give drink to the thirsty, and care for the sick—all acts of mercy mentioned in Matthew’s Gospel as good works that would merit salvation at the last judgment (Matthew 25:31– 46). These instructions, however, provided no concrete details on any institutional structure to provide care for the sick. Moreover, throughout all the books of the Apostolic Constitutions, the text referred to leprosy only in the context of Jesus’s command to

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the lepers whom he healed to keep the law of Leviticus and show themselves to the priests.44 There are no exhortations to assist lepers. Our survey of early Christian references to charity indicates that bishops had not yet focused attention on assisting the victims of Elephant Disease. It is possible that Christian leaders felt more comfortable following Jewish traditions of helping orphans, widows, and strangers. Perhaps they considered Jesus’s command to touch the lepers and cleanse them too threatening to the health of the early Christian communities that they shepherded. Perhaps they also were conscious of the law of Leviticus that lepers were to be separated from the healthy. It is also possible that Elephant Disease had not become a serious health problem in the Roman Empire before the fourth century. The few cases that occurred among a Christian community of any city might have been handled on an individual basis so that no Christian writer felt that he had to dictate a policy for assisting the victims of Elephant Disease. Regarding the frequency of leprosy, we should remember that, except for Aretaios of Cappadocia, ancient medical writers did not consider Elephant Disease a widespread illness. Pliny the Elder stated specifically that elephantiasis had appeared in Italy only during the time of Pompey, and that it did not remain a long time on the peninsula.45 Galen’s letter to Glaucon, which contained the famous physician’s most complete discussion of Elephant Disease, described the illness as a problem in Alexandria but not a major danger to health elsewhere.46 In his treatise against empiricist doctors, however, Galen mentioned a village near his home city of Pergamon where one man had infected members of his family and his community. In this same essay, Galen referred to two other people near Pergamon who came down with leprosy. Was Galen describing here a localized outbreak, or was Elephant Disease sweeping through the Eastern provinces infecting up to 10 percent of the population with the dreaded disease, as Aretaios’s description suggests?47 Although it is always risky to make an argument ex silentio, it does seem unlikely to us that Christian sources of the second and third centuries would have remained indifferent to the victims of Elephant Disease if many people were, in fact, staggering along the roads of Asia Minor or Syria stricken with the crippling lepromatous form of the disease. By the fourth century, however, the sight of many lepers both along the roads of Cappadocia and in the towns of Pontus and Bithynia did indeed move many bishops to tears as

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they themselves stated and to dynamic action to assist these suffering people with money, supplies, and permanent shelters. Christian sources from the fourth century suddenly begin to describe Elephant Disease as a major problem in the Eastern Mediterranean. Using almost the same words that Aretaios had, bishops such as Gregory of Nazianzos and John Chrysostom constantly referred in their sermons to many who had been stricken with this ailment. Hagiographical texts also began to mention those who suffered from elephantiasis. This sudden focus on leprosy in Christian circles corresponded to the very period when the emperor Constantine was transforming the old provincial city of Byzantium into Constantinople, the new center of the Roman Empire in the Greek East. As we shall see, this reorganized Byzantine state, along with a new generation of Christian bishops, could no longer pass over in silence Elephant Disease.

Chapter 2

Leprosy in the Byzantine Empire

When Emperor Constantine was choosing a location for his new capital of Constantinople in the 320s, he ultimately settled on Byzantium, an ancient urban site on the European side of the Bosporos that the emperor converted into an impregnable fortress, surrounded on three sides by water and protected by massive landward walls. At the dedication of Constantinople in 330, however, the emperor was unprepared for the threat that soon would confront the city’s residents. Within a few years people from all classes in society began contracting a strange and disfiguring disease, the dreaded “Elephant Disease,” described by Aretaios. By the time of the reign of Constantine’s son, Constantius II (337– 61), it had become necessary to build an asylum for victims of the disease on the north side of the city’s harbor, called the “Golden Horn,” at a safe distance from heavily populated districts.1 Eleven centuries later, people from the highest class were still falling victim to the disease. In 1428, Emperor Manuel II’s third son, Andronikos, died of leprosy in the famous Pantokrator Monastery at the very center of Constantinople.2 Over these many years Byzantine society debated the social,

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religious, and medical implications of leprosy, which they usually called “elephantiasis,” or “Elephant Disease.” Medieval Greek physicians never found a cure, but Byzantine ecclesiastical and political leaders managed to create an environment in which victims received palliative care and were never expressly banned from society, as occasionally happened in the medieval West. In this chapter we briefly recount the history of leprosy in Byzantine society beginning in the fourth century. Cases of elephantiasis seem to have multiplied at the very time when the Eastern Empire was still evolving into its new identity as the Christian Roman Empire. We present the evidence that cases of leprosy in Constantinople and Asia Minor became a major health issue during these years, a problem that required attention from both the state and the Christian Church. The ecclesiastical leaders of the day discussed how to assist lepers and worked to alter society’s attitude toward them. They renamed leprosy the “Holy Disease” to convince people that God had used this illness not to punish lepers as sinners but to purify them for Heaven—to make them holy.

Early Accounts of the Disease The fourth century not only witnessed the birth of Constantinople and the separation of the Greek-speaking provinces from the Latin West, but it also produced Byzantium’s greatest Christian writers—Basil of Caesarea, Gregory of Nyssa, Gregory of Nazianzos, and John Chrysostom. All four of these men, often called the “fathers of the Eastern Church,” responded to what they took to be a growing public health crisis. Their views and their actions would shape all subsequent debate in Byzantium concerning leprosy and its victims. Both Gregory of Nyssa and Gregory of Nazianzos composed powerful sermons that addressed the plight of lepers, sermons in which they described the throngs of sick in the cities and along the roads of Asia Minor.3 Gregory of Nyssa delivered his sermon during Lent, circa 370, in the modest Cappadocian town of Nyssa. He reminded the faithful of his city that they had a duty to help those in need and especially to assist the victims of leprosy who lacked everything because they had lost even the use of their hands and feet, their only means of earning a living. The urgency of his

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rhetoric suggests that the disease was spreading rapidly; indeed, that it represented a new problem: We should do this (carry out the works of mercy) especially now when the commandment takes much more substance according to the present condition of life when many are in need of necessities but many are also in need regarding their own bodies, people who have been wasted away by this terrible disease. . . . Because [the leper] has nothing from home and is completely incapable of becoming a hired person, he is of necessity completely lacking in the basic supports of life. He is bound like a prisoner by the disease.4

Gregory depicts victims deprived of the ability to function in society. In addition to having lost toes and fingers, and even hands and feet, sufferers frequently had difficulty breathing and spoke in a raspy voice, a classic sign of true leprosy. Other victims had such damage to their faces, especially around the mouth and nose, that they had difficulty eating—a description that seems to indicate the modern Hansen’s disease. He also mentions that victims lacked feeling in their bodies. Although the language he uses is highly rhetorical, he might have been describing the anesthetizing effects of Hansen’s disease on the arms and legs of victims. Modern clinicians consider this a symptom that clearly distinguishes Hansen’s disease from other skin ailments.5 [Are they distressed] because in their feeling they suffer the misfortune of the dead or because they have been deprived of their sense perception? Where is their sense of sight? Where is their sense of smell? Where is their sense of touch? Where are their other senses which, as the disease progresses, its corruption consumes little by little.6

Gregory’s description of these suffering sick matches the symptoms of Elephant Disease as they were described by Aretaios and Galen, but, strangely, Gregory never names the disease. Having studied both medicine and the sacred scriptures, he was probably aware of the problems involving terminology. Finally, Gregory spoke to the fact that the increasing numbers of lepers in Asia Minor were becoming a social problem. Expelled by family and

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friends from their homes and communities, they formed their own migrating societies that wandered from place to place begging for food. They won the sympathy of healthy people by displaying their disfigured limbs and by grotesque singing and dancing to draw the attention of passersby.7 At almost the same time Gregory of Nyssa delivered his sermon, Gregory of Nazianzos gave a similar oration in his town, a speech that likewise spoke to the Christian duty to assist those suffering from elephantiasis. Gregory of Nazianzos never stated specifically that the disease was becoming a more serious problem, but his vivid accounts of the large numbers of people driven from their homes, banned from their towns, and forced to beg in the roads suggest that the numbers of lepers had been increasing in Asia Minor. It is significant too that in a sermon concerning how to love the poor, Gregory focused entirely on the plight of lepers and the absolute moral obligation to overcome one’s aversion to these victims, even if their terrible disfigurements made it difficult to look at them, and especially to touch them.8 A few years later, John Chrysostom delivered several sermons in which he too described the plight of lepers and the Christian obligation to assist them. He and Basil of Caesarea are particularly notable in that they took concrete action to help people suffering from the disease. Once they were elected bishops, both Chrysostom and Basil sponsored the construction of large asylums to provide food, shelter, and comfort for victims of leprosy. In 373, Basil opened a facility outside Caesarea, not far from Nyssa and Nazianzos, where the two Gregorys served as bishops. Basil’s asylum grew to such a size that Gregory of Nazianzos described it as a new city. Although it treated patients who suffered from other illnesses, it focused especially on the care of lepers.9 When John Chrysostom became bishop of Constantinople in 398, he saw to it that a large leper asylum was built outside the capital city. An anonymous funeral oration, delivered shortly after Chrysostom’s death in 407, explained how the bishop had been inspired to construct this institution.10 On the Asian side of the Bosporos in the province of Bithynia, he had seen countless victims of leprosy abandoned along the highways. This experience convinced him to build a facility large enough to care for a great number of lepers.11 Another account that provides additional information regarding leprosy’s spread during the fourth century can be found in the legend of Saint Zotikos. Zotikos had established an orphanage within the walls of Con-

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stantinople and a well-known leprosarium across the Golden Horn. His efforts to establish these institutions are mentioned not only in the Zotikos legend but also in reliable sources of the fifth century, including a law issued by Emperor Leo I in 472.12 The author(s) of the Zotikos legend describe a capital city so full of lepers during the reign of Constantine the Great (305– 37) that Zotikos’s program to feed them threatened the city’s grain supply.13 While the Zotikos legend cannot be taken at face value as a reliable source for reconstructing events of the fourth century, the basic narrative of the founding of both the orphanage and the leprosarium has been confirmed by other texts that do in fact date from the fourth and early fifth centuries. Nearly contemporary sources also claim that Zotikos founded both charitable foundations during the reign of the heretical emperor Constantius, because Zotikos himself had served as a priest under bishops of Constantinople who belonged to the heretical Arian party of the Christian church (see chapter 4).14 It would be unwise, therefore, to dismiss out of hand the account of the leprosy epidemic in Constantinople as described in the Zotikos legend. Indeed, on the basis of long-lasting traditions among the people of Constantinople, George Sidéris has argued forcefully that even the legend’s strange tale concerning Emperor Constantine’s order to round up all lepers and drown them in the sea reflects a real attempt to drive victims of Elephant Disease from cities. According to Sidéris, this program was launched not by Constantine but by local polis governments, the policies of exclusion so harshly condemned by Gregory of Nyssa and Gregory of Nazianzos.15 In the end, it is impossible to prove that Asia Minor and Constantinople suffered from a dramatic increase in cases of leprosy during the fourth century, but it is clear that church leaders believed that they were living in the midst of a grave public health crisis, grave enough to spur a substantial charitable response. The two sermons of Gregory of Nyssa and Gregory of Nazianzos confirm this general picture, as does the funeral oration delivered in honor of Chrysostom and the legend of Zotikos. When one considers that Christian texts prior to 300 such as the Apostolic Constitutions describe active deeds of charity in many forms but never mention the need to alleviate the suffering of lepers, it is difficult not to believe that the fourth-century Greek fathers were witnessing a dramatic increase in the incidence of Elephant Disease, a situation that called for a radical new approach to loving one’s neighbor.16

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Egypt, Syria, and Palestine Having considered the accounts of leprosy in Asia Minor and in the Byzantine capital, it is instructive to compare them to the responses of nearly contemporary fourth- and fifth-century sources from Egypt, Syria, and Palestine, which were also part of the Eastern Empire during this time. We should recall that Galen, writing in the second century, had identified Alexandria as a locality where elephantiasis had claimed the greatest number of victims.17 According to one of the tales recorded by Egyptian monks, a man named Eulogios, a teacher in Alexandria, circa 330, decided to become a monk, but he did not want to join an organized monastery—what the Egyptian monks termed a coenobium.18 Instead, he wished to live a life of celibacy and self-sacrifice in his own home in Alexandria. One day in the marketplace of the city, he met a leper who had lost both his hands and his feet, and as a result of his helpless state, he survived by begging. Although the sick man had lost his limbs, he had a sharp tongue with which he insulted those who passed him by without leaving some donation. Eulogios made a vow to God to take care of this helpless man as long as the leper lived. Subsequently, Eulogios managed to convince him to come to his house for care. Eulogios offered the leper the guest room in his house. He fed him, washed him, and provided all the care suitable for the treatment of leprosy. For fifteen years the pair lived together, during which time Eulogios never wavered in performing his duties to care for the ailing man. After so many years together, however, the leper’s attitude suddenly changed. As the author of this tale explained it, an evil spirit took possession of the sick man, but the details of the story suggest that he was growing bored with life in Eulogios’s house and was dissatisfied with the monotonous diet of bread and vegetables that the ascetic Eulogios offered him. “I want meat,” the leper shouted. So Eulogios began to purchase meat, but the leper grew all the more angry with his benefactor. “I want the crowds,” he demanded. Eventually, he grew so enraged with Eulogios that he would have strangled him if he had only had his own two hands intact. Eulogios was on the point of returning the leper to the agora of Alexandria and throwing him back to beg from the crowds when he decided to seek the advice of Antony, the famous desert hermit and father of Egyptian monasticism. Antony scolded the leper for his evil temper and Eulogios for his inconstancy in keeping to the vow he had made before God. Antony told

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the two to return to Alexandria and to stay together, for God was about to call them to their blessed reward. Indeed, forty days later, first the ill-tempered leper and then Eulogios left this life in peace. Whether every word of this story is true is less important for our purposes than the fact that in the story leprosy is depicted as an unexceptional part of everyday life in Alexandria. People contracted leprosy and as a result often had to resort to begging, but they were not expelled from the city or even treated with fear and loathing. Otherwise, it would seem hardly believable that the leper in Eulogios’s house would have preferred the excitement of the marketplace to the dependable though monotonous meals prepared by his ascetic caregiver. As Galen had observed, leprosy was endemic in Alexandria, and people had learned to live with it. Some eighty years later, in 417, Patriarch Cyril of Alexandria issued his traditional Easter letter to the Christians of Egypt. He used his letter to announce the date of Easter for that year and to exhort his flock to undertake their Lenten fast and accompanying good works with a spirit of joy in anticipation of the great feast of Easter and of the heavenly banquet for which all Christians yearn. Cyril then listed a number of good works that Christians should perform during Lent: taking care of the poor, giving comfort to widows and orphans, visiting those in prison, and providing relief for lepers “through the appropriate therapies.”19 In Egypt the care of lepers had become an accepted Lenten discipline, and the treatment specific to leprosy— soothing baths and proper diet—had apparently become common knowledge. Moreover, alleviating the misery of people suffering from the disease had now taken its place beside the traditional Judeo-Christian good deeds toward widows and orphans. There is also evidence that Elephant Disease afflicted the lands between Egypt and Asia Minor. Fifth- and sixth-century Palestine had a number of special facilities for lepers, which we shall examine in the chapter on leprosariums. By the late fourth century, Antioch had constructed a hospital for victims of Elephant Disease outside the city’s gate, an institution just like the one Chrysostom wanted to build across the Bosporos from Constantinople.20 To the east of Antioch, on the border with Persia, lay Edessa. When Rabbula became bishop of this city in 411, he found lepers forced to live beyond the walls in poverty. They were “hated and contemptible,” according to Rabbula’s biographer. The bishop assigned a deacon to assist these sick people and appointed additional personnel to provide food and palliative

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care. Moreover, Rabbula paid for the lepers’ food and other supplies with church funds.21

After the Arab Conquest As late as 633, the Byzantine Empire included all regions of the Eastern Mediterranean basin, but in 634 this began to change. In that year the first caliph of Islam, Abu Bakr, died and was succeeded by Umar, who proceeded to expand Muslim rule deep into the Byzantine Empire. In 636, at the Yarmouk River, south of Damascus, Arab forces smashed the Byzantine army, a victory that guaranteed Muslim dominance in Syria, Palestine, and Egypt until the present day. The Byzantine army managed to regroup in Asia Minor behind the Taurus Mountains. For two centuries these imperial troops waged a continuous war against Arab attacks. On two occasions, Muslim land and sea forces almost conquered Constantinople. During these same centuries, the Byzantine military also had to repel barbarian invasions from north of  the Danube River in Europe. The empire survived these years on the defensive, but the state underwent many radical changes, including a reduction in its territory and population. Despite the steep fall in population after 634, the problems posed by elephantiasis continued in areas of Asia Minor and the Balkans, which remained under Byzantine rule. The easiest way to demonstrate that the disease continued to thrive despite a significant population decline is to trace the renovations and expansions made by successive emperors to Constantinople’s largest leprosarium, the Zotikos asylum on the north shore of the Golden Horn. According to an old tradition in Constantinople, sometime before 360 Emperor Constantius II had transformed the humble settlement of lepers, established by the priest Zotikos, into a large complex of buildings. Two hundred years later, Emperor Justin II (565–72) provided funds to refurbish the leprosarium. At the end of the sixth century, Emperor Maurice (582– 602) twice rebuilt the institution following destructive raids by barbarian tribes from the north. Since the Zotikos Leprosarium was across the Golden Horn, it was not protected by the impregnable walls of Constantinople. In rebuilding the leprosarium a second time, Maurice replaced the old wooden roofs with stone arches.22 From 637 to the tenth century—the period during which the Byzantine Empire suffered attacks from well-organized Muslim armies and destruc-

The Mediterranean World, Eleventh Century AD

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tive raids from barbarian tribes—we find no evidence of any additional reconstruction or expansion of the Zotikos Leprosarium. It is possible that the government was too involved in military matters to spare resources for renovations during this period. On the other hand, few sources survive from these centuries, so it is at least conceivable that an emperor of the seventh or eighth century expanded the Zotikos facility, with no records surviving from the project. Although no sources mention that the Zotikos Leprosarium was renovated after the reign of Maurice (d. 602), evidence survives that it continued to function. The famous scholar Nikephoros served as supervisor of both the Zotikos Leprosarium and the Orphanotropheion before he was chosen to be patriarch of Constantinople in 806.23 Since the leprosarium’s founding in the fourth century, Constantinopolitans had linked it to the capital’s most renowned philanthropic institution, the Great Orphanage, on the ancient citadel of the city, because Saint Zotikos had founded both institutions (see chapter 4). Moreover, the late ninth-century summary of administrative bureaus, found in the Kletorologion of Philotheos, recorded that the supervisor of the Zotikos Leprosarium still reported to the government bureau of the Orphanage (Orphanotropheion).24 This close administrative connection between the Zotikos Leprosarium and the Orphanage of Constantinople provides additional evidence that Christians after 300 began to see the care offered to victims of Elephant Disease as one of the hallmarks of an active faith alongside the traditional assistance offered to orphans. During the tenth century, however, Byzantine emperors began again to enlarge the Zotikos Leprosarium and to improve its physical plant. Constantine VII added dormitories, and a few decades later John Tzimiskes (969–76) more than doubled the number of rooms available for disease victims.25 These expansion projects no doubt reflected population growth near Constantinople and in western Asia Minor as well as an increase of imperial territory southward into Syria. In the eleventh century Emperor Romanos III (1028–34) restored the leprosarium following an earthquake and added new buildings.26 Finally, in the twelfth century, Emperor John II Komnenos provided a substantial grant of money to build additional dormitories and increase supplies to support more patients at the Zotikos Leprosarium.27 Significantly, he supported these expansions after Turkish military victories in the eleventh century had substantially reduced imperial territory in Asia Minor.

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After 1204 When Constantinople fell to the soldiers of the Fourth Crusade in 1204, the Byzantine state was forced to relocate to Nicaea in Bithynia. In this capital of the Byzantine government in exile, the emperors soon financed a new asylum for lepers, which functioned throughout the thirteenth century.28 Meanwhile, on Crete, which the Republic of Venice had seized following the conquest of Constantinople, the Venetians also faced the problem of leprosy. Once they controlled the island, they decided to build their own leper asylum outside the walls of Candia, the Cretan capital. In organizing this leprosarium, the Venetian government probably copied institutions in the mother city rather than any preexisting Byzantine facilities, although over time Greek practices may have been introduced.29 During the fourteenth and fifteenth centuries, no Byzantine sources refer to leprosariums within imperial territory. For example, following the Byzantine retaking of Constantinople in 1261, no evidence survives indicating that the emperors ever restored the Zotikos Leprosarium, which Westerners had neglected in the aftermath of the Fourth Crusade. There exist, however, references to victims of leprosy who sought miraculous healing at the church and monastery of the Life-giving Spring (Zoodochos Pege). Around the year 1300, Manuel Philes dedicated two poems to people with elephantiasis who had come to the healing waters and miraculous icon at the Zoodochos Pege in search of a cure. Philes described one man in an advanced stage of the disease who apparently regained his health through divine intervention.30 Philes wrote a longer, more complex poem in honor of a leprous monk who never was healed of his illness but who bore his suffering without losing his faith in God’s goodness.31 Nikephoros Kallistos Xanthopoulos recorded two additional miraculous cures at the Zoodochos Pege, cures that occurred during the reign of Andronikos II (1282–1328). From Xanthopoulos’s description it seems clear that one of these people was suffering from elephantiasis because Xanthopoulos stressed that the victim was plagued with ulcerous sores and had lost his fingers and toes.32 The second miracle story might well be describing a case of elephantiasis, but the narrative employs the vague term lepra, which, as we have explained, could refer to a number of skin diseases.33 In addition to these cases from the early fourteenth century, we should recall that in the

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fifteenth century Emperor Manuel II’s son Andronikos developed Elephant Disease while defending Thessalonica from the Turks.34 We also have supplementary evidence from former Byzantine provinces, both in Europe and in Asia. Before his death in 1331, the Serbian king Stephen Uroš III built the monastery of Dečani, northwest of Skopje. To the monastic complex Stefan added an asylum for lepers from all parts of Serbia. The author of Stefan’s biography described these sick as having necrotic skin, crooked hands, and rasping voices—all clear signs of elephantiasis.35 More than seventy years later, circa 1401, the fearsome Mongol conqueror Timur invaded Cappadocia and besieged the city of Sebasteia. The Greek historian Chalkokondyles recounted how Timur undermined the walls and then ravaged the city, killing every man, woman, and child, including a large number of lepers. Sebasteia had supported a famous leprosarium a thousand years earlier at the same time Saint Basil constructed his leper asylum in nearby Caesarea. Is it possible that the tradition of aiding lepers had survived in Sebasteia, even after the Turks had gained control of that city in 1091? In any case, Chalkokondyles preserved evidence that elephantiasis was still claiming victims in central Asia Minor, a territory that had once belonged to the empire.36

Leprosy and Sin Leprosy not only inflicted physical sufferings on its victims and made them repulsive to others, including family members and friends, it also left at least some of them with a deep sense of guilt. Not surprisingly, Byzantine Christian writers struggled with how to interpret the significance of leprosy. Was leprosy a sign of God’s punishment or a mark of God’s favor? Christians were conscious of the tradition of ancient Judaism that leprosy sometimes struck human beings because of some sin they had committed. Since the time of Origen, Greek Christian thinkers had closely studied the Old Testament, and in doing so they naturally followed Jewish scholars of the Hebrew scriptures. Thus we might expect them to connect leprosy with sin and divine punishment, as did Jewish scholars who viewed leprosy (tsa’arath) as punishment for sin on the basis of the Old Testament stories about Miriam, Gehazi, and King Uzziah.37 And while this is certainly the case, it is also true that Christian writers frequently interpreted Old Testa-

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ment stories symbolically rather than literally. So, for example, at the beginning of the fourth century, Methodius, bishop of Olympus in Lycia, wrote a tract dedicated to interpreting Leviticus 13. Rather than viewing leprosy as a punishment for sins committed, he interpreted the disease as a complex symbol for moral transgressions. He presented an elaborate scheme of color imagery, which matched the hue of each leprous skin blemish described in the Leviticus text with a specific deadly sin: a white discoloration symbolized lust, a gray color fear, green blemishes jealousy, and red marks anger.38 Patriarch Cyril of Alexandria (412– 44) specifically warned Christians not to take literally the rules of Leviticus, but he himself interpreted leprosy as a powerful symbol of sin in his commentary regarding the Jewish ceremony required by lepers whenever they were cleansed of their disease. According to Leviticus 14:1– 8, a leper, cleansed of his disease, had to present the priest with two birds; one of these was to be killed and its blood sprinkled, first, on the second bird, which was then set free, and second, on the former leper. Cyril firmly believed that this ceremony only made sense if leprosy symbolized sin and the blood of the bird prefigured Christ’s saving sacrifice on the cross.39 Both Methodius and Cyril assumed that Christians would interpret Old Testament laws against lepers as allegories. Nevertheless, some Christian writers confused symbol with reality and followed Jewish scholarly traditions in adopting a more literal understanding of the Leviticus text and of the stories concerning Miriam, Gehazi, and Uzziah. In one of his letters the Egyptian monk Isidore of Pelusium claimed that God punished couples who indulged in sex during the woman’s menstrual period by visiting leprosy upon the children of such people. Thus the mother would always regret her disregard of the Law of Moses every time she gazed upon her suffering child. In this letter, Isidore expressed the idea that leprosy was punishment for the sins of the parents, a view that he clearly derived from Jewish commentaries.40 Sophronios, the seventh-century patriarch of Jerusalem, however, made the most graphic connection between leprosy and sin in his Miracle Tales of Saints Cyrus and John. Sophronios had visited the shrine of Saints Cyrus and John south of Alexandria in Egypt. In honor of these saints, he collected eighty-one examples of miraculous cures, which he credited to the supernatural interventions of these holy men. Miracle 13 recounts the story of Elias, who had suddenly contracted leprosy over his entire body.41 In the tale

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Sophronios labeled the ulcers and tubers of leprosy as marks of sin. Referring to Leviticus, Sophronios warned that persons who bore these marks should be banned from the camp of Israel. When Elias found that physicians could not heal his illness, he sought assistance from Cyrus and John by sleeping in the church dedicated to the two saints. Such incubation, as it was called, in the churches of saints recognized for their miraculous cures was a common practice in the Byzantine Empire. It clearly evolved from the preChristian custom of sleeping at the temples dedicated to Asklepios, the god of healing.42 Eventually Saints Cyrus and John appeared to Elias but disguised as monks and on the streets of Alexandria during the day, not in their church in the middle of the night. They told Elias to find four camels hitched together. He should then collect the dung from one of these camels—the saints emphasized that it should be the dung from only one of these camels. Taking water from a nearby well, Elias should make a paste of the dung and spread it over his entire body. Elias immediately carried out the detailed instructions, but naturally he was repulsed at the thought of rubbing camel dung on his face, so he decided to omit that part of this strange therapy. When Elias washed off the paste, his leprosy had disappeared, except for on his face. As Sophronios stated, Elias bore the marks of leprosy on his countenance until his dying day as a sign of his disobedience. In a subsequent miracle tale (no. 15), Sophronios begins by referring to the leprosy of Leviticus 13 as elephantiasis. That is, he equates Old Testament leprosy (tsa’arath) with incurable Elephant Disease, probably common in seventh-century (AD) Egypt and Palestine. According to Sophronios, Moses had expelled the victims of elephantiasis from the camp of Israel to drive out the wild passions. He added the observation that men frequently contracted the disease from intercourse with menstruating women. Here the persons committing the sins were punished with elephantiasis for their lack of self-control, not the children of their passionate unions, as Isidore of Pelusium had taught.43

The Holy Disease Although some Greek Christian writers connected leprosy with punishment for sin, others warned against such a view as a grave error. John Chrysostom

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observed that God used leprosy in the Old Testament to teach the Hebrews a moral lesson about sin as a father would employ simple concrete images to instruct his children. In an extended commentary on the story of King Uzziah’s violation of priestly rights (II Chron 26:16–23), Chrysostom warned that while the Jews were required by the Mosaic Law to ban Uzziah from Jerusalem, Christians should never understand this story as justifying the rejection of lepers from family and society.44 Patriarch Cyril of Alexandria objected even more strongly to a literal interpretation of Old Testament laws banning lepers. He argued that it would be a sinful act against God’s law of love to exile from society those who have fallen ill from any disease. God requires Christians to treat lepers with mercy, not to punish them with additional penalties.45 Other Christian writers emphasized that leprosy could be interpreted as a trial to perfect good people rather than as punishment meted out to sinners. In the third century, Origen stated that God had permitted Satan to strike Job with elephantiasis as the ultimate test of the holy man’s righteousness.46 Following Origen, Gregory of Nazianzos linked closely the sufferings of Job with those endured by the victims of leprosy.47 In addition, both Gregory of Nazianzos and Gregory of Nyssa believed that the sick man, Lazarus, lying at the gate of the rich man in Luke’s Gospel (16:19–31), symbolized the sufferings of lepers. As a result of Lazarus’s tribulations in this life, after his death he immediately attained bliss in the bosom of Abraham.48 Because of this interpretation, Gregory of Nazianzos referred to leprosy as the “Holy Disease,” the illness that marked those destined for heaven rather than those stained with sin, as Methodios’s essay suggested through its elaborate use of color symbolism.49 Even Sophronios, who labeled the ulcers of leprosy on the face of Elias as glaring signs of his disobedience, referred to Job as smitten by leprosy.50 Gregory of Nazianzos’s oration on behalf of the poor (Oration XIV) presented the most compelling argument for considering lepers as blessed by God rather than cursed because of sin. Gregory wrote this extended sermon to deliver at a great Christian festival at Nazianzos.51 His purpose was to describe agape (love), the greatest Christian virtue, and to demonstrate the most sublime form of such charity—the love for the poor. Gregory emphasized that the poorest among those who had nothing were the lepers. These people had lost even the use of their own bodies to improve their lot through manual labor. The lepers, more than any other victims of misfortune, needed the help and support of Christians.52

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Gregory not only described the horrible disfigurements of Elephant Disease, he also called attention to the economic hardships that drove even lepers from aristocratic families to beg in the streets. Gregory stressed, however, that the root of all this suffering was society’s rejection of these helpless victims, a rejection forcing them to lead lives of exile and isolation. Their mothers and fathers disowned them; their families and friends fled them; and their cities banished them.53 Gregory pleaded with conscientious Christians to remember that each leper had been made in God’s image and had been saved by Christ’s death on the cross. No Christian should reject these sick but, rather, should embrace them as brothers.54 After these comments, Gregory began his attack on Christians who argued that lepers were suffering in their bodies as punishment for their sins, a chastisement that these misguided people believed had come from God. Gregory condemned such ideas as worse than the ravings of pagan priests. Who would imagine himself so wise as to understand God’s will? What human being dared to claim that he knew the mysterious plans of the Creator? Just like great wealth, good health might easily be a curse, leading many people to the pinnacle of pride. Disease, on the other hand, humbled its victims and purified them. Leprosy was preparing its victims for paradise, while good health and beauty might be leading those it favored to eternal damnation.55 Let someone else be bold and daring concerning such things; or rather let no one be so bold. I, however, shrink back from counting punishment in this life as due to evil or a pleasant life as due to piety. It happens, when it serves some useful purpose, that evil is held in check by the punishment of the wicked and the way of virtue is paved by the good experiences of those who are better, but this is not at all true in all cases, but such belongs only to the coming age according to which some will receive rewards for their virtue and others punishment for their vices.56

Gregory’s arguments implied that the Old Testament laws banning lepers from the camp did not refer to the expulsion of those who were physically ill but to those who suffered from a sickness of the soul, far more lethal than Elephant Disease.57 He firmly believed that an example of such a deadly spiritual sickness infected the wealthy of his own day. Rising to the dramatic climax of his sermon, Gregory described lepers who lay outside the elegant villas of wealthy citizens around Nazianzos. The

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sick scarcely had the strength to stretch forth their hands to beg. They had no voices strong enough to entreat those entering these villas, nor feet to run to the wealthy to ask for their help. Meanwhile, inside these mansions, affluent guests reclined at banquet tables where the floors were strewn with redolent flowers. Slaves in dazzling costumes and with elaborately curled hairstyles offered the guests all sorts of exotic wines, imported from the far corners of the empire, while other attendants cooled the guests, overheated by their excessive eating and drinking, with spectacular feathered fans. Such wealthy people had clearly been afflicted with a deadly disease of the soul, far more dangerous than the leprosy that infected the sick people begging at the gates.58 Gregory’s Oration XIV contributed to fundamental changes in the popular response to leprosy. Despite occasional references to sin as leprosy, no Byzantine intellectual, ecclesiastic, or political figure thereafter ever suggested that Christians should ban the victims of leprosy from churches, cities, or public places. No Byzantine emperor or provincial official ever issued an order to arrest or expel lepers or forcibly confine them anywhere.59 Finally, it is a measure of the success of Gregory of Nazianzos’s Oration XIV (and of other Christian treatises on charity) that throughout the Byzantine world the Greek term Holy Disease came to refer only to Elephant Disease. Prior to the fourth century, the term was used to identify a completely different illness— epilepsy.60

Preaching by Example Religious leaders changed society’s attitudes toward lepers not only through powerful sermons but by their personal behavior. After building a leprosarium outside of his home city in Cappadocia, the renowned theologian and bishop Basil of Caesarea cared for the leprous patients there with his own hands, embracing them and even kissing them. Roughly a century later, Theodosios, one of the leaders of Palestinian monasticism, was also known to kiss the lepers at the leprosarium he had attached to his monastic community.61 In fact, bestowing a kiss on a victim of leprosy subsequently became a symbol of devoted service to those who suffered most, not only in the Byzantine East but also in the Latin West. A contemporary of Basil’s, the Western saint Martin, bishop of Tours, supposedly kissed a leper whom he met outside the gates of Paris.62 Many

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other Western saints kissed lepers, but the most famous to do so was Saint Francis of Assisi. In the early thirteenth century Francis overcame an innate fear of leprosy to approach one of its victims and offer him a kiss.63 Such a  gesture of love for the most wretched among humans seems to have emerged during the fourth century spontaneously in widely separated provinces of the empire, Gaul and Cappadocia, from common Christian principles. This is an example of how Christians in both the East and the West had finally come to appreciate, at almost the same time, the radical nature of Christ’s teaching to accept and embrace those whom society had rejected. By kissing the lepers, both Basil and Martin wanted to show love as Christ commanded, but they also viewed such a kiss as a sacrificial act; kissing a leper represented taking up one’s cross—that is, performing an inherently difficult and unpleasant task. In Saint Francis of Assisi’s kiss there was also a strong element of sacrificial offering as well as a gesture of acceptance. Twenty years after Basil had opened his leper hospital in Caesarea, John Chrysostom tried to build a new leprosarium in Constantinople. Moved to tears by the suffering of lepers, he bought property for an asylum, but his enthusiasm for this project played a significant part in his losing the episcopal chair of the capital city. Wealthy people who owned landed estates near Chrysostom’s proposed leprosarium complained to the empress Eudoxia, who then used the bishop’s project as part of a campaign to depose him from the episcopal office of Constantinople. The anonymous eulogy of Chrysostom portrayed him as a martyr who suffered humiliation at the hands of the empress and of selfish magnates because these people feared a contagious disease more than the commands of the Lord to assist those in need.64 Many stories concerning the Egyptian monks described their heroic efforts to assist those with Elephant Disease. We have already recounted the case of Eulogios’s patient service on behalf of a particularly ill-tempered leper. Around the year 400 another ascetic named Daniel brought a leper to the monastery of the Scete in the desert. He washed and fed the leper each day and even helped the sick man chew his food by patiently moving his deformed jaws. Daniel performed these arduous tasks to atone for having murdered a barbarian who had held him in captivity for many years.65 Even aristocratic laywomen of Constantinople labored to assuage the pains of Elephant Disease. The ninth-century monastic leader Theodore of Stoudios considered his mother a paragon of Christian virtue even before she entered the monastery. As a mother she had taught Theodore’s sisters to

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wash the ulcers of lepers with their own hands. Moreover, she herself often worked with the director of the Zotikos Leprosarium in caring for the sick who resided there.66 The examples set by bishops such as Basil and monks such as Theodosios in Palestine inspired even the emperors to assist lepers. We have already seen how emperors supported the Zotikos Leprosarium in Constantinople. The emperor John Tzimiskes (969–76), however, not only multiplied the dormitories for patients at the Zotikos hospital, but he also visited the residents in person, distributed gold coins to them, and even personally treated their ulcerous sores.67 The emperor Michael IV (1034– 41) descended into the bath for the lepers at the Zotikos asylum, poured warm water over them, and wiped their feet.68 The rhetorician and intellectual Michael Psellos described how Emperor Constantine IX (1042–54) also washed lepers at the Zotikos and even kissed them as Saint Basil had.69 One version of the eleventh-century Zotikos legend implied that many Byzantine emperors had washed lepers at the Zotikos Leprosarium.70 In fact, it appears that a visit to this leper hospital had become by the reign of Michael IV one among many liturgical duties of the emperor, probably performed on a particular feast of the Church’s calendar. The emperor would arrive at the Zotikos Leprosarium to distribute gold coins to the patients, and then he proceeded to the baths, where he helped some lepers bathe, applied appropriate medicines, and, at least in the cases of Michael IV and Constantine IX, embraced and kissed them.71 Emotional sermons such as Oration XIV of Gregory Nazianzos and even more powerful gestures such as Basil’s embrace of lepers won for the victims of this frightening disease a privileged position in Byzantine society. Lepers suffered from a horribly disfiguring illness, but this very affliction sanctified them and made them holy in the image of Job and the poor man Lazarus. There are indications, however, that the ideals of the Greek fathers did not totally eliminate prejudice against the victims of elephantiasis among the general populace. A story from the eleventh-century Life of Saint Athanasios, founder of the Great Lavra Monastery on Mount Athos, described a young man who suffered both from Elephant Disease and poverty, two conditions intimately connected, as both Gregory of Nyssa and Gregory of Nazianzos had emphasized. What weighed on the sick man most heavily, however, was that many people turned from him and fled. Echoing Gregory of Nazianzos, the author of the vita

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contemned such people as merciless and inhumane. The story, however, demonstrates that, despite the writings of the fathers and the exemplary gestures of holy men and women and even of the emperors, many people in the Byzantine Empire still feared leprosy as contagious and repulsive.72 Another indication that the general public was never totally convinced that it was safe to live in close contact with lepers comes from the twelfth century. In 1137, Emperor John II Komnenos laid down precise rules as to how the monks of his Pantokrator Monastery were to live together and pray together. In Byzantine law, such a monastic rule was called a “typikon.” In addition to regulating the ascetic routines of the monks, Emperor John II used this typikon to establish two charitable institutions—a hospital (termed xenon in Byzantine Greek) to cure the sick and a rest home (termed gerokomeion) to care for the aged and for those with chronic, incurable diseases. These two philanthropic facilities were located next to the monastery in central Constantinople, and the monks were to guarantee the smooth functioning of both of them.73 Emperor John II, however, planned a third philanthropic institution affiliated with the Pantokrator Monastery, a leprosarium near the xenon and gerokomeion. The emperor admitted, however, that such a leper asylum would have created problems for those living nearby and would have presented “difficulty of access.” The emperor claimed that the central problem was the crowded nature of the Constantinopolitan urban environment rather than any opposition on the part of neighbors to the presence of a leper asylum in their midst.74 Despite the euphemisms in the typikon, however, it seems clear that the city residents in the Pantokrator neighborhood organized enough opposition to the emperor’s plans for a leprosarium that John II decided to endow some new dormitories at the Zotikos Leprosarium rather than to carry out his initial plan.75 It is important to note, however, that Emperor John II carefully avoided stating openly that residents of Constantinople did not want a leprosarium near their homes. Such blunt language would have been politically unwise, even for an emperor. To have attributed such an attitude to the citizens of the capital would have cast them together with the selfish landowners who had persecuted John Chrysostom or placed them in the company of the selfindulgent rich of Gregory’s Oration XIV, pleasure seekers who, without mercy, condemned the lepers at their gates as sinners suffering the just punishments for their sins.

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Some writers from Western Europe expressed their fear of leprosy more directly than did Byzantine authors. In this regard, it is enlightening to compare the statements of the Pantokrator Typikon with a nearly contemporary description of the Jerusalem Hospital of the Knights of Saint John (also known as the “Hospitallers”). This religious order from the Latin West won fame for supporting a large hospital in Jerusalem and later for taking up arms against Muslim raiders. The Byzantine government had ruled Jerusalem until 638, but in that year the city fell under Muslim rule. By the twelfth century, however, Western crusaders controlled the Holy City. Just prior to Saladin’s reconquest of Jerusalem in 1187, an anonymous German monk visited Palestine and left a detailed treatise to explain how the Knights of Saint John had organized their large hospital in Jerusalem. In his treatise, this ascetic pilgrim from the Catholic West observed that all the sick, no matter how poor, received care and medical treatment at the Jerusalem Hospital of the Knights of Saint John. The Knights, however, excluded lepers because that disease is “hateful and is denied contact with any others and is placed in a deserted place of solitude.”76 After the riveting images of Gregory’s sermon and the dynamic embrace of lepers by Basil of Cappadocia and Theodosius the Cenobiarch, no prominent Byzantine figure of either church or state would have dared make such a direct statement about the need to isolate lepers as did this Western monk. Residents of Constantinople did not want to live near a leper asylum as the emperor John II indicated in his typikon for the Pantokrator Monastery. People in twelfthcentury Constantinople, however, were not willing to state openly that they wished to expel lepers from their city or even their neighborhoods. We have now seen that Elephant Disease attracted the attention of the Church, the state, and the general population in Byzantine society. Early on, Church leaders began to reshape the image of leprosy as a symbol of sin and of rejection by God into a sign of blessedness—the Holy Disease. But what did Byzantine men of science say about leprosy? In the following chapter we examine how Greek physicians described leprosy and how Christian ideas about Elephant Disease gradually reshaped medieval medical opinions.

Chapter 3

Byzantine Medicine

Mapping the relationship between Byzantine medical science and leprosy is a difficult task because at present so little is known about medieval Greek physicians and their profession, especially in the centuries after the Arab conquest of the Middle East. Over two thousand Byzantine manuscripts devoted to medical works survive in European libraries. A third of these contain works by a single author such as the second-century Galen of Pergamon; the remaining manuscripts have selections from different classical and Byzantine medical writers. In this second group of manuscripts, scattered among the selections culled from treatises by well-known physicians, are many anonymous antidotaria—lists of pharmaceutical treatments for specific diseases, some as long as eighty-five folios.1 So far scholars have studied only a small number of these antidotaria. Most have never been examined carefully, and only a few are available in any printed edition. No researcher has yet prepared a list of the diseases discussed in these treatment lists. As a result, one cannot consult a modern

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monograph or handbook to determine how many of these antidotaria include instructions for treating victims of leprosy. Modern scholarship has so far ignored even the works of the most prominent Byzantine physicians. Theophanes Chrysobalantes wrote a popular epitome of Greek medicine, perhaps under the patronage of Emperor Constantine VII (913–59), a medical handbook in which Theophanes did include a section on Elephant Disease. Although his work survives in over fifty manuscripts, at present the only available text is an uncritical edition printed at the end of the eighteenth century.2 John Zacharias (also called the aktouarios), another key figure in the history of Byzantine medicine, wrote extensively in the fourteenth century. Scholars have only managed to edit some of his works, and no thorough study of his place in the development of Greek medicine exists. He too dealt with elephantiasis.3 The case of the Tetrabiblos of Aetios of Amida presents the most striking example of the problems facing historians who undertake research on Byzantine medical science. Aetios assembled the various texts for his Tetrabiblos in the mid-sixth century. From then until the fall of Constantinople, Byzantine physicians considered Aetios’s compendium of passages excerpted from Greek medical texts of the Hellenistic and Roman periods a valuable source of information. Despite the importance of the Tetrabiblos, there exists today no printed Greek text of the second half of this work, the section that included a description of Elephant Disease. As a result, in conducting our research for this project, we were able to study Aetios’s chapter on leprosy only through a sixteenth-century Latin translation, published in Venice and Basel.4 In addition to the problems involved in identifying and editing Byzantine medical texts, scholars still have not come to an agreement on how medieval Greek physicians practiced medicine. Many medical practitioners trained and worked in Christian hospitals, but others, especially outside of Constantinople, continued to work as had the physicians at the time of Galen. Some Byzantine physicians in Cappadocia worked in Christian leper asylums as Gregory of Nazianzos’s Oration XIV implied.5 Did their service to the lepers in such institutions allow them time for treating private patients in the homes of these sick people?6 In view of these many problems, we shall limit the study of Byzantine medicine and elephantiasis to examining how Christian ideas about leprosy helped shape Byzantine medical theories about the disease. This discussion

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will focus, first, on the problem of contagion regarding Elephant Disease, second, on the notion that leprosy increased sexual desires in its victims, and finally, on the methods of classifying leprosy as a disease. In addition, our discussion will examine how Greek medical ideas about leprosy influenced Christian leaders in constructing leprosariums and in organizing therapeutic routines for patients in these institutions.

Contagion Although medieval Greek physicians made innovations in the diagnosis and treatment of diseases, they never severed their close ties to ancient Greek medicine. Therefore any study concerning what Byzantine physicians believed about leprosy must begin with the ancient Greek doctors. We have already discussed the views of Galen of Pergamon and Aretaios of Cappadocia regarding Elephant Disease. These two physicians, however, described leprosy very differently. Galen attributed its cause to an excess of black bile that the body of the sick person had been unable to eliminate properly. As a pneumatist, Aretaios claimed that inhaling the corrupted air due to the breath of other lepers or from another cause (“something from those [things] outside”) altered the pneuma in the body and brought on Elephant Disease.7 As a result of their different theories of causation, these two physicians had differing views on how contagious Elephant Disease was. Galen emphasized diet and environment as the causes of leprosy and did not claim that leprosy spread from person to person; Aretaios, on the other hand, warned that Elephant Disease was a highly contagious illness, like the plague that had fallen upon Athens during the Peloponnesian War.8 Aretaios, however, was not widely read by subsequent generations, probably because of his strange Ionic Greek that was difficult to read. Moreover, the fourth-century compiler of Greek medical texts, Oribasios, did not incorporate any selections of Aretaios in his chapter on elephantiasis.9 Oribasios, often classified as the first Byzantine medical author, reproduced Galen’s account of leprosy from his Ad Glauconem, along with Rufus of Ephesus’s short essay and a long list of palliative treatments from Philomenos, a physician who lived during the early Roman Empire. For some reason, Oribasios chose to ignore Aretaios’s remarkably detailed account of Elephant Disease.10

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Despite the lack of interest shown by subsequent generations in Aretaios’s original writings and Oribasios’s failure to quote him, the ideas of Aretaios about leprosy survived due to the vast encyclopedia of the second great medical compiler of the Byzantine period, Aetios of Amida. In the sixth century, Aetios collected passages from many Greek physicians of the past and organized them according to his own system. Aetios’s summary survives in 140 manuscripts, and many short passages from his work also appear in numerous Byzantine antidotaria.11 Aetios did not preserve Aretaios’s comments on leprosy directly, but in Book Thirteen of his compendium he included a section on Elephant Disease consisting of a short essay that Archigenes, a physician of the first century, had written.12 Like Aretaios, Archigenes was a pneumatist and in fact had greatly influenced Aretaios.13 According to the section by Archigenes, which Aetios had recopied, leprosy was dangerously contagious. In commenting on the widely held suspicion that elephantiasis passed from person to person, Archigenes stated: And thus, the disease (elephantiasis) creates the suspicion that it might be contagious, and I affirm that it is indeed a disease which comes from conversation with these [victims of the disease] because the air is contaminated by the corruption of their ulcers and by the contaminated exhalation of their breath which we take in when we breathe.14

This passage by Archigenes in the pages of Aetios’s work was widely read by subsequent generations of Byzantine physicians and by liberally educated laymen. His words presented an even more alarming impression of the danger posed by the contagious Elephant Disease than Aretaios’s statements had. Practicing medicine at Alexandria in the first half of the seventh century, Paul of Aegina wrote another compendium of ancient medicine, but he did not simply excerpt passages from Galen, Archigenes, and other Hellenistic and Roman-era medical writers as Oribasios and Aetios had done. Rather, he presented novel interpretations of medical issues by weaving together ideas from many ancient writers and combining them with his own observations. Agreeing with Archigenes and Aretaios, Paul also maintained that leprosy was highly contagious.15 Working in Egypt where Elephant Disease had been prevalent for centuries, Paul combined his own personal observations of leprosy with the

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opinions of both Galen and Aretaios. For example, Paul began his section on Elephant Disease by acknowledging Aretaios’s statement about the strength of the disease, but he accepted Galen’s view that the illness arose from an excess of black bile.16 Influenced surely by Aretaios and perhaps also by Aetius’s compendium, Paul also stressed that elephantiasis spread easily from person to person. As a result, he recommended that lepers live away from towns in deserted areas, preferably with a cooler climate and fresh air. The best place for them would be an isolated area, but near enough to their friends and relatives so that these people could visit the lepers frequently. In this passage, Paul was probably referring to the leprosariums that the Christian bishops and monks of Egypt had been erecting since the fourth century.17 We will return to the subject of Egyptian leper asylums in the next chapter. Professional physicians were not alone in viewing leprosy as contagious. The popular opinion was even stronger than the belief of medical experts that elephantiasis attacked those who approached its victims. We have already discussed how the wealthy of Constantinople vehemently opposed Chrysostom’s proposed leprosarium because they feared contagion. They claimed that leprosy could seize anyone who came close to a person with Elephant Disease. Those who had property downstream from the proposed site of Chrysostom’s asylum even feared that the water would carry the pollution to their estates.18

The Campaign against Contagion Gregory of Nazianzos discussed such fear of contagion in his Oration XIV and identified it as the cause of greatest suffering for lepers. Because of this fear, even mothers refused to embrace their sons and fled from their own flesh as though from an enemy. Alluding to the theory of contagion based on air polluted by the breath of lepers, Gregory claimed that some healthy people grew angry with the sick if they had to inhale the same air that those with elephantiasis had exhaled. Gregory claimed that many people refused even to approach water that lepers had touched. Thus the healthy drove the sick away from city fountains, baths, and even streams and rivers.19 Gregory of Nazianzos did not directly refute the belief that leprosy was dangerously contagious, but he suggested that not all the evidence pointed in that direction. Many physicians had treated people with Elephant Dis-

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ease and had never fallen sick with the illness. So too had caretakers— probably attendants at leprosariums—spent many years in service of leper patients without contracting the disease.20 Gregory of Nyssa, however, focused more attention on the issue of contagion in his sermon on leprosy. He emphasized that such a fear was the chief cause of why even believing Christians ignored Christ’s stern warning to visit the sick and minister to them. As a result, Gregory attacked the very concept of contagion. Following Gregory of Nazianzos, Gregory of Nyssa repeated the examples of those who worked with lepers and never developed the disease. In Gregory’s words, “these caretakers are not harmed at all with respect to the good order of their nature.”21 The bishop carefully crafted this phrase to emphasize that, according to the dominant medical theory, sickness was not an ontological entity like an elephant but a disordering of the natural balance of humors. Gregory added a careful analysis of the cause of leprosy. The disease began with the corruption of black bile, as Galen had taught. This corrupted black bile entered the blood and polluted it. Thereupon, the imbalance of humors in the blood spread throughout the entire body. Gregory emphasized that this imbalance did not come from approaching lepers but from a common environmental problem, coming from outside the sick person, from corrupted air or water.22 In this passage, it is clear that Gregory had in mind not air or water contaminated by the sick but environmental elements polluted by meteorological phenomena or topographical conditions that, according to the Hippocratic treatise Airs, Waters, Places, generated epidemic diseases.23 Gregory of Nyssa, therefore, stressed that the medical opinion consensus concerning the nature of disease was that a condition such as leprosy was not contagious but originated from an imbalance of humors caused by improper diets, excessive lifestyles, or environmental factors. In fact, Gregory was maintaining the traditional Greek attitude toward sickness, which Plutarch had supported in his debate with Philon. Gregory supported the traditional view of disease as an imbalance because he wanted people to overcome their irrational fear of leprosy. There was no need for families to expel the victims of Elephant Disease from their homes, or for cities to exile them from the polis community. Cruelty toward lepers both violated Christ’s law of love and ignored the most widely held scientific opinion concerning illnesses.

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In his sermon on the plight of lepers, Gregory of Nyssa boldly asserted that diseases did not spread by contagion. In his theological treatise against Eunomios, however, he claimed that spending too much time explaining the history of heresies might pass this spiritual illness on to Gregory himself, just as people could develop eye infections from too much contact with victims of conjunctivitis or other ophthalmic illnesses. In this context, Gregory claimed that contagion was a danger. What did he really believe?24 Historians and theologians have sometimes criticized the Greek fathers for their rhetoric—their frequent use of analogies to make spiritual points— and for their failure to develop a consistent theological system. Which of Gregory’s two statements about contagion did he believe? In the great mass of his literary output, was he even aware of the contradiction? What is certain, however, is that his attack on contagion in his sermon on behalf of lepers had profound implications on the ethical treatment of victims of Elephant Disease and even on subsequent medical views, whereas his comment about contagious eye infections remained a rhetorical simile.

Contagion Theories after Paul of Aegina As we noted previously, writing in the seventh century, Paul of Aegina continued to assert that leprosy passed from person to person. Gregory of Nyssa’s arguments against contagion apparently had no influence on Paul’s medical opinion about leprosy. It is a remarkable fact, however, that no Greek medical text after Paul’s Epitome ever again mentioned that Elephant Disease was contagious. After Paul of Aegina died (ca. 650), the Arab invasions and the barbarian attacks from the north shook the Byzantine Empire to its foundation. Not until after 800 do we have another summary of Byzantine medicine that mentions leprosy, an epitome written by an obscure physician named Leo for his student George. Leo repeated Galen’s reference to corrupted black bile as a cause of elephantiasis and included a few palliative remedies. He also introduced into medical handbooks a new name for leprosy. He called it “elephantiasis,” but also “kelephia,” originally an Aramaic word. Leo, however, did not mention that leprosy was contagious.25 Leo’s description of leprosy is so short that his omission in stating that leprosy spread rapidly from person to person is perhaps not significant,

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but the tenth-century compiler of medical wisdom, Theophanes Chrysobalantes, also removed any reference to contagion from his section on leprosy in his Epitome de curatione morborum.26 As we saw earlier, Theophanes’s Epitome was extremely popular with subsequent Byzantine physicians, since no fewer than fifty-eight manuscripts have preserved the complete text of his summary, and many more contain excerpts of his work. That Theophanes omitted any reference to contagion as a danger in cases of leprosy is especially significant because he took almost all of his comments on Elephant Disease directly from Paul of Aegina. Theophanes’s recommendation regarding bathing and ointments for leprous skin followed Paul’s directives almost verbatim.27 Why, then, did he not mention contagion? From the eleventh century we have a poem on medicine written by the famous scholar and teacher Michael Psellos, a poem that also contains a short section on leprosy. Psellos mentioned the great strength of the disease, how it came from corrupted black bile, and how it could not be cured, but he never stated that it was contagious.28 After the capture of Constantinople in 1204, a comprehensive antidotarium was prepared for use probably in the Aegean Islands or mainland Greece. This Therapeutics of the Physican John is one of the few Byzantine antidotaria to have been thoroughly studied. Its modern editor, Barbara Zipser, has identified two different versions of this text. The first version, written in high Greek, does not contain any reference to Elephant Disease, but the second version, rewritten in the colloquial Greek of the late thirteenth century, adds a section on leprosy to the part of the antidotarium dealing with remedies for skin ailments.29 This demotic version is extremely interesting, because the author has taken almost all of the remedies for leprosy directly from Aretaios and even follows Aretaios’s order of treatments, beginning with bleeding, followed by purgatives with hiera (a compound drug of many ingredients) and also radishes, and anointing after bathing with many of the same ingredients mentioned by Aretaios.30 This text suggests that Aretaios’s treatise on Elephant Disease was more widely read than the limited number of surviving manuscripts might suggest. Despite its dependence on Aretaios, however, this antidotarium does not mention that elephantiasis was contagious. That John’s Therapeutics did not refer to leprosy as contagious reflects the nature of such antidotaria because they rarely contained any theoretical

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discussions and concentrated only on medications. However, the fourteenthcentury physician and prolific medical writer John Zacharias did write longer essays on medical subjects that included observations on how diseases arose in the body. But he also failed to mention contagion as a prominent characteristic of leprosy, even though his discussion of Elephant Disease relied heavily on Paul of Aegina. Zacharias began his description of leprosy by comparing it to cancer, just as Paul had done. Moreover, Zacharias distinguished between two distinct forms of leprosy, types that Paul had first identified in his study.31 In view of both Zacharias’s and Theophanes’s dependence on Paul of Aegina, why did they not repeat the Alexandrian physician’s warnings concerning the contagious nature of leprosy? One answer to this question might be that Byzantine physicians had come to see such a view concerning the propagation of leprosy and perhaps other diseases as immoral and unethical. After the sixth century, the Byzantine medical profession developed much closer ties to the Christian Church. Many physicians worked in Christian hospitals supported by bishops or monasteries. By the eleventh and twelfth centuries, physicians often were educated in church-run xenones and obtained their medicines from hospital pharmacies.32 In such an environment one would expect that the ideas of men such as Gregory of Nyssa and Gregory of Nazianzos would influence medical theories about disease. In 1998, Vivian Nutton, an expert on ancient medicine, suggested that physicians of the classical Greco-Roman world never focused on contagion as a significant cause of disease because society would have been unwilling or unable to enforce quarantines of individuals or isolation of infected communities.33 On the contrary, in the case of leprosy, Greeks who lived before 300 AD were willing to exile victims of Elephant Disease. Galen mentioned a man who lived not far from Pergamon who contracted leprosy. When members of his family and community began to fall sick too, those who remained healthy exiled him to a deserted hillside.34 Aretaios of Cappadocia also emphasized how people frequently expelled lepers from their homes and cities.35 Moreover, we have studied in detail how the two Gregorys saw the expulsion of lepers by their families and city communities as a grave tragedy and a moral outrage, yet all too common in Asia Minor. The fourth-century Cappadocian fathers— Gregory of Nyssa, Gregory of Nazianzos, and Basil of Caesarea—began an effort in the 370s to alter how people in the Greek world reacted to elephantiasis. Basil focused on

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building leprosariums, but he also underlined the Christian obligation not to reject or isolate lepers by his personal service in their care and by his dramatic kiss. Gregory of Nazianzos harshly condemned those who categorized lepers as those God had marked as sinners. Gregory of Nyssa, however, attacked the very concept of contagion. In his sermon, he insisted that leprosy did not infect healthy people who came near the sick. As we have seen, Gregory’s opinion that leprosy was not contagious did not immediately have an impact on medical opinion. In seventh-century Alexandria, Paul of Aegina strongly supported the view that leprosy was among the most contagious diseases. After Paul, however, no subsequent Byzantine physician described leprosy as contagious, even though some of these medical writers were directly dependent on Paul’s work. Popular opinion might still fear lepers, and as we saw with respect to the young man Saint Athanasios the Athonite healed of elephantiasis in the eleventh century, some people still fled from victims of leprosy. Official statements, however, avoided any reference to Elephant Disease as contagious. As we have seen, when in 1136 the emperor John II Komnenos attempted to explain why the crowded conditions of central Constantinople blocked his plans to build a leprosarium there, he carefully avoided suggesting that people feared leprosy because they believed that it could potentially spread from one person to another.36 One should also consider the possibility that Byzantine medical writers after Paul of Aegina abandoned contagion as an explanation of how people developed leprosy, because Galen, the most respected of ancient physicians, had not stated that Elephant Disease was transmitted from one person to another. Byzantine physicians after 640 thus had access to two traditions regarding leprosy—the Galenic texts that did not claim that elephantiasis was contagious and the pneumatist tradition of Aretaios and Archigenes that forcefully maintained that it was. At this point, it is instructive to examine what Arab physicians said about leprosy, because Muslim medical writers also had access to the works of Galen in Arabic translations and to the opinions of Archigenes through Arabic versions of Aetius of Amida’s compendium. Thus Archigenes’s warning that an individual could be infected even by conversing with lepers also came to the attention of Muslim physicians. Through some process of translation into Arabic, Archigenes’s essay on Elephant Disease fell into the hands of the most famous of Muslim physicians,

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the tenth-century polymath Ibn Sina (known to medieval Europe as Avicenna). In his massive medical encyclopedia, called the Canon, Avicenna repeated many of Archigenes’s comments about leprosy. It is therefore no surprise that Avicenna maintained that one cause of leprosy was breathing in the air contaminated by the breath of lepers.37 Archigenes’s warning against conversing with lepers passed to the physicians of Western Europe through Avicenna’s Canon. Working in Toledo (Spain), circa 1180, Gerald of Cremona completed a Latin translation of Avicenna’s work, which many Latin physicians subsequently read.38 Through this translation, Archigenes’s ideas spread across Latin Europe. The strongest restatement of Archigenes’s observations about how leprosy passed from one person to another appeared in the pages of an anonymous medical compendium from thirteenth-century Italy called the Breviarium practicae: For lepers infect the air and when infected air is breathed in by those who converse with lepers, this air infects their bodies within. Because of this process, lepers ought to be segregated from healthy men.39

Archigenes’s pneumatist theory of contagion was repeated in works attributed to other writers of the Latin West, such as the Franciscan scholar Bartholomeus Anglicus and Arnold of Villanova.40 As in the Byzantine Empire, so too in the Islamic world an effort was made to suppress the concept of contagion as a cause of disease. Early Muslim traditions about the Prophet did not agree about the contagious nature of leprosy and some other diseases. One early tradition claimed that Muhammad had advised his followers to flee from a leper as one would flee from a lion. The Qur’an, however, stated that there was no fault in the blind, no fault in the lame, no fault in the sick (Surat al-Nur [24], verse 61), a verse that argued against any fear of the sick as being dangerous spiritually or bodily. Despite ambiguity in the early tradition of Islam, Muslim scholars came to see the idea of contagious diseases as limiting the absolute power of God’s will. Writing in the ninth century, the learned scholar Ibn Qutayba admitted that one could contract leprosy by engaging in sex with a leper or by inhaling corrupted air from a leper’s breath (Archigenes’s explanation of transmission), but he still rejected contagion as an actual cause of disease because it would imply a mechanistic explanation of sickness rather than a divine

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cause in the absolute will of God.41 Despite theological views that rejected contagion as an explanation of how diseases were propagated, we have seen that Arab medical writers such as Avicenna continued to repeat the statements of Greek pneumatists who claimed that healthy people could catch Elephant Disease from the breath of lepers. Contrary to what occurred among Muslim physicians and their Western Christian imitators, Byzantine physicians after the seventh century appear to have rejected the view that leprosy was contagious, even though Aretaios, Archigenes (through Aetios), and the influential Byzantine physician Paul of Aegina had asserted the contrary. Later Byzantine medical writers, however, did not reject contagion as an explanation of the cause of leprosy for theological reasons, as some Muslims did. Rather, they appear to have been influenced by the powerful sermons of the two Gregorys and by the examples of Basil and John Chrysostom to reject contagion in the case of leprosy for ethical reasons, because such a belief impaired the practice of the highest Christian virtue of philanthropia toward those who most needed the love and care of their fellow creatures.

Byzantine Divorce Law A short examination of Byzantine laws regarding divorce reinforces the evidence that East Roman society ultimately rejected the idea that leprosy was contagious for philanthropic reasons. In 741, Emperor Leo III and his son, Constantine V, issued a new code of law known as the Ecloga. The emperors intended this code to provide a useful summary of the much longer Corpus juris civilis issued by Emperor Justinian two hundred years earlier. Because Byzantine society had undergone many changes as a result of the Arab invasions, these two emperors also felt that Justinian’s laws were in need of revisions.42 Thus the Ecloga did not simply summarize the Corpus juris civilis; rather, in some areas, it introduced substantial innovations as, for example, regarding the regulations for legal guardianship over orphaned children.43 With regard to divorce, the Ecloga reduced the legally valid grounds for dissolving a marriage from Justinian’s eight reasons to two. The Ecloga, however, added a third valid ground for a legal divorce not mentioned by Justinian. If either the wife or the husband contracted leprosy, the healthy partner could obtain a legal divorce.44

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Why did the emperors Leo and Constantine add this new reason for a valid divorce? It is possible that they considered that the burden of caring for a leprous spouse would be too difficult an undertaking and beyond the obligation imposed by Christian marriage. It is probable, however, that they also considered Elephant Disease contagious, and that continuing to live with an infected spouse placed the healthy partner, as well as any children in the household, in danger of contracting the disease and eventually dying. The Ecloga’s rules regarding divorce remained in effect for more than a hundred years.45 At the end of the ninth century, however, the emperors Basil I (867–86) and Leo VI (886–912) reformed Byzantine laws again.46 Basil issued the first code in 886, which he called the Epanagoge. In the section on divorce, he removed the rule that allowed a healthy spouse to divorce a leprous partner.47 Moreover, the Prochiron, another summary issued by Leo VI, also eliminated any reference to elephantiasis as legal grounds for a divorce.48 Neither the text of the Epanagoge nor that of the Prochiron mentions why the ninth-century emperors eliminated leprosy as a reason to sanction a divorce. Basil and Leo did, however, state that they considered the Ecloga to be the work of heretical emperors, because Leo III and Constantine V had initiated iconoclasm, a movement in the Byzantine church that was later rejected as heretical. As a result, Basil and Leo tried to return to the laws of Justinian purified of innovations found in the Ecloga, a work of emperors who were subsequently not considered orthodox. Regarding the Ecloga’s regulation validating divorce in the case of leprosy, however, Basil and Leo probably considered as well the demand of Christian philanthropia toward the victims of Elephant Disease. To allow the healthy spouse to divorce a leprous partner would have meant that the risk of infection outweighed both the duty of charity toward the sick in general and the obligation of a married person toward a suffering spouse in particular. Moreover, it would have supported fear of contagion, the very fear that the Cappadocian fathers had condemned so harshly as the root cause of cruelty to the unfortunate victims of elephantiasis.

Leprosy and Lust As we saw in chapter 1, Rufus of Ephesus was among the first learned physicians to discuss leprosy in an extant scientific treatise. He mentioned that

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earlier medical experts had referred to the illness as satyriasis because “a certain drive toward the pleasures of Aphrodite takes hold of those who suffer from the disease.” 49 Composing his essay on leprosy only a few decades later, Galen never mentioned an increase in sexual drive as a symptom of Elephant Disease.50 In his thorough discussion of elephantiasis, however, Aretaios twice referred to enhanced sexual desire as an important symptom. First, he repeated Rufus’s explanation of the term satyriasis used by physicians as a name for leprosy, and second, only a few paragraphs later, he identified as a key symptom of Elephant Disease “a raging appetite” for sex on the part of the patient, followed by a sensation of exhaustion.51 Although Aretaios influenced Paul of Aegina’s observations on leprosy and Paul in turn was summarized by subsequent Byzantine physicians, Aretaios’s description of Elephant Disease was never directly quoted in later medieval encyclopedias. The views of Rufus of Ephesus, on the other hand, were repeated in the huge compendium of ancient medical sources compiled by Oribasios in the fourth century.52 Moreover, in reproducing the text of the first-century physician Archigenes, Aetios of Amida also emphasized concupiscence as a symptom of Elephant Disease.53 Aetios’s compendium obviously had a major impact on later generations of Byzantine physicians, since it has survived in so many manuscripts.54 As a result, there can be no doubt that professional medical men in medieval Byzantium were well aware of the scientific theory that victims of Elephant Disease felt abnormally powerful sexual impulses. Until recently, modern physicians ridiculed as pure fantasy the observations of Rufus of Ephesus, Aretaios, and Archigenes. Under modern clinical conditions, leprosy damages the testicles and lowers the level of testosterone in the bloodstream of those with modern Hansen’s disease. As a result, physicians have concluded that rather than enhancing sexual desire in male patients, the disease reduces it. Recent analyses of blood extracted from leper patients, however, have shown that male lepers have reduced testosterone levels but increased amounts of luteinizing hormone (LH), a substance that stimulates testosterone production.55 When leprosy goes into temporary remission, the patient’s elevated levels of LH will stimulate a veritable surge of testosterone production. Thus these recent blood studies confirm exactly what Aretaios claimed to have observed: namely, that male lepers suffered from an attack of raging sexual desire, followed by a sudden drop in energy as the period of remission ended.56

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As we saw previously, Paul of Aegina opened his discussion on leprosy with a reference to Aretaios’s essay, but Paul did not repeat the Cappadocian physician’s statement that elevated sexual urges assailed the victims of leprosy.57 Although Byzantine physicians who wrote after Paul also had access to Aretaios’s observations of lepers’ hypersexuality and had many copies of the encyclopedic works of both Oribasios and Aetius, none of these writers mentioned that lepers suffered from an enhanced sexual drive. Thus Theophanes Chrysobalantes and John Zacharias indicate that Byzantine medical opinion supported Paul of Aegina and Galen in discounting concupiscence as a symptom of Elephant Disease. Even the thirteenth-century account of elephantiasis in the demotic version of John’s “Therapeutics,” a section clearly derived from Aretaios’s text, fails to mention sexual desire as a symptom. The reason for rejecting hypersexuality as a symptom of leprosy has it origin not only in the scientific views of Galen and Paul but is a result also of the strong statements of Gregory Nazianzos in his Oration XIV. As discussed earlier, Gregory of Nazianzos wanted to portray leprosy not as a mark of sinfulness but as a blessing–a holy disease that purified those whom it disfigured so that they might ascend to God after they had learned humility through their trials here on earth.58 For Christian ascetics such as the fourth-century Greek fathers, it would have been a serious setback in their campaign to cleanse leprosy of its Old Testament associations with ritual impurity and punishment for sins if they had acknowledged that this disease augmented the desire for pleasures of the flesh. Byzantine accounts of leprosy—even when they linked the disease to sexual desire—avoided any implication that Elephant Disease plagued its victims with a greater sexual drive and thus a greater temptation to sin against chastity. In fact, Byzantine texts that describe monks with leprosy sometimes portray the illness as rescuing its victims from excessive sexual desires. The seventh-century monastic writer John Moschos provides a perfect example of this attitude. In his Spiritual Meadow, John recounted a story about a certain monk from the Monastery of Penthouklas in Palestine. This man scrupulously practiced the ascetic discipline, but he had to wage a continuous battle against porneia, the desire for illicit sex. Finally, he could endure the struggle no longer. He left the monastery and traveled to Jericho in order to satisfy his fleshly desires. As he entered a prostitute’s house, however, he was struck with lep-

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rosy all over his body. When he saw his condition, he immediately returned to his monastery and began to praise God for his illness that had saved him from the far greater disease of lust. His leprosy had made him holy.59 The fourteenth-century diplomat and court poet Manuel Philes emphasized the same point almost seven centuries later. Philes dedicated one of his many poems to a monk who had been afflicted with the worst type of lepromatous Elephant Disease.60 In vivid language, Philes described how the disease had literally severed the poor ascetic’s limbs from his body. The monk had sought healing from this terrifying illness at the Monastery of the Lifegiving Spring just outside the walls of Constantinople, but God never healed him. The horribly disfigured man died of his ailment. Philes, however, never suggested that leprosy had come as a punishment for sin, nor did he comment on why God did not grant the monk healing. Rather, he focused on how the monk’s patient suffering had purified him from all physical passions, including those of sexual desire. He (the monk) offered every limb for cutting Lest he be carried away by the rush of the passions. Through the amputation of his extremities, He struck and killed the audacious Satan.61

Philes ended his poem by describing how the monk, thus purified, rose from his leper’s cot to enter heaven and the company of the angels. As he approached death, he had never ceased praising God for his sufferings in the presence of others. Philes clearly rejected any link between leprosy and concupiscence. In the Western medieval world, on the other hand, the raging lust of male lepers emerged as a common image, especially in literature. Perhaps the most famous example appears in the Tristan legend. In a Norman French version of the tale composed circa 1190, the author, Beroul, altered the story about King Mark’s attempt to execute Isolde for her unfaithfulness. In Beroul’s version, a group of lepers begged King Mark not to burn Isolde at the stake for her betrayal but to surrender her to the lepers so that they could ravage her until she died. The story about the lepers does not appear in the more famous German rendering of the legend by Gottfried of Strassburg, but the other German version of the tale by Eilhart includes the

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episode about the lustful lepers. In fact, Eilhart’s version may predate the French poem of Beroul by several decades.62 Professional medical opinion in the medieval West supported the popular image of the raging sexual desires among male lepers. The thirteenthcentury Italian physician Taddeo Alderotti mentioned that lepers craved sexual activity.63 Moreover, a fourteenth-century medical guide for distinguishing victims of Elephant Disease from those suffering from other forms of skin ailments states specifically that the fifth symptom of true leprosy was moral depravity, including “a violent drive to concupiscence.” 64 Finally, in the early sixteenth century, Giambattista Fracastoro, the man who first suggested the existence of germs, firmly believed that heightened sexual desire plagued male lepers.65 Some historians have claimed that such views about lepers’ exaggerated sexual drives came originally from Aretaios but had passed through Arab medical texts into the Latin tradition, but we have been unable to confirm this link. First, Aretaios’s treatise could not have directly influenced Western physicians because it was apparently not translated into Latin before the sixteenth century.66 Second, neither the eleventhcentury translation of Ibn Jazzār’s essay on leprosy nor the twelfth-century Latin version of Avicenna’s Canon mention increased sexual drive as a symptom of leprosy, although some historians have cited these works as the source of this belief.67 Oribasios’s encyclopedia, which included Rufus of Ephesus’s comments on the increased libido of lepers, however, was translated into Latin twice during the sixth century, at the very beginning of the Latin Middle Ages, in or near the Ostrogothic capital of Ravenna in northern Italy. Medieval scribes continued to recopy these two translations of Oribasius’s work into the twelfth century, the time when Beroul and Eilhard composed their versions of the Tristan legend.68 Certainly not all Western medieval doctors repeated the statements of Rufus of Ephesus, found in Orbasius’s compendium. The Western physician who wrote perhaps the most accurate description of leprosy, Theodoric of Cervia, did not list concupiscence as a symptom of Elephant Disease.69 In general, however, one would have to conclude that Western Christian leaders were less successful than their Byzantine counterparts in convincing medical experts to eliminate lustful drives as one of the recognized symptoms of leprosy.

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Categorizing Leprosy In his analysis of leprosy, Galen linked the disease closely with cancer. According to Galen, both illnesses originated from an excess of black bile that accumulated in the veins. In the case of leprosy, the superfluous black bile is not eliminated properly and pushes up to the skin throughout the body. In the case of cancer, the excess of black bile is localized in the tumor.70 Influenced by Galen, Paul of Aegina also maintained that cancer and leprosy both had their origins in an excess of black bile, but Paul linked the two illnesses even more closely. He asserted that cancer was in fact a form of leprosy concentrated in one part of the body.71 If Hippocrates had found that physicians could not cure cancer, how could they successfully treat a cancer that attacked the whole body? In his summary, Theophanes Chrysobalantes did not include Paul of Aegina’s statement that cancer and leprosy derived from a similar excess of black bile in the bloodstream. John Zacharias, on the other hand, restated Paul’s teaching by reversing the comparison. According to Zacharias, “Leprosy, being a cancer of the whole body, is distributed throughout a person’s flesh.”72 Because we know so little about Byzantine medicine and have so few published sources available, it is impossible to trace the route by which Paul of Aegina’s doctrine linking leprosy to cancer found its way into the De medendi methodo of Zacharias. With regard to the shared etiology of cancer and leprosy, Paul of Aegina followed Galen closely, but he made a major innovation in the study of leprosy by observing that there existed two different types of leprosy.73 In this finding, his observations agree with modern medical science, which has distinguished tuberculoid Hansen’s disease from the more serious lepromatous form of the ailment.74 Paul claimed that the lesser type of leprosy originated when excessive black bile accumulated in the veins. The second and more severe form of leprosy occurred when there arose an excess of overheated yellow bile in the vessels of the body, which then corrupted the black bile. This second form of leprosy led to the loss of the extremities, the type of disfigurement that Gregory of Nazianzos described so vividly in Oration XIV. Theophanes Chrysobalantes did not mention the two distinct categories of leprosy. As in the case of leprosy’s link to cancer, however, John Zacharias did follow closely Paul’s teaching concerning two distinct types of leprosy.

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Chapter 3 Initially, this disease (leprosy) takes its origin from black bile. If this condition arises because the blood has been corrupted and changed into melancholic blood (blood with large amounts of black-bile sediments), it makes the patients reddish but with less serious effects. If, on the other hand, the origin of the disease arises in the melancholic humor from altered yellow bile, you will see cases of leprosy which are far more serious and corrosive which consume all parts of the body like fire.75

Some Arab physicians, such as the Persian-born al-Majusi (known to the Latin West as Haly Abbas), adhered to Paul of Aegina’s teaching that there were two forms of leprosy.76 Others, however, expanded the various types of leprosy from two to four categories. One of these was Ibn al-Jazzār, who practiced medicine in the North African city of Qayrawan during the tenth century.77 In addition to his famous Viaticum, a medical handbook for laymen, al-Jazzār wrote a treatise about leprosy (called judham in Arabic). In this study, he linked each of the four categories of elephantiasis to one of the four humors where the corruption had first begun in the body.78 According to al-Jazzār’s system, which other Arab physicians in Spain adopted, if the process of corruption began with black bile (Paul of Aegina’s less serious form of leprosy), al-Jazzār called it elephantine judham. If the corruption began with yellow bile (Paul’s lepromatous leprosy), al-Jazzār identified it as leonine judham. If the disease originated in corrupted phlegm, he named this type tyrian judham. Finally, if the blood itself first experienced the corruption, the physician from North Africa used the term alopecian judham. Arab medicine thus evolved a complex system of classification based on all four Galenic humors.79 Modern clinical medicine has established two basic forms of leprosy— the severe lepromatous form and the milder tuberculoid form—a system resembling the distinctions made by Paul of Aegina. Modern researchers, however, have also found gradations of severity between tuberculoid and lepromatous Hansen’s disease. Perhaps the Arabic system of four types of leprosy was trying to reflect these subtle gradations of the disease.80 In the eleventh century, Constantine the African used al-Jazzār’s treatise on judham in preparing the second book of his medical manual called the Pantegni, basically a translation into Latin of Haly Abbas’s ninth-century medical manual with additions from the works of al-Jazzār. Into his Pantegni, therefore, Constantine incorporated al-Jazzār’s division of leprosy into

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four types based on the four humors. Constantine’s section on leprosy was in such demand that he reissued it as an independent tract that he named De elephancia. Through the Pantegni, but especially through his separate treatise De elephancia, Constantine introduced the four types of leprosy, first into the teaching program at Salerno and subsequently into the essays of physicians throughout the Latin West. By the thirteenth century, the Italian Dominican priest and physician Theodoric of Cervia (also known as Teodorico dei Borgognoni) incorporated the four types of leprosy into his widely read manual on medical science and surgery.81 In commenting on the medieval system of categorizing types of leprosy, Françoise Beriac observed that this system, articulated by the Arabs and adopted by Latin physicians, did not distinguish the four forms of Elephant Disease according to severity. Beriac maintained that all of these categories simply applied to various manifestations of lepromatous leprosy and left the tuberculoid symptoms of modern Hansen’s disease to be classified as other less severe skin ailments.82 Paul of Aegina, however, obviously recognized a more serious form of leprosy and a much less dangerous category of the same disease. Because of this distinction, based on severity, not on humors, it appears that Byzantine doctors correctly identified the relationship between lepromatous and tuberculoid forms of leprosy, whereas classical Greek physicians, Arab medical experts, and Western medieval doctors failed to make this distinction.

Byzantine Medicine and Leprosariums Did the scientific opinions of Byzantine physicians, discussed earlier, influence the organization and treatment programs employed in the leprosariums of the empire? What evidence suggests that those in charge of leper asylums followed accepted medical opinions in both organizing leprosariums and in providing treatment? Unfortunately, we have little information concerning what kind of therapies Byzantine leper hospitals offered their patients. No detailed descriptions or official regulations have survived that outline the daily routines of leprosariums. We also have no list of food supplies or medicines ordered by administrators, and no descriptions of how the facilities were constructed.

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In their sermons urging Christians to assist victims of leprosy, Gregory of Nyssa and Gregory of Nazianzos suggested that physicians did, indeed, work in leprosariums. Both of these bishops referred to doctors and their assistants who spent their whole lives treating lepers but managed to avoid catching the disease. The most likely context for such continuous service on behalf of lepers would have been working in the leprosariums of Cappadocia, such as the one Basil was constructing near Caesarea at the very time the two Gregorys delivered these orations.83 With regard to the Zotikos Leprosarium of Constantinople, we have a direct statement that medical science had helped shape the treatment program. The anonymous author of an eleventh-century version of the Zotikos legend explained that the emperors had supplied the institution with various palliative medicines “through the hands of the physicians.” In other words, emperors at some point prior to the reign of Michael IV (1034– 41) had provided medicines that professional medical men had recommended for treating the sores that plagued the victims of Elephant Disease.84 The most obvious way that leprosariums followed medical advice was in building asylums near a supply of fresh water, either rivers or springs. Galen, Aretaios, and Paul of Aegina all prescribed frequent baths as the most effective treatment for leprosy. Paul of Aegina recommended: Let patients be anointed in the bath with salves from a decoction of beets or fenugreek together with sodium carbonate or soap or myrobalum and sometimes with depilatories.

Theophanes Chrysobalantes repeated Paul’s bath therapy word for word, but he mentioned only sodium carbonate as a cleanser and omitted soap or myrobalum.85 Following such medical advice, circa 400, John Chrysostom sought out a place to build his new leprosarium near Constantinople. Chrysostom was searching for a place with an exposure to healthful breezes and in close proximity to a river where the lepers could frequently bathe to alleviate the discomfort caused by their oozing sores.86 Located in Pera, the Zotikos Leprosarium also had a convenient source of fresh water. According to the Zotikos legend, Emperor Constantius himself had tortured the saint so severely that the man’s right eye had been knocked out of its socket. Where it fell to the ground, a healing spring of water rushed forth. As the Zotikos

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Leprosarium was expanded first by Constantius and then by many subsequent emperors, the complex of buildings always included this spring within the boundaries of the institution.87 An eleventh-century miracle tale about a eunuch named John proves that this spring of Zotikos played an important part in the treatment of leper residents. When John had discovered that he had Elephant Disease, he entered the Zotikos Leprosarium. As a resident, he was able to bathe at the spring frequently and also sipped oil from the lamp burning by the side of the founder’s tomb. As a result of these actions, John eventually experienced a miraculous healing through the intercession of Saint Zotikos. It is important to notice that by the eleventh century a bathing facility had been constructed at the site of the spring.88 Other passages provide additional information concerning the nature of the baths at the Zotikos Leprosarium. When Emperor Michael IV (1034– 41) made his visits to the institution, he assisted the lepers in bathing. In describing Michael’s service, one version of the Zotikos legend indicates that the pool at the spring was large enough for the emperor to enter the water, along with several leper patients. Michael helped the patients wash and then assisted them in climbing out of the pool and escorted them back to their beds. From this account, we learn that the leper bath included a pool large enough for several people to enter at the same time, that is, a bath similar to bathing facilities in ancient Greco-Roman cities.89 The bath at the Zotikos Leprosarium had not taken on the form of some medieval bathing facilities that no longer had an open pool but only a steam room with individual basins where patrons washed in private alcoves.90 Leo the Deacon described how Emperor John I Tzimiskes (961–76) frequently visited the lepers at the Zotikos. He not only distributed gold coins to them, but he also treated them personally with whatever medicines were suitable—probably the unguents composed of beets and fenugreek recommended by Theophanes Chrysobalantes.91 One of the most detailed descriptions of Byzantine leprosariums comes from fourteenth-century Serbia. By that time the Serbs had won their political independence from the Byzantine Empire, but their religious institutions stood firmly within the thousand-year tradition of the Byzantine church. Thus when King Stephen Uroŝ III (1321–31) built his famous monastery of Dečani, he followed Byzantine precedents. As part of this monastic complex, but outside the monastery’s walls, King Stephen built a leprosarium

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with everything necessary for the comfort of the lepers. He provided them fragrant unguents “to cool the fire of the disease,” as Stephen’s biographer described the medicines’ effects. In addition to these unguents, King Stephen also supplied the lepers with special garments made of silk that would feel comfortable against their skin. This is the only reference in Byzantine sources to special clothing for lepers in general or for patients at leper asylums in particular.92 Among Greek and Byzantine medical texts, we have located only one passage that referred to clothing as part of a palliative therapeutic regime for victims of Elephant Disease. Aretaios of Cappadocia maintained that lepers should have their clothes frequently cleaned in order to reduce skin irritation and itching.93 Paul of Aegina also mentioned that soft cloths should be used to rub down leprosy patients after they had taken their baths and used the medicinal unguents.94 In the spirit of these observations, subsequent Byzantine physicians may well have suggested silk garments for patients because of this material’s soft surface, but so far we have not managed to uncover any specific medical text that made such a recommendation. Providing silk garments for patients at the Dečani Leprosarium raises the wider issue of whether or not lepers in asylums had to wear distinctive uniforms. Except for this reference in the biography of Saint Stephen, no evidence has come to light that residents at the Zotikos Leprosarium or in any other leprosarium wore any sort of clothing that would mark them as lepers. Although we have found no references to leper uniforms in Byzantine sources, it is indeed possible that leprosarium residents did wear special clothing. We know from many sources describing institutions in the Latin Christian world that leprosariums required patients to put on uniforms. These Western uniforms were modeled on monastic habits. At the leper hospital of Saint Michael in Whitby, England, the sick received old Cistercian habits to wear. Often such habits were entrusted to the lepers by the local bishop, just as was done in the case of monks in a monastery.95 In addition to these few references in the sources to treatment procedures in Byantine leper hospitals, we have some evidence that medical classifications of diseases influenced the organization of leprosariums. Writing while still a presbyter at Antioch (i.e., before 395), John Chrysostom described those patients who lived at the leprosarium located beyond the walls of the Syrian capital. Chrysostom mentioned that the male patients were consumed by elephantiasis, but he referred to the women as eaten up by cancer. In this

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passage, Chrysostom maintained that leprosy and cancer were two different illnesses, but similar in that physicians could cure neither condition.96 The founders of this charitable institution at Antioch were apparently following medical opinion by placing both cancer patients and leprosy victims in the same facility for those with incurable illnesses. Most likely the same leprosarium administrators also believed that both diseases derived from a similar condition of corrupt black bile, as many medical experts asserted. Because so little information survives about the details of medical treatment at leprosariums, we cannot ascertain whether or not leper hospitals provided viper flesh for their patients—a remedy strongly recommended by Galen, Aretaios, and Paul of Aegina. We also have no idea whether medical workers at leprosariums frequently performed phlebotomies on patients, although Greek physicians repeatedly advised frequent bloodletting as the first step in eliminating an excess of black bile from the bloodstream. While medieval sources say little about therapeutic treatment at leprosariums, they agree that one key doctrine of Greek medicine not only helped shape the nature of Byzantine leper asylums but contributed to the initial impulse to establish such institutions. Despite Gregory of Nyssa’s assertions to the contrary, professional medical opinion from the fourth to the seventh centuries considered leprosy highly contagious. This scientific doctrine reinforced popular fears of contagion that had led to the persecution of lepers, persecution that both Gregory of Nyssa and Gregory of Nazianzos had depicted so vividly in their sermons. One immediate way to assist those who suffered from leprosy and at the same time respect society’s concerns about the contagious nature of the disease was to build special facilities for its victims. In the next chapter we will examine how Christian leaders first established leprosariums and how these charitable institutions evolved within the context of other Christian philanthropic programs in the territories ruled by the government of Constantinople.

Chapter 4

Byzantine Leprosariums

The East Roman Empire first opened leprosariums during the fourth century when Church leaders perceived an increase in the number of those with elephantiasis.1 From 400 to 1300, specialized institutions continued to care for lepers within Byzantine territory. During the fourteenth and fifteenth centuries, however, no texts describe functioning leprosariums, but as we shall see, that does not mean that they ceased to exist, especially in view of the leper hospital founded by King Stephen Uroš III at the Dečani Monastery in Serbia. In this chapter we examine the origins of these leprosariums. We focus on when they first appeared and on their connection to other philanthropic institutions, especially hospitals for treating patients with curable diseases, a classification that excluded leprosy. A close study of the relationship between leprosariums and hospitals for treatable ailments will provide some new insights into the development of Byzantine philanthropic institutions in general and on the origins of medical hospitals in particular. In addition, a careful study of Byzantine leper asylums will aid in answering some of the puzzling issues surrounding the sudden appearance of

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both leprosariums and general hospitals in Western Europe following the First Crusade. Some medievalists have seen the founding of leprosariums in Italy, France, and the other regions of Catholic Europe during the twelfth and thirteenth centuries as evidence of a leprosy epidemic that struck these countries as Crusaders brought the disease back with them from Palestine to their homelands. Other scholars, however, have rejected the idea that the founding of leprosariums indicates an increase in cases of Elephant Disease. Rather, they maintain that the rapid growth in the number of leprosariums in Western Europe was linked to an increasing desire to found hospitals for the poor and sick in general, that is, a new enthusiasm to support a wide range of charitable institutions.2 As we emphasized in the introduction, none of the many recent studies on leprosy, leprosariums, and hospitals in Western Europe has carefully considered the evidence from Byzantium. This seems especially myopic when one considers that the warriors of the First Crusade marched through the Byzantine heartland and seized lands in Syria and Palestine, including Jerusalem, where previous generations of Christians, following Byzantine traditions, had been maintaining leper hospitals for centuries. We also examine how Byzantium financed leprosariums. As in the case of general hospitals for the sick, the East Roman emperors, local bishops, monastic leaders, and wealthy laymen all contributed resources to sustain the activities of leper asylums.3 Leprosariums however, also developed sources of financial support that other types of philanthropic institutions never used. Finally, we study some of the motives for establishing leprosariums, and in doing so, we return to the revolutionary ideas of the Greek fathers that helped shape new attitudes toward victims of elephantiasis. Their words and actions challenged accepted notions of classical civilization and also forced Christians, after three hundred years of silence, to address the problem of Elephant Disease and its victims.

Asia Minor and Constantinople The first leprosarium mentioned in Byzantine sources was located at Sebasteia in central Asia Minor. Writing about 400, Epiphanios of Cyprus referred to it in his history of Christian heresies. According to Epiphanios,

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this leprosarium had opened sometime before the monastic leader Eustathios ascended the episcopal throne of Sebasteia in 357. At that time Eustathios ordained one of his ascetic disciples as a priest of the city and placed him in charge of his leper asylum—Eustathios called this institution a “ptochotropheion” (literally, a shelter for the poor). Despite this name, it served as a refuge for those crippled by leprosy or by other chronic diseases.4 Before becoming bishop of Sebasteia, Eustathios had promoted a form of monasticism that historians have identified as urban asceticism. These monks did not flee the Greco-Roman polis to live in the deserts of Egypt or in the rugged hills of Palestine, or even the remote regions of Asia Minor. Rather, they organized their communities in or near cities where they served the poor (ptochoi, in Greek).5 Historians are certain that this same urban monastic movement, centered around the teaching of Eustathios, inspired the form of asceticism promoted by Basil, the famous bishop of Caesarea.6 Thus it comes as no surprise that when the Christians of Caesarea elected Basil as their new bishop in 371 he began building a charitable facility outside his city, modeled on the institution of Sebasteia. Basil himself referred to his charitable institution as a “ptochotropheion,” a word that Eustathios had popularized throughout Asia Minor.7 In other eastern provinces, however, Christians had been using the words “xenodocheion” and “xenon” for charitable institutions.8 That Basil chose to call his leper asylum a “ptochotropheion” strengthens the argument that it was modeled after Eustathios’s institution. Gregory of Nazianzos has left us a lengthy description of Basil’s ptochotropheion in his funeral oration for his close friend. First, Gregory indicated its large size by calling it a new city and comparing it to the seven wonders of the ancient world. Second, he described the patients at the institution as being dead before their death, as having died in most of their limbs; as driven from cities, homes, markets, sources of water; as known only by their names, not their appearance.9 Gregory had used these same rhetorical expressions to describe the victims of Elephant Disease in the vivid prose of his Oration XIV.10 Gregory left no doubt that Basil’s ptochotropheion was designed to assist lepers. How many other bishops in Asia Minor had opened such leprosariums? In describing Eustathios’s leper asylum, Epiphanios stated that other bishops of northern Asia Minor supported similar institutions, also called “ptochotropheia.”11 Moreover, in their sermons promoting charity toward lepers,

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both Gregory of Nazianzos and Gregory of Nyssa mentioned physicians, physicians’ assistants, and other caretakers who constantly worked with lepers but never contracted the disease.12 In both their speeches, the Gregorys also stressed that the traditional Greek city-states had rejected lepers, even if they came from powerful families. Mothers, fathers, brothers, and friends also drove them away from home because of the fear of contagion. The only places where lepers could have enjoyed the attention of physicians and other charitable workers would have been in the ptochotropheia sponsored by the bishops of Asia Minor. Thus both Gregorys provide additional evidence that ptochotropheia for lepers were becoming relatively common in Asia Minor. Writing in the sixth century, Procopius, the historian of the emperor Justinian’s reign, described another leprosarium, located on the Asiatic shore of the Bosporos, where the waters of the Black Sea enter the straits. In cataloging the many building projects of Justinian (527– 65), Procopius included this leprosarium and its church dedicated to the doctor saint Panteleemon. According to Procopius’s account, however, Justinian did not establish a new leper asylum in this location; rather, he restored the old one that had been neglected for many years.13 Procopius described this leper asylum as “a refuge (katagogion in Greek) from ancient times for those poor who had been incurably disfigured by leprosy.” He avoided using the word “ptochotropheion” because no classical author had employed this technical term. Nevertheless, it is probable that we have here another example of a fourth-century leprosarium, one of the ptochotropheia supported by bishops in Asia Minor. The most significant leprosarium of the fourth century—and as we saw in chapter 2 the empire’s central facility for victims of Elephant Disease— was the asylum located outside of Constantinople. A careful examination of its early history will show that it too first opened its doors to victims of leprosy in the mid-fourth century and was associated with the urban monastic movement, which had inspired Eustathios’s ptochotropheion at Sebasteia and Basil’s leprosarium at Caesarea. Traditions concerning the founding of this leprosarium have been handed down to us through three versions of the Zotikos legend, which we discussed in chapter 2.14 It is important to note that the Zotikos legend does indeed contain fictitious elements such as the bizarre story of Zotikos’s execution by Emperor Constantius who supposedly ordered a team of horses

3. The martyrdom of St. Zotikos, as depicted by an eleventh-century anonymous artist. Zotikos founded both an orphanage within the walls of Constantinople and a leprosarium on the north side of the Golden Horn. According to legend, Zotikos was killed by the heretical emperor Constantius II, who ordered a team of mules to drag the saint up and down the hillside of Pera. (Walters Art Museum. Acquired by Henry Walters, 1930)

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[mules?] to drag the saint up and down the hillside of Pera. There are good reasons, however, to believe that the Zotikos legend correctly identified where Zotikos built his leprosarium—on a hill called “Elaiones” (The Olives) in Pera across the Golden Horn from Constantinople—and when he opened it— during the reign of Emperor Constantius II (337– 61).15 Many sources from various periods of the empire’s history confirm the location of the Zotikos Leprosarium in Pera as all versions of the Zotikos legend maintain.16 Reliable legal sources from the fifth century also indicate that Zotikos did indeed work in Constantinople when Constantius was emperor. A law issued by Emperor Leo I in 472 stated that Zotikos had lived and died in the capital many years earlier. This same law emphasized that Zotikos was especially famous in Constantinople for having established the city’s orphanage rather than for founding the leprosarium.17 After Zotikos’s death the two philanthropic institutions—the leprosarium in Pera and the Orphanotropheion within the walls of Constantinople—were always administered together by one official called the “orphanotrophos” (the guardian of orphans). In fact, administrative tradition in Constantinople considered Zotikos to have been the first orphanotrophos of the city and thus the supervisor of the city’s orphanage, the Zotikos Leprosarium, and several other charitable facilities.18 One version of the Zotikos legend stressed that the saint had lived a monastic life in Constantinople. He had practiced celibacy, humility, and personal poverty, not in the desert or the mountain wildernesses but in the heart of the capital, where he devoted his energies to serving the poor.19 These attributes of Zotikos’s life fit exactly the monastic lifestyle promoted by Eustathios at Sebasteia. In fact, Eustathios had visited Constantinople in the 350s before he became bishop of Sebasteia in 357, that is, during the reign of Emperor Constantius II. Eustathios had introduced to the capital his form of urban monasticism dedicated to assisting the poor and the sick. Eustathios had trained a devoted disciple, the deacon Marathonios, who then organized small monastic communities in Constantinople and also allied with Makedonios, at that time bishop of the city. Careful consideration of the evidence reveals that Zotikos became an ascetic follower of both Eustathios and Marathonios.20 First, one version of the Zotikos legend as well as the fifth-century historian Socrates identified the Zotikos Leprosarium as a ptochotropheion.21 Zotikos selected the same term for his leper asylum as had Eustathios in

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Sebasteia and Basil in Caesarea. Second, Zotikos served the Church of Constantinople when several Arian bishops controlled the city—first, Makedonios (342– 48 and 350– 60), then Eudoxios (360– 69), and finally Demophilos (369– 80). These bishops were later labeled Arians by orthodox Christians because all three rejected the Nicaean Creed, which had been drafted by the Council of Nicaea in 325. If Zotikos himself was closely associated with the Arian movement in Constantinople, this would also strengthen the evidence linking him to Eustathios of Sebasteia. Despite Eustathios’s influence on Basil of Caesarea with regard to ascetic discipline, the bishop of Sebasteia always held an Arian view concerning the relationship of the Logos (God the Son) to the Father, a relationship defined by the Council of Nicaea.22 The strongest evidence that Zotikos belonged to the Arian Christian communion in Constantinople is provided by his burial site located at his leprosarium in Pera. We know from Emperor Leo’s legislation of 472 and from other administrative sources that Zotikos had won a high place in the Church of Constantinople and in the city administration because he had established the Orphanotropheion. Zotikos, however, was not buried at his orphanage but outside the city at his leprosarium. In 380, Emperor Theodosius, a staunch supporter of the Council of Nicaea and an opponent of all forms of Arianism, expelled Arian Christians and their clergy from Constantinople, but he allowed them to retain control of Christian sanctuaries outside the walls of the city.23 Since Zotikos’s leprosarium was located beyond the walls, he either left the city himself to live and die at his leper asylum, or, if he were already dead by 380, his fellow Arians, probably urban monks, translated his relics to the leprosarium that Arians still controlled.24 We know that after their expulsion from Constantinople, Arian communities continued to conduct elaborate liturgies on Sundays and especially during great Christian feasts to attract residents from within the city to worship with them. When he became bishop of the capital in 398, the staunch Nicaean John Chrysostom was upset that Arians were still using religious processions within the city to lead people to their sanctuaries beyond the walls to celebrate the major feasts of the Church.25 The Zotikos Leprosarium was well known in Constantinople as the place where the Arians commemorated the Ascension of the Lord. As late as 428, citizens of the capital were accustomed to cross the Golden Horn on Ascension Day to mark the feast at the leper asylum in Pera.26

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We should note one additional piece of evidence in support of Zotikos’s Arian associations. In his Novel 43, issued in 537, Emperor Justinian reformed a system of revenues to provide free funerals for citizens of Constantinople. The preface to this law frankly admitted that heretical groups had established many of Constantinople’s philanthropic institutions.27 Justinian was probably referring here to the Orphanotropheion and the leprosarium founded by Zotikos and to the famous hospital next to Hagia Sophia, established by another Arian, the physician Sampson, whose tomb was also located outside the fourth-century walls of the city.28 Zotikos himself was likely not a man interested in the subtleties of theological definitions—whether God the Father and the Logos (God the Son) were of the same substance as the Nicaean Creed stated, or of similar substance as moderate Arians such as Eustathios of Sebasteia, Deacon Marathonios, and Bishop Makedonios held. Rather, Zotikos had devoted himself to philanthropia—first to organizing the Orphanotropheion and then to building his shelter for lepers. Because of his love of the poor, the Church of Constantinople continued to honor him as a saint despite his association with Arianism. Even Gregory of Nazianzos, a faithful supporter of the Nicaean Creed, defended Arian urban monks such as Zotikos and the physician Sampson because of their kindness to those in need.29

Antioch and Chrysostom As a priest at Antioch from 386 to 398, John Chrysostom had occasion to describe a leprosarium in the Syrian metropolis. In an essay to a spiritually discouraged friend named Stagirios, Chrysostom recommended that his friend contemplate the sufferings of others in order to overcome his own emotional depression. He should visit the prisons and also the portals of the city’s bathhouses where the half-naked and starving poor gathered to beg. In addition to these places, Chrysostom recommended that Stagirios visit two philanthropic institutions. He should first enter the city’s hospice or hospital (in Greek, xenon) and contemplate the patients there who were suffering from every sort of disease. As Chrysostom wrote, “You can see the roots of bodily diseases and the strange forms of illnesses.” Then Chrysostom recommended that Stagirios go beyond the city gates to the refuge (in

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Greek, katagogion) for the men who suffered from leprosy and the women oppressed by cancer.30 Chrysostom’s words confirm what we have already seen at Caesarea and Constantinople, that is, that the leprosarium lay just outside the city’s circuit of walls. Church leaders obviously placed these leprosariums there because of the fear of contagion on the part of the population and also to remove victims of Elephant Disease and cancer from public view, although no source explicitly mentioned these reasons. Chrysostom also distinguished clearly the leprosarium from the city’s xenon. The leprosarium received patients who suffered from leprosy and cancer, two diseases that, according to some medical experts, took their origins from an excess of black bile in the veins. As we saw in the previous chapter, Galen and Paul of Aegina agreed that these diseases were incurable after their initial stages. Thus this refuge outside of Antioch accepted lepers and victims of cancer to care for these unfortunate people until their deaths, not to cure them. The xenon, however, received patients with many different diseases. We should consider Chrysostom’s account of this xenon together with an extended metaphor composed by Neilos of Ankyra, no more than twenty years after Chrysostom wrote his essay for Stagerios. In this metaphor, Neilos described a Christian hospital that resembled the xenon at Antioch. According to Neilos, men have many sins hidden deep within them. Christ, the physician of human souls, knows how to examine the secret places of the human spirit. Neilos continues: Many are the sick and paralyzed people in the hospital (nosokomeion) of this present age. The same medicine does not fit them all, nor is the same diet right for all. The physician assigns the medicines and diet appropriate to each patient. The physician says, “Let one sick person be comforted often with honey. Let another be pulled together by the bitterness of absinthe. Let another partake of the discomfort of hellebore (a famous purgative).”31

By the time Neilos wrote these words, Christian hospitals where physicians examined patients with different diseases and ordered appropriate treatments to cure the various ailments had become so common that they could serve as an image to illustrate Christ’s care of each sinful soul who sought his help in the hospital of the world.

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Let us return to Chrysostom’s xenon at Antioch. Although he mentioned no physicians at this charitable facility, he described patients with many different diseases with diverse root causes (humoreal imbalances). Some of these cases could be cured; others could not. Neilos’s image suggests that physicians began working in these institutions to distinguish who could be cured and by what means such cures could be obtained. In 398, Chrysostom left Antioch to become bishop of Constantinople. As soon as he arrived, he assigned for charitable purposes funds that his predecessor, Bishop Nektarios, had used for personal expenses at the episcopal palace. With this money, Chrysostom expanded an existing hospital and also established several new ones. In addition, he hired physicians, cooks, and servants to assist the patients in these institutions.32 Chrysostom, however, was not satisfied with these hospitals, since they focused on curing patients, not on long-term care for victims of Elephant Disease. He especially desired to assist the many lepers whom he saw abandoned along the roads of Bithynia. As we have seen, Chrysostom decided to build a leprosarium across the Bosporos, an institution distinct from his hospitals for people with treatable diseases.33 Why would Chrysostom want to build a new asylum for lepers if the Zotikos Leprosarium was already assisting the victims of Elephant Disease? The answer, of course, was that an Arian community still controlled the Zotikos Leprosarium where they were holding elaborate liturgical celebrations on high feast days. Chrysostom sought to build a new leper hospital under the patronage of the Nicaean (or Orthodox) community of Constantinople.34

Egypt One would expect that the earliest references to Byzantine leprosariums would have come from Egypt, where elephantiasis first appeared in the Mediterranean basin. Egyptian sources, however, do not describe a leprosarium there until circa 400, some fifty years after Sebasteia had its ptochotropheion. In his history of Egyptian monks, written in the early fifth century, Palladius told the story of a wealthy widow in Alexandria whom the priest Makarios tricked into donating 500 denarii (gold solidi?) to the hospice for lepers he supervised. Eventually, Makarios invited the widow to see the

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leprosarium. The male lepers lived on the first floor and the women on the second floor. We find the same arrangement to separate the sexes in some of the better-documented leprosariums of the medieval West.35 A story about the monk Pâmbo, also dating to circa 400, mentions a large leprosarium at Alexandria that by this time received more than sufficient shipments of grain from the state-controlled wheat supply (what was called the “annona”). This leper hospital had so much grain that Pâmbo took some of it to redistribute to the rural poor. According to the same story, Pâmbo also established a tradition of collecting one arataba of wheat from each of the monks and hermits of Egypt to give to the many hospices for lepers throughout the land as well as to widows and orphans. From the Pâmbo story we can see that by 400 there not only existed a leper asylum in Alexandria but a whole network of such institutions throughout Egypt. Moreover, Pâmbo placed the support of leprosariums on an equal footing with the traditional Judeo-Christian obligation to give generously to widows and orphans.36 Obviously these Egyptian leprosariums had existed for some time, but when had they first been established? We suggest that the Arian leader George of Cappadocia introduced these institutions into Egypt during his tenure as bishop of Alexandria from 356 to 361. Before he became bishop of Alexandria, George had served as a treasury official in Constantinople. There he would have become familiar with the system of free burials provided by the imperial government for citizens of the capital since the reign of Emperor Constantine.37 According to Epiphanios of Cyprus, when George of Cappadocia became bishop of Alexandria, he initiated a number of new philanthropic programs, one of which was a system to provide free Christian burials for the people of the Egyptian metropolis.38 In introducing this burial program in Alexandria, George followed closely what Constantine had established in Constantinople. According to Constantine’s plan, 950 shops in the capital received a tax immunity in return for which these same shops had to supply workers to serve as lektarioi, persons who carried caskets and dug graves. The bishop (patriarch) of Constantinople administered the entire program.39 In his brief historical account, Epiphanios of Cyprus did not provide many details concerning George’s funeral system for Alexandria, but in 416 and 418 imperial laws added valuable information. These laws regulated workers called “parabalani” who were recruited from the city’s guilds (shops) and

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placed under the control of the city’s bishop, as were the lektarioi in Constantinople.40 Moreover, parabalani are mentioned together with lektarioi in an Egyptian papyrus document listing minor ecclesiastical officials.41 We maintain that these parabalani and lektarioi formed a contingent of pallbearers and grave diggers in Alexandria on the model of those in Consantinople, and that George of Cappadocia first established this burial system in Egypt, as Epiphanios has testified. The imperial law of 418 regulating these parabalani, however, did not specifically mention their obligation to bury the dead. Rather, it described their work as caring for the sick. A later commentator on this law, renowned for his accuracy, stated explicitly that these parabalani were to assist the city’s lepers.42 If, as we have suggested, George of Cappadocia established the parabalani as part of his philanthropic burial service, and if their duties included assisting victims of Elephant Disease as the imperial legislation of 418 implies, then it would seem that George of Cappadocia also established institutions in Alexandria to which the parabalani could bring the lepers for palliative care. That the duties of parabalani included both burying the dead and assisting lepers whom they found on the streets can be explained in part by the vivid image of lepers as “walking corpses.” During the fifth and sixth centuries, Egypt continued to maintain leprosariums. One papyrus document from the city of Hermopolis, drawn up on the eve of the Arab invasion, listed seven hospitals in the city’s territory; two of these, or 28 percent of the total, were leprosariums. Unfortunately this document—a list of tax-paying landholders of the city—is not complete. Several other papyrus documents of the sixth and early seventh centuries also mention leper asylums in Egyptian cites.43

Syria and Palestine As we have seen, the Syrian capital of Antioch had a leprosarium when Chrysostom served that church as a priest from 386 to 398. When Rabbula became bishop of Edessa in 411, however, that important city—a center with a much stronger Syrian ethnic component than Antioch—still had no facilities for victims of Elephant Disease. The biography of Rabbula described the lepers as people detested by the local population and forced to live outside the walls of the town with no assistance. Rabbula appointed a deacon

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and several reliable brethren (most likely ascetics) to live with the lepers and provide food for them at the expense of the episcopal church.44 This leper colony, however, still did not have any permanent structures. Bishop Nonnos (457–71) constructed a hospital building (nosokomeion) for the sick at this settlement and built a church for them dedicated to the healing saints Kosmas and Damian.45 Further south in Palestine, the first leprosariums were associated with the empress Eudocia. Several contemporary sources describe Eudocia, the dynamic wife of Theodosios II (410–50), as founding many of the philanthropic institutions in and around Jerusalem after she moved there permanently in 441.46 One of these institutions was a large leprosarium just outside the northern wall of the Holy City.47 According to the chronicler Nikephoros Kallistos Xanthopoulos, Eudocia’s leprosarium housed four hundred victims of Elephant Disease. Xanthopoulos has provided the only surviving reference to the number of patients at a Byzantine leprosarium.48 Unfortunately, he did not write in the fifth century, but almost one thousand years later, circa 1300. Nikephoros, however, worked in the patriarchal archives in Constantinople and may have found this reference to four hundred lepers in a primary source that has since disappeared.49 In support of Xanthopoulos’s figure of four hundred lepers, one should consider the testimony of a reliable source of the sixth century concerning a contemporary hospital built by Emperor Justinian in Jerusalem. According to this Vita of Saint Sabas, Justinian constructed a nosokomeion with two hundred patient beds. Given that Byzantine hospitals maintained large staffs of physicians and trained medical assistants, the expenses of a two-hundredbed hospital were comparable to those of a leprosarium for four hundred persons where the staff provided only palliative care, not intensive therapies such as surgery.50 Saint Theodosios, the Cenobiarch, perhaps the most famous monastic leader of fifth-century Palestine, built a leprosarium next to his ascetic community near Jerusalem. Theodosios came to Palestine from a village near Caesarea in Cappadocia and probably patterned his monastery and its adjoining philanthropic institutions on Basil’s ptochotropheion.51 The biography of Saint Euthymios mentions a group of people called Lazariotai who worked in fifth-century Jerusalem. According to this source, these Lazariotai found a monk in the desert dying from the bite of a viper

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and carried him back to a hospital in Jerusalem for treatment.52 The name “Lazariotai” implies that these people were also responsible for rescuing victims of leprosy who were left along the roads of Palestine. After 350, Christian writers and orators assumed that the poor man Lazarus in Luke’s Gospel had suffered from Elephant Disease.53 Perhaps these Lazariotai performed services similar to those of the parabalani in Alexandria who cared for both the dead and the walking corpses, the victims of Elephant Disease. By the sixth century leprosariums had become common in Palestine. A wealthy layman of that time wrote a letter to Barsanouphios and John, two monastic sages living in an ascetic community near Gaza. He asked the monks whether or not he had a moral obligation to provide home care for a slave of his who had contracted leprosy. The monks maintained that the wealthy man did not have such a moral responsibility, since home care might pose difficulties for other members of the household. The monks counseled instead that this landowner should place the leprous slave in a leprosarium and provide for his food, clothing, and bedding.54 This letter shows, first, that Palestine now had leprosariums throughout the territory, since Barsanouphios and John did not even consider the possibility that the letter writer might not live close to a leper asylum. Second, it demonstrates clearly that the campaign of the Cappadocian fathers had not been completely successful in convincing people to accept lepers without fear or loathing. The letter also reveals, however, that leprosariums offered conscientious Christians the opportunity to avoid direct contact with leprous members of their household but would still provide them shelter nearby in a Christian leper hospital.

After the Arab Invasion As we explained in chapter 2, despite the huge losses in territory and population that the Byzantine Empire suffered following the Arab invasion of 634, the government and church of Constantinople continued to maintain the Zotikos Leprosarium across the Golden Horn from the capital city. The number of leprosariums in provincial cities, however, seems to have dropped significantly. From the seventh to the thirteenth centuries, surviving sources mention only two leper asylums outside of Constantinople.

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Shortly before 806, Theophylakt became bishop of Nikomedeia in Bithynia, where he soon opened a hospital. For this institution he built an impressive two-story building and a church dedicated to Saints Kosmas and Damian. Moreover, he hired physicians to treat patients there. This hospital, however, also included a section for those suffering from elephantiasis. Theophylakt’s biographer described how the bishop visited some patients at this hospital every Friday, washed them in the bath, and anointed their sores—a treatment procedure that we have seen was recommended for patients with leprosy. He bequeathed this tradition of visiting the lepers to those who succeeded him as bishop of Nikomedeia.55 The second provincial leprosarium was described by Theodore Metochites in his speech praising the city of Nicaea in the late thirteenth century. At that time, however, Nicaea was an exceptional provincial town because it was serving as the emperor’s capital after the conquest of Constantinople by the soldiers of the Fourth Crusade. In fact, Metochites emphasized that the emperors played a major role in financing this leper asylum as well as two other charitable facilities. Metochites identified three separate philanthropic institutions in Nicaea: a hospital staffed by physicians, a hostel for the homeless poor, both from the city and from outside of it, and a leprosarium designed for victims of Elephant Disease, people who had lost all hope of living. After Emperor Michael VIII recaptured Constantinople in 1261 and relocated the seat of government to the ancient capital, the leprosarium at Nicaea continued to function, at least until Metochites composed this tract in praise of this city, circa 1290, and perhaps until the Turkish conquest of the town in 1331.56 Although Byzantine sources only twice refer to provincial leprosariums, it is likely that many small leper hospitals existed outside of Constantinople. Byzantine writers rarely used lobotropheion, the technical term for a leprosarium. As we have seen, the bishops of fourth-century Asia Minor referred to the first leprosariums as “ptochotropheia.”57 Moreover, sources describing the Zotikos Leprosarium of Constantinople usually employed the term ptochotropheion, or its variant, ptocheion, for this famous institution overlooking the Golden Horn. Only once does a surviving source call it a “lobotropheion,” in a passage where the twelfth-century chronicler George Kedrenos described how Emperor Romanos III made repairs to the Zotikos Leprosarium after an earthquake had damaged it.58

4. Lead seal of the Monastery of St. Zotikos, twelfth century. Obverse: St. Zotikos standing to front with hands held in supplication. Reverse: Inscription in Greek reading “Seal of the brothers of St. Zotikos.” (© Dumbarton Oaks, Byzantine Collection, Washington, D.C.)

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This same writer, George Kedrenos, also used the term gerokomeion (old-age home) in an earlier passage referring to the Zotikos leper hospital. In recounting how Emperor Maurice rebuilt the Zotikos Leprosarium following an attack by Slavic tribes in 596, Kedrenos stated: (Maurikios) built the gerokomeion of the lepers in a place called Erion, [an institution] which is called the residence of Zotikos, because, being made of wood, it had been burned down by the Sklavenoi. Maurice supplied the institution with many things for the care of the leprous brothers.59

We do not know whether Kedrenos himself or the source he was copying originally selected the term gerokomeion for the Zotikos Leprosarium. This passage, however, demonstrates that a leprosarium also could be called a “gerokomeion.” What, precisely, did gerokomeion mean? From the Greek roots geron (old) and komizo (care for; supply), we can see that the word strictly applied to a home for old people, too weak or confused to care for themselves. Byzantine sources, however, show that gerokomeion had a much wider application. In a law issued in 964, Emperor Nikephoros II classified all of the empire’s philanthropic institutions as either xenones or gerokomeia.60 We know from many other sources that a xenon (also called a “nosokomeion”) was an institution that aimed to cure patients. In fact, one tenth-century source referred to physicians at the Euboulos Xenon in Constantinople who removed a patient from the hospital when they determined that he could not be cured by medical therapies.61 A gerokomeion, on the other hand, was an institution for patients with chronic conditions, including old age. The famous twelfth-century author Theodore Prodromos received medical treatment in a xenon, but when his physicians determined that hospital therapies could not cure him, Prodromos retired to a gerokomeion “not because of old age, but because of his chronic illness.”62 So, too, the twelfth-century gerokomeion founded by Isaak Komnenos near Ainos in Thrace accepted people with chronic diseases. Isaak’s regulations for this institution specifically forbade the staff to expel patients before their natural death or their recovery from the chronic illness.63 In other words, Isaak did not want his gerokomeion to function as a Byzantine hospital.

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Byzantine philanthropic tradition, therefore, came to distinguish two basic categories of charitable institutions for the sick: xenones (nosokomeia) designed to cure patients as quickly as possible and gerokomeia designed for long-term care until patients died or, in a few cases, recovered their strength.64 Some of these gerokomeia were designed for lepers. In fact, the Pantokrator Typikon described a dormitory complex at the Zotikos Leprosarium as the gerokomeion of Romanos, a clear reference to buildings constructed by Emperor Romanos III, circa 1034, at the leper hospital.65 Following the reconquest of Constantinople from the Latins in 1261, Byzantine sources no longer refer to leprosariums. Moreover, we have no evidence that the Zotikos facility was refurbished, although Emperor Michael VIII did reestablish the Orphanotropheion, and it is certainly possible that as part of this effort he also restored the leper asylum in Pera, which had always been closely connected to the orphanage of Constantinople. Some gerokomeia, however, may also have continued to admit lepers, as did some monasteries. As we saw in chapter 2, Nikephoros Kallistos Xanthopoulos mentioned two lepers who came to the Monastery of the Life-giving Spring. Manuel Philes also dedicated two poems to victims of Elephant Disease at this monastery, and his verses describing the leper monk were addressed to a third leper seeking a cure at the shrine. It seems possible that this monastery maintained some special facility—a hostel or gerokomeion—that provided food and some care for victims of Elephant Disease as they prayed at the shine and washed in the miraculous waters.66 With regard to Palaeologan leprosariums, it is important to revisit the monastery established by King Stephen Uroš III of Serbia. The short biography of this saint and ruler referred to the leper asylum as a monastery, a subsidiary to the principal monastery of Dečani. In conceiving his facility to assist lepers as an extension of the central monastery, Stephen was probably following contemporary practice within Byzantine territory.67 For example, when Manuel II’s son, Andronikos, had to withdraw from political life sometime before 1428 because of elephantiasis, he entered the Monastery of the Pantokrator in Constantinople. Although this monastery had maintained a fully equipped hospital in the twelfth century, we have no indication that this medical facility survived the Latin occupation or was reestablished by a Palaeologan emperor. It is possible, however, that the Pantokrator hospital continued to support a modest gerokomeion where Andronikos lived out his final days.68

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Resources Leprosariums received financial support from many of the same sources as other Byzantine philanthropic institutions—from bishops, emperors, wealthy private persons, and probably monasteries. As we learned from the report of Epiphanios of Cyprus, the bishops of Asia Minor built the first Christian leprosariums in their cities during the mid-fourth century.69 For example, as bishop of Caesarea Cappadocia, Basil constructed his leprosarium and hospital outside of his city circa 371. More than four centuries later, Theophylakt opened an identical institution when he assumed the office of bishop of Nikomedeia.70 As the new bishop of Constantinople, John Chrysostom assigned revenues (prosodoi) to pay for the construction and maintenance of a new institution for lepers outside the capital city. Prosodos in Greek probably means revenues from land, although it could also refer to cash allotted to the leprosarium project directly from the bishop’s treasury.71 When, several years later, Bishop Rabbula reorganized the leper colony outside of Syrian Edessa, he provided supplies from the common episcopal storehouse instead of donating land to the asylum as a permanent endowment.72 During the fifth century, Church law came to require that local bishops supervise charities within their dioceses, a category that, of course, included leprosariums. In the following century, the civil legislation of Emperor Justinian reinforced the rules of the Church regarding bishops’ authority over philanthropic institutions, although it also strengthened the role of wealthy lay donors in overseeing charitable facilities that they themselves had financed.73 Although bishops initiated the movement to found Christian leprosariums, the emperors soon stepped in to expand these institutions. After Zotikos founded his leprosarium in Constantinople, Emperor Constantius II approved cash donations to the institution and assigned it some of the best imperial estates as a permanent endowment.74 In the sixth century, Emperor Justin II augmented the regular income of the Zotikos Leprosarium by requiring that the Orphanotropheion pay a stipulated sum of money each year to the leprosarium supervisor.75 Finally, in his history of the emperors, Leo the Deacon stated that upon the accession of John Tzimiskes in 969 the new emperor gave away some of his family estates to the Zotikos asylum.76 Other sources mention similar donations to the Zotikos Leprosarium on the part of individual emperors. It is important to remember, however, that

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from its foundation the Zotikos asylum had been administered as part of the Orphanotropheion. When, in the ninth century, Emperor Nikephoros I transformed the Orphanotropheion from an ecclesiastical institution into a state agency, this also altered the status of the leper hospital across the Golden Horn. Thereafter, the emperors were ultimately responsible for financing both the Orphanotropheion and the Zotikos Leprosarium in their official capacity as the sovereigns of the state.77 Wealthy individuals also supported all types of charitable foundations. For example, in the fifth century a prosperous widow founded a small institution for homeless children in Constantinople, and in the ninth century a landowner from Bithynian Prousa established an orphanage for eighty children near his city. Similarly, wealthy laypersons supported hospitals for patients with curable ailments, both in Constantinople and in provincial cities.78 With regard to private endowments to leper hospitals, we have the case of Saint Zotikos. One version of his legend states explicitly that Emperor Constantius II approved the use of Zotikos’s personal property to finance the saint’s leprosarium.79 Because Zotikos also served as a priest in the Constantinopolitan church, he may also have been acting as an agent of Bishop Makedonios or his successor, Eudoxios, in supporting this leper hospital. The authors have so far identified no other wealthy individuals who established leprosariums, unless one were to consider the empress Eudocia a private person when, exiled from Constantinople, she financed her large leprosarium near Jerusalem sometime before 450. In addition to endowments, leprosariums had another source of income, the families of those who fell ill from Elephant Disease. Gregory of Nazianzos emphasized that leprosy not only afflicted the poor but also struck down those who were prosperous and had relatives with substantial resources.80 In planning his leprosarium near Constantinople, John Chrysostom expected that fathers who had expelled their leprous sons and daughters from their homes would support their children’s maintenance in the bishop’s asylum. Chrysostom specifically asked fathers of families to donate some portion of their sick children’s inheritance to the leprosarium.81 Chrysostom’s idea apparently became a standard practice. As we saw previously, the monks Barsanouphios and John advised the man whose slave had contracted Elephant Disease to place him in a leprosarium but also to provide for his meals, clothing, and even bedding so that the sick slave would not suffer in deprivation.82 It is important to recall that according to

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Roman law slaves were classified as members of the family. From this letter it appears that leprosariums often expected patients from families with property to provide for most of their personal needs. Did monasteries also support leprosariums? One would suppose that they did, given that monastic communities were associated with hospitals and gerokomeia in Constantinople and the provinces. The earliest leprosariums had been founded by bishops, such as Eustathios, closely associated with the Anatolian urban monastic movement. Moreover, in fifth-century Palestine, Theodosios the Cenobiach supported a leprosarium connected to his famous cenobetic monastery.83 It is curious, therefore, that among the fifty-one surviving monastic rules (known in Byzantine Greek as “typika”), only two mention lepers. We have already discussed one of these, the typikon of the Pantokrator in Constantinople. The only other monastic typikon to mention lepers comes from the thirteenth-century Monastery of Machairas on Cyprus. Nuns attached to this community were to feed the poor and assist the victims of Elephant Disease, but there is no reference to an institution for lepers.84 Regarding the Zotikos Leprosarium in Constantinople, the story about the eunoch named John (see chapter 3) claimed that after bathing in the water from the saint’s spring, the man joined a monastery next to the leper asylum. There is no evidence, however, that the monks there had any formal relationship with the Zotikos Leprosarium.85 Despite the lack of evidence, it is possible that Byzantine monasteries did support leprosariums, just as they did hospitals, gerokomeia, and almshouses. The documents that described such institutions have simply not survived. The strongest evidence that monastic leprosariums did in fact exist comes from fourteenth-century Serbia where, as we have seen, King Stephen III Uroš attached a leprosarium to his famous Monastery of Dečani. We should also note that monastic gerokomeia, which are mentioned in several typika, may also have accepted lepers.

Balancing Charity and Public Health Leprosariums did not exist in the Greco-Roman world before Emperor Constantine’s conversion to Christianity in the early fourth century. Writing during the prosperous second century, Galen described a man living near

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Pergamon who contracted leprosy. When his family members suspected that others were catching Elephant Disease “by speaking with him,” they built a small hut for the sick man, away from other people but near a spring. Galen mentioned a second leper, a man of some wealth, who also had to leave his home. He took with him his favorite slave girl, and the two found a place to live that was so isolated it was infested with snakes. Both of these stories show clearly that no institutions existed for the care of people with leprosy, and this during an age when Pergamon and other cities of Asia Minor were supporting many elaborate civic institutions such as theaters, libraries, and monumental baths. Galen’s stories also reveal another aspect of the pre-Christian attitude toward victims of elephantiasis. Near the hut of the first leper, some agricultural workers were laboring in the fields. They had brought along with them a jug of wine for refreshment. After some hours of work in the hot sun, they lifted up the jug to pour some wine when a dead viper fell out of it. Because the workers thought that the viper had poisoned their wine, they decided to quell their thirst with some water instead and to offer the wine jug to the leper residing nearby, as Galen said, “because of philanthropia.” The workers believed that the poor man would be better off dead than suffering from leprosy. Galen returned to the same theme in the second story. When the slave girl saw a viper crawl into the wine jug of her leprous master, she considered this event to be a gift from the god Hermes because the poison of the viper would kill her master and end his suffering. Galen described a third victim of Elephant Disease who had suffered for many years from this incurable illness. Since the leper was “of a philosophical spirit,” he told Galen that he would be better off dead than living with such a disease. Apparently, this man agreed with the spirit of Plato’s remarks in the Republic that there was no need to treat victims of incurable diseases, since such people were of no use to themselves or the polis.86 As we noted in chapter 1, there is also little evidence that Christian communities developed any organization to assist lepers prior to the fourth century. Following Jewish concepts of charity, early Church communities organized orphanages, visited the sick, and ransomed captives and those condemned to gladiatorial battles, but they apparently supported no institutions for lepers. Only in the fourth century did Christian leprosariums appear. In part, this was a response to a perceived increase in the number of people who

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contracted Elephant Disease, but it also required a change in attitude on the part of Christians toward lepers. As we have explained, the fourth-century Greek fathers developed a radically new view of leprosy as a way to salvation— both for victims of the disease whose sufferings purified them for heaven and also for the healthy who now had the perfect recipients of charity, the victims of elephantiasis. Such people were in need of everything, since leprosy had deprived them of family, friends, the city community, and their bodily capacity to help themselves. Gregory of Nazianzos thus called leprosy the “Holy Disease,” a name that Byzantine writers continued to use when referring to Elephant Disease until the end of the empire.87 This revolutionary view of leprosy encouraged the founding of leprosariums in Asia Minor, Constantinople, and other Byzantine provinces. There can be no doubt, however, that leprosariums also succeeded because they met a basic need of society—a place to house lepers at a safe distance from the residences of healthy people. Despite the ideas of the Greek fathers, medical experts and the common people continued to consider leprosy contagious. Remember the statements of Aretaios and the stern warning, found in Aetios’s compendium, that even the breath of lepers polluted the air. Fear of contagion no doubt explains the location of Byzantine leprosariums beyond the walls of the cities they served. The Zotikos Leprosarium was built on the north side of the Golden Horn so that this body of water separated the institution from Constantinople. Basil located his famous ptochotropheion outside the city of Caesarea in Cappadocia. When he became bishop of Edessa, Rabbula found the lepers already banned from the city and living in a wretched colony outside the walls. He and his successors turned this settlement into a leprosarium with a church and hospital facilities. Fear of contagion also lay behind the advice that Barsanouphios and John conveyed to the wealthy man of sixth-century Palestine. The two monks counseled him not to burden other members of his household by caring for his leprous slave in his home but to bring him to a nearby leprosarium. The monks thought that both the noxious appearance and odor of lepers as well as the contagious miasma that the sick exuded made a leprosarium a better place to care for such unfortunate people than a villa full of family members and healthy slaves.88 We have also seen how in the twelfth century Emperor John II Komnenos decided not to construct a leprosarium in the heart of Constantinople,

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probably because local residents did not want to risk contracting the disease or to see and smell the lepers. Finally, King Stephen III Uroš guaranteed the safety of his monks at Dečani by building the subsidiary leprosarium three stadia from the main monastic complex.89 Most subjects of the empire accepted the moral imperative of the Greek fathers that they assist lepers in their distress, but not the claim that they need not fear the disease. In writing a commentary to Gregory of Nazianzos’s Oration XIV, an obscure scholar of the tenth century observed that many people in Gregory’s time had an irrational fear of leprosy. This scholar argued that people did not need to shun rivers and streams where lepers bathed because the rapid flow and the quantity of water neutralized the contagious effluence from the sick people.90 Such a comment represented a position of compromise between the inordinate fear of leprosy and Gregory of Nyssa’s assertion that Elephant Disease did not pass from one person to another. Some Byzantine observers were apparently developing an opinion about leprosy, based to some extent on experience, an opinion that avoided an unwarranted fear of contagion but also rejected the idea that the disease was not at all contagious. Intimate contact with victims of Elephant Disease seemed to risk the health of family members, but visiting sick relatives in an institution did not pose a grave threat to one’s health. For most Byzantine Christians, then, placing their loved ones in a nearby leprosarium provided a way both to protect their family’s health and to meet the demands of charity toward the sick. Having discussed Elephant Disease in the Byzantine Empire, we now turn our attention to the medieval West. In examining leprosy in Italy and the lands that would become medieval France, the Netherlands, England, and Western Germany, we will continue to compare the Byzantine experience with Elephant Disease to the way in which Westerners reacted to the same terrifying illness.

Chapter 5

Leprosy in the Latin West

On a visit to southern France in June 1321, King Philip V first heard about the leper plot, probably from the mayor of Periguieux. Records from that city reveal that in April the mayor had begun to arrest lepers accused of planning to poison the wells of the town. Some lepers had already been burned at the stake for their alleged involvement in the conspiracy. As a result of what he heard, King Philip issued an order on June 21, 1321, that defined participation in this poisoning plot as an attack on the king’s majesty and therefore subject to the authority of the royal courts.1 As news of the supposed conspiracy spread throughout France, fear and hatred against people with Elephant Disease flared up. At Rouen in Normandy, crowds burned lepers without trials. Similar riots broke out throughout France. As a result, the king ordered that vagrant lepers be arrested and held in leprosariums to protect them from popular outrage rather than to punish them.2 Records from the court of the inquisition at Pamiers, not far from Toulouse, record the testimony of a leper named Guillaume Agasse who admit-

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ted that a year earlier, in 1320, he had participated in several meetings held at one of the leprosariums in Toulouse. At these meetings, the lepers had allegedly organized a plot to poison wells throughout France. They were to use a strange mixture that would either kill healthy people or give them leprosy. Agasse quoted the head of the leprosarium in Toulouse as having stated: “You all see and hear how the Christians in good health hold us lepers in opprobrium and abjection and how they bar us from their company, and hold us in derision.” Agasse maintained that the leper conspirators were in league with the Muslim emir of Granada and with the Jews.3 The panic that swept over France in the summer of 1321 did not last long. On August 16 the king relinquished his seizure of leprosariums in France, and on August 24 he pardoned all victims of elephantiasis who had been found guilty during the time of hysteria. The king’s pardon demonstrates that the royal government, at least, now considered the leper plot to have been a hoax.4 Meanwhile, many lepers had been killed in riots or burned at the stake without trials. There are no estimates of the number of victims throughout France, but a monk from the abbey of Uzerche in Limousin recorded that forty-three lepers were burned in the lands administered by his monastery.5 Historians have suggested a number of underlying causes for the leper plot hysteria. The resurgence of Islam under the Mamluks and the loss of all crusading territory in the Middle East in 1299 had rekindled fear of a Muslim attack on Europe, and, indeed, Islamic rulers were accused of helping to organize the leper conspiracy.6 The early fourteenth century also was experiencing economic shifts, especially in France, which might also have contributed to uneasiness and instability.7 The lepers who had testified before the inquisition in Pamiers, however, clearly saw the cause of their conspiracy in the physical separation from the society of the healthy and in the disdain that healthy people manifested toward those who suffered from this illness.8 With regard to the Byzantine Empire, we have no indication that any similar persecution of lepers ever occurred. Of course, one must keep in mind that few government documents survived from the thousand-year history of the Eastern Empire. Moreover, few sources reflected the local conditions in the empire outside of Constantinople. On the other hand, wellcrafted, detailed narrative histories, composed in Constantinople, covering almost the entire period 330–1453, provide a picture of major events in the

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empire’s long life span. It is doubtful that persecution of lepers—something that would have profoundly violated the ethical principles enunciated by the Greek fathers of the fourth century—would have escaped the notice of secular historians, or would have avoided a firestorm of protest from church leaders. Hostile orthodox writers never even accused the heretical emperors who fostered iconoclasm of having perpetrated persecution of those suffering from Elephant Disease. Our research has only identified two Byzantine sources that mention the persecution of lepers. The first is found in the Zotikos legend. According to this tale, after Constantine was miraculously cured of leprosy in the waters of baptism, government officials, deluded by Satan, ordered that all lepers be rounded up to be thrown into the sea or into raging rivers. Satan had deceived these officials by convincing them that leprosy was contagious. This story is probably apocryphal, although it is possible that some bureaucratic decision to remove lepers from Constantinople did occur in Constantine’s reign. That Satan was credited with inspiring such a persecution, however, demonstrates that Byzantine opinion, enlightened by the fourth-century fathers, ultimately came to consider such an attack as profoundly evil.9 The second passage to mention an attack against lepers comes from the historical account by Chalkokondyles. In describing Timur’s conquest of Sebasteia in Asia Minor in 1401, Chalkokondyles claimed that the brutal Tartar ruler executed all the people in the city because they had tried to resist him. The author added that Timur also exterminated the lepers he found in the town. Chalkokondyles no doubt added this detail to underline Timur’s boundless cruelty.10 Returning to the French leper hysteria of 1321, we cannot know for certain whether some lepers did indeed plot to poison the wells and springs of Aquitaine, or whether the society of nonlepers simply feared that such a plot had been hatched. We do know that in either case some lepers involved in the plot believed that society maintained a strict separation between the victims of Elephant Disease and the healthy population. Indeed, the Leper Massacre of 1321 provides the most compelling evidence that medieval society did persecute the victims of leprosy, as so many general histories about the Middle Ages and the development of Western medicine have claimed. It often has been asserted in these books for students and the educated public that this tendency to separate lepers from society and sometimes to persecute them was inspired by Christian prejudice—a view

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of leprosy derived from the Old Testament, which saw this disfiguring disease as punishment for sin. In a widely used textbook on the history of medicine, Vivian Nutton has connected the injunctions of Levitcus 13 to exclude lepers from society with a drive by the Catholic Church in the twelfth century to isolate victims of elephantiasis in leprosariums.11 In a fascinating monograph on contagious diseases, Sheldon Watts repeated in even more strident tones that European Christians based their exclusion of lepers from society on the Law of Moses, which had banned the leprous from the camp of Israel. As Watts states, “On this foundation (the Christian exegesis of the Mosaic Law) would be built the conviction that leprosy was God’s punishment for sin and that lepers must be driven out of the camp.”12 In a monograph dedicated to the history of hospitals, Günter Risse echoed the views of Nutton and Watts. Christian society in Europe isolated lepers because of their supposed sinfulness. Christians saw “sinful behavior as the primary cause of the disease (Elephant Disease).”13 Finally, in the entry on leprosy in the Dictionary of the Middle Ages, a standard reference work for medieval European studies, Stephen Ell wrote: In the High and later Middle Ages, the leper was legally and religiously cut off from the rest of society. He was seen as morally unclean. Special hospitals served to segregate lepers. Fear of the disease, religious impulses, and social attitudes combined to create this situation.14

What Ell maintained in his encyclopedia entry might reflect to some extent the situation in fourteenth-century France that led to the Leper Massacre of 1321, but his view would not be true for all areas of Europe at all times. As we emphasized in the introduction, recent research, based on a far larger sampling of published and unpublished sources, has revealed more complex responses to leprosy and its victims than one finds in nonspecialist books and articles. Moreover, we have demonstrated that Ell’s statement and others by scholars such as Nutton and Risse never applied to the Byzantine Empire. Therefore, whatever moved Western Europeans in some regions to isolate lepers by force and subsequently to engender a wall of mistrust between society at large and those with leprosy must apply to Latin Europe but not to Byzantine society. In what follows we examine Christian religious writing about leprosy both as punishment for sin and as a sign of blessing. We

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also study the legal regulations regarding victims of Elephant Disease. Finally, we discuss Latin medical treatises regarding leprosy. Where Latin ideas in any of these areas differ from those we have studied in medieval Greek society, we will perhaps have discovered our answer.

Leprosy in Christian Thought As we have seen, Byzantine writers, influenced by the Jewish exegesis of the Torah, interpreted leprosy as both a symbol of sin itself and as divine punishment for sin. Byzantine religious thinkers, however, also saw Elephant Disease as a sign of holiness. A study of Western medieval writers will show many of these same themes repeated in Latin religious literature. According to a North Italian chronicle of the thirteenth century, people in the Lombard plain claimed that anyone baptized in the sacred fonts in the churches of Lodi would never get leprosy.15 This local belief rested on the Old Testament story of Adam and Eve and on a symbolic connection between the original sin of the first man and woman, washed away by the regenerative waters of baptism, and the physical disease of leprosy. Such an image was deeply rooted in Western Europe because of the popular Constantine legend. In the basic version of this story, when Emperor Constantine first gained control of Rome, he began to persecute Christians. As a result, God punished him with leprosy. The emperor consulted pagan priests, who told him that a bath in the blood of slaughtered infants would cure his ailment. Before he could carry out this abominable deed, Peter and Paul appeared to him in a dream. On the next day, he summoned Pope Sylvester, who explained to the emperor that he should be baptized. When the emperor emerged from the waters, he was liberated not only from original sin but from his leprosy.16 This legend developed in Rome during the 400s without the approval of the official Roman Church because it clearly contradicted history. Constantine had never persecuted Christians in 312; he was not baptized by Pope Sylvester in Rome but by Bishop Eusebius of Nikomedeia in Constantinople; and, finally, he never contracted Elephant Disease.17 Despite these inaccuracies, the Constantine legend was added to the Life of Pope Sylvester, which was written in 521 and incorporated into the Liber Pontificalis.18 This offi-

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cial life of Sylvester, however, eliminated all of the more bizarre features of the Constantine legend, such as the bath in the blood of infants.19 From Rome the Constantine legend spread throughout the West. Gregory of Tours repeated it.20 In celebrating the finding of the Holy Cross, a sermon, attributed to the venerable Bede (672–735), also included the story. This version, however, dropped the story about Constantine’s having persecuted Christians and replaced it with a strange tale about a giant serpent in Rome that was eating men and animals. Constantine managed to kill the snake, but he was bitten and developed leprosy from the serpent’s venom. The author of this sermon, however, retained the key element of the story— how the waters of baptism washed away the impurity of leprosy.21 Against the background of the Constantine legend, one can better understand how the people of Lodi and its environs came to believe that their baptismal fonts protected their infants from Elephant Disease. The Constantine legend, however, was also widespread in the Byzantine world. In fact, it was incorporated into the legend of Saint Zotikos, the founder of Constantinople’s great leprosarium, although again with alterations. In this version, Constantine caught leprosy naturally, not from the bite of a serpent or as punishment for persecuting Christians.22 The story even found its way into the sober history composed by Emperor John VI Kantakouzenos to justify his coronation as emperor in 1343.23 Although most Byzantinists have maintained that the Constantine legend originated in Rome in the fifth century and only came to Byzantium in the eighth century, Françoise Bériac’s research has traced its origins to the Syrian monophysite circles of the fifth century.24 What is beyond dispute, however, is that the story flourished both in the Latin world and in the Byzantine East. Leprosy not only symbolized the sin of Adam, but it could also indicate the presence of personal sin. In fact, in the original version of the Constantine legend, the emperor was struck with Elephant Disease because he had persecuted Christians.25 Western Christians also believed that God punished less dramatic sins with leprosy. In writing about miracles that had occurred at the tomb of Saint Martin, Gregory of Tours (late sixth century) warned couples that if they engaged in sex on Sundays their children might develop leprosy. Gregory was clearly trying to frighten his flock into keeping the Lord’s day holy. According to Gregory’s interpretation, keeping the Lord’s day holy required abstaining from sexual activity.26

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Gregory, however, was simply expanding on a theme enunciated by Byzantine moralists. As we noted in chapter 2, Isidore of Pelusium had claimed that God often punished married couples who engaged in sex while the woman was menstruating by striking the children of such encounters with Elephant Disease.27 In the early seventh century, Sophronios interpreted leprosy (elephantiasis in his text) as a symbol of wild sexual passions that must be driven out of the “Camp of Israel.”28 In his account of Saint Martin’s miracles, Gregory of Tours made these wild passions specific— Christians should drive out the wild passions by overcoming the desire for sex on Sundays. In the early seventh century, Isidore of Seville (d. 636) also used leprosy as a symbol of sin in his explanation of stories from the New Testament. Isidore claimed that the ten lepers whom Jesus cured in Luke’s Gospel (17:11– 19) represented ten different doctrines of heresy, a form of intellectual sin. In his commentary, Isidore also mentioned the varied colors of leprosy described in Leviticus 13, a color symbolism that we have seen before in the essay on leprosy written by Methodius of Olympus in fourth-century Asia Minor.29 Throughout the Middle Ages in the Latin West, leprosy often symbolized sin or punishment for sin. In his book The Disease of the Soul, Brody analyzed how, in chivalric romances of the High and Late Middle Ages, pride, lust, and other vices were punished by leprosy.30 Such stories, however, appeared not only in fantasy literature but also in local histories. One especially strange tale appears in a local chronicle from Bologne in Champagne (France), composed by a Premonstratensian monk at the beginning of the thirteenth century. Two friends from the territory outside of Bologne sat down at a table to dine on a roasted rooster. They cut the bird up into pieces and bathed it in a sauce seasoned with pepper. One man said that even Saint Peter could not cure this rooster. The other retorted that this bird would never return to life even if Christ himself should command it. At these words, the rooster leaped up, fluttered his wings, began to crow, and shook his miraculously regenerated feathers. As a result of ruffling his feathers, the bird sprinkled the men with the pepper sauce. The two sinners were immediately struck with leprosy wherever the droplets fell on their skin.31 This far-fetched tale from Western Europe does not differ much in texture from the Byzantine story that we examined in chapter 2, the story from

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seventh-century Alexandria about Elias, who sought a cure for leprosy at the shrine of Saints Cyrus and John. As in the case of the two men from Bologne, the blemishes of leprosy remained on Elias’s face as marks of his personal sin.32 In all of these examples, one can perceive a common thread woven into both the Byzantine and the Western narratives. This is not to say that Bishop Gregory of Tours or any of the other Latin authors consciously copied Byzantine archetypes. Rather, Latin Christian writers were educated in an environment that shared a common classical and Christian culture with the Greek-speaking East. People still traveled back and forth from the West to the East after the Arab invasions of the seventh century. As late as the 800s the city of Naples had Greek congregations with their own clergy who spoke and chanted in Greek. Duke Sergius, who ruled Naples from 840 to 864, could read both Latin and Greek manuscripts.33 By the thirteenth century, when the Premonstratensian monk composed his rooster tale, the two halves of the Christian world had drifted much farther apart, but they still shared common roots. The following example shows how easily edifying stories could travel from the Byzantine Empire to the West. Circa 600, Pope Gregory I gave a sermon in the Church of Saint John Lateran. In his address, the pope recounted what he had heard from one of his deacons, a man named Epiphanios, who had arrived in Rome from Isauria in Byzantine Asia Minor. Epiphanios’s story concerned the pious monk Martyrios whose monastery was located in Lycaonia, a province that lay to the north of Isauria and bordered Cappadocia, that is, from the heart of Asia Minor. According to Epiphanios, Martyrios had decided to travel from his own monastery to that of his spiritual father. On the journey, Martyrios met a leper with crippled and fetid limps who was too weak to proceed to his home. Martyrios took off his cloak, wrapped it around the leper, hoisted the man up, and slung him over his shoulder like a backpack so that he could carry the leper with him. As Martyrios approached his adviser’s monastery, his spiritual father cried out, “Martyrios is carrying our Lord on his shoulders.” As Martyrios set the leper down on the ground, the sick man was transformed into the recognizable form of the redeemer of the world. Subsequently, Jesus ascended into heaven and disappeared from sight.34 In this story, the man with Elephant Disease had committed no sin; rather, he was the redeemer of the world’s sinners. Pope Gregory told this story to

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5. Saint Benedict of Nursia healing a leper. Gregory the Great recounts this story in Book II of his Dialogues. Eleventh-century fresco excavated from the church of San Crisogono in Rome.

demonstrate Christ’s presence in those who were considered by worldly men to be the lowliest. Gregory also wanted to encourage acts of charity on behalf of the most disparate in society. Gregory’s sermons were copied into countless manuscripts and read throughout Western Europe. Latin Christians thus had access to a story from Asia Minor about Christ disguised as a leper. In fact, Latin writers of the Middle Ages continued to use this motif into the thirteenth century.

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In a sermon given circa 1220 in a leprosarium, Cardinal Jacques de Vitry presented the theme of the sacred leper in another context. A pious woman lived with her husband, an impetuous knight who feared nothing but detested lepers. One day, while the knight was out hunting, the wife was alone in the manor house when a leprous man came to the door and asked for food and drink. She immediately brought him what he had requested, but the leper protested that the weather was too hot for him to eat outside. He asked her to carry him inside. The wife told him about her husband’s hatred of lepers, but the man persisted. She picked him up in her arms (apparently he was so malnourished that the woman had no trouble carrying him) and brought him in. When he began to groan from pain and exhaustion, she decided to place him in the bed she shared with her husband. She positioned a splendid pillow under his head, covered him with a luxurious blanket, and withdrew to give the poor man a chance to recuperate. At that moment, the husband returned from the hunt and wanted to take a nap. The wife tried to stop him, but he angrily pushed her aside and entered the bedroom. The woman resigned herself to death at the hands of her furious husband. Instead of shouts of rage came a long silence. Eventually the husband emerged from the bedroom and began to praise his wife for having prepared the bed in such a beautiful manner and having filled the room with a wonderful perfume, so redolent that the knight thought he had entered paradise. Of course, the leper had vanished.35 Religious writings from the High Middle Ages are filled with such tales. According to the version of Saint Francis’s vita by Thomas of Celano, the key event in the saint’s process of conversion occurred while he was riding his horse in some open country outside of Assisi. As we saw in chapter 2, Francis had always abhorred lepers, and that day a particularly repulsive leper crossed his path. Francis suddenly realized that his loathing violated Christ’s command to love. He jumped down from his horse, gave the sick man some money, and then kissed him in the tradition of Basil and Martin of Tours. When he remounted his horse and turned to salute the leper, the man had vanished.36 Christ often appeared as a leper in Western literature, but occasionally so did Satan. In the ninth century, the chronicler Notkar recorded the story of a young man whom Charlemagne had recently appointed bishop. This man tried to lead a holy life, but during Lent he began to feel too weak to carry out his episcopal duties. With the advice of his clergy, he ate some meat. On

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the Vigil of Easter, the devil appeared to him as a hideous leper with a rasping voice and oozing sores to taunt him for having broken the Great Fast.37 In both the Byzantine East and the Latin West, leprosy had this strange, ambivalent connotation: it might represent sin, or punishment, or even the devil, but it might also symbolize virtue and the divine. Moreover, its victims were considered cursed or blessed. We have seen that Gregory of Nazianzos popularized the name “Holy Disease” for leprosy because it purified its victims for heaven. Although this terminology never was directly translated into Latin, the concept did transfer to the West. In introducing new regulations for the leprosarium of Lille in 1239, Bishop Walter called the lepers God’s friends, visited with the sign of his love for them because the disease had marked them for heaven.38 Because Christian writers both in Byzantium and the West used leprosy to symbolize both good and evil as well as suffering and salvation, we must look elsewhere to find the causes of the Leper Massacre of 1321 and the deep-seated alienation between the world of the healthy and the lepers that this attack revealed.

The Laws As Françoise Bériac observed, Western Europe had no universal law that established a quarantine of lepers. Neither the Roman law nor the canon law of the Catholic Church required that victims of Elephant Disease have limited or no contact with healthy society.39 In the Byzantine legal tradition, however, we noted that the eighth-century Ecloga altered the Roman law by allowing a healthy person to divorce a partner who had developed leprosy because of the risk of contagion, but this law was removed one hundred years later by the Macedonian emperors Basil I and Leo VI.40 In the West, the papal regulations regarding marriage closely paralleled the legal evolution that we have studied in the Greek empire. On a visit to Gaul in 754, Pope Stephen II issued several rulings on marriage, baptism, and other matters of Church law. Regarding lepers, the pope stated that if one of the partners in a marriage came down with Elephant Disease, the healthy person should separate from the sick person so that the couple would not pass on the disease to their children. Stephen probably believed that elephantiasis was congenital, but he might also have been concerned about

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contagion.41 At the Council of Compiègne in 757, the bishops of Gaul, under the leadership of King Pepin III, confirmed Pope Stephen’s ruling about divorcing a leper, although they moderated it to the extent that the healthy person could remarry after separation, only if the leprous spouse gave consent.42 A little more than one hundred years later, however, Pope Nicholas I (858–71) overturned Stephen’s ruling and forbade any divorce because of illness, a view that was affirmed by later bishops of Rome.43 In the High Middle Ages, Pope Alexander III (1159– 81) issued a statement specifically concerning the inviability of marriage in the case of leprosy.44 Despite the growing political and cultural differences between the eastern Roman state and the former Latin provinces of the Roman Empire, the Western legislation closely followed Byzantine reforms. Pope Stephen II allowed divorce in the case of leprosy only a few decades after Emperor Leo III had issued the Ecloga. Moreover, Pope Nicholas I overturned Stephen’s regulation at the very time that Basil I seized the throne in Constantinople and repealed the same Ecloga. These vacillations in the Western rules regarding the right to divorce victims of leprosy again show how the Latin Christian world still maintained close ties to the Byzantine Empire even in the eighth and ninth centuries. In 643, the Lombard king Rothari issued a written code of his people’s customs. Although written in Latin, Rothari’s Edict, as this code was called, recorded Germanic laws. Regarding lepers, the Edict stated that once the judge or the people confirmed that a person had Elephant Disease, that individual was forced to leave the community and live in isolation. Moreover, the leper lost all control over his or her property as though he or she had died. The victim retained only a right to receive sustenance from the revenues of his or her property, which apparently the leper’s heirs now owned.45 This Lombard law resembled no piece of legislation in Byzantine law codes. Indeed, it sanctioned the very behavior that Gregory of Nazianzos and the other Greek fathers had so harshly condemned—driving lepers from their homes, their families, and their cities. In emphasizing the hostilities that had raged between the Roman Byzantine city of Naples and the Lombards of inland Italy, one Neapolitan writer of the ninth century attributed the victories of his city over the Lombards to the town’s acts of mercy and piety. This same author pointed out that the citizens of Naples sought out lepers to assist them. Was this writer comparing Lombard cruelty toward

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the victims of Elephant Disease with the Christian philanthropy of Roman (i.e., Byzantine) Naples?46 The provision against lepers in Lombard law influenced Carolingian legislation. In issuing a series of laws—what the Franks called “capitularies”— for his entire empire in 789, Charlemagne included a clause that forbade lepers to have any contact with the rest of society.47 Another example of harsh laws against lepers comes from the High Middle Ages. In the early thirteenth century, Henry of Bracton wrote a commentary on English common law, the system of Germanic customary law that had gradually emerged as an organized system when royal justices began to record the decisions that they had made for specific cases. In summarizing these many judicial rulings, Bracton classified those with leprosy together with the insane and minor children without guardians, people who were unable to perform valid legal actions. Just like the insane and children, people with Elephant Disease lost the capacity to sue in court, to inherit property, or to make contracts. Unlike the Edict of Rothari, however, English judges allowed lepers to retain control of property that they had owned when they first became ill.48 As one would expect, English common law followed the example of the customary laws in Normandy, where lepers also lost many legal rights when they contracted the disease.49 Moreover, another law code, nearly contemporary with Bracton’s commentary, followed closely the principles found in English common law regarding lepers. This legal code from North Germany, called the “Sachsenspiegel,” had been composed in a part of Germany least influenced by Roman legal traditions.50 One cannot deny that the hard legal sanctions that separated lepers from healthy society— even from their own families—had their origin in Germanic legal codes, not in the Roman legal tradition. Although modern historians have failed to notice that the most severe measures taken against lepers appeared only in collections of Germanic customary laws, a nineteenth-century French legal scholar did make such an observation. In 1875, Louis Guillouard maintained that the harsh restrictions on the legal rights of lepers in Normandy ultimately derived from Scandinavian customs that oriented its legal system to benefit the strong and useful members of society, not those who were weak and unable even to help themselves.51 In other words, these Germanic laws outlined an ethical sys-

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tem diametrically opposed to the Christian moral scheme annunciated by the Greek fathers in the fourth century. Sometime prior to 1181, Pope Alexander III wrote a letter to the archbishop of Canterbury. He described the plight of those with Elephant Disease in these words: “It is known to us that by general custom those with leprosy are separated from human communion and are transported to solitary locations outside cities and villages.”52 Alexander’s testimony suggests that all over Latin Christendom, not just in regions where Germanic law applied, legal customs, first expressed in Rothari’s Edict, had promoted the isolation of lepers in many regions of Western Europe. Unlike the bishops of fourth-century Asia Minor and Constantinople, the Western Church did not effectively oppose these Germanic customary laws to isolate lepers. In answer to questions that Saint Boniface asked in 726 concerning church organization in newly converted German territory, Pope Gregory II responded with a long list of directives. Regarding lepers, the pope stated that they should be allowed to receive Christ’s body and blood in communion but not to celebrate the liturgy along with healthy believers.53 Bishops in Germany subsequently observed Pope Gregory’s ruling because they added it to the decisions of a synod of bishops held at Worms in 868.54 In 751, in another letter to Saint Boniface, Pope Zacharias confirmed the Lombard custom of isolating lepers. According to Zacharias, lepers should be taken outside the city, although the pope added that the people should offer them alms.55 Pope Zacharias’s statement is especially interesting in that he himself had come to Rome from Byzantine territory before his election as pope. His statement requiring the isolation of lepers in a settlement outside the city violates the ethics of inclusion, which we saw in Gregory of Nazianzos’s Oration XIV, but as we stressed in the last chapter, founders of Byzantine leprosariums such as Basil at Caesarea and Zotikos at Constantinople also had constructed their leprosariums outside the walls of their cities to limit the spread of the disease. Despite the legal restrictions in Germanic law codes and their apparent diffusion throughout Europe by means of the Carolingian capitularies, Françoise Bériac has found that in the documents of southern France lepers made contracts, sold property, and added legacies to their wills, just as did healthy persons. Even lepers who resided in leprosariums carried out legal actions as independent agents. One should note especially that Bériac’s

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evidence demonstrating that victims of elephantiasis behaved as persons with full legal rights comes from those very areas in southern France where the Leper Massacre had its origin in 1321.56

Medical Science Medieval Latin physicians practiced the same Galenic medicine as did Byzantine doctors. We have seen how Greek texts such as the massive encyclopedia of Oribasios were translated into Latin in sixth-century Italy and later copied throughout the Carolingian Empire. Latin physicians, however, produced no new medical texts during the early medieval period beyond simple remedy lists. Eventually, during the eleventh and twelfth centuries, Western medical science experienced a revival, first in Salerno and then in Spain and at Montpellier in southern France. Circa 1070 in Salerno, Constantine the African began to translate works by Arab doctors. As we saw in chapter 3, he excerpted a short section on leprosy from his Pantegni and called it the “De elephancia.” Constantine’s focus on leprosy is one of many indications that Elephant Disease was becoming a more serious health problem in Western Europe toward the end of the eleventh century.57 During the twelfth century, translations of Arab medical works appeared in Spain, including Gerald of Cremona’s Latin rendering of Avicenna’s Canon, a massive summary of Greek and Arabic medicine.58 Stimulated by these new translations, Latin physicians began composing original works during the thirteenth century on diagnosing and treating many illnesses, including leprosy. The Latin medical tradition of the High Middle Ages was inspired by Greek medicine both through direct contact with Greek manuscripts and by practicing Byzantine physicians in southern Italy and, indirectly, through Arab authors. Thus much of what the Western physicians wrote concerning Elephant Disease repeated observations made by Galen, Aretaios, Archigenes, in the pages of Aetios of Amida, and Paul of Aegina, but in two areas the Latin physicians diverged from the direction taken by later Byzantine medical writers. They differed in that some Western physicians continued to emphasize how contagious leprosy was, while others developed more precise methods of diagnosing Elephant Disease.

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Constantine’s De elephancia reproduced the complicated Arab system of cataloging different types of leprosy based on the four humors, but this Latin translation from eleventh-century Salerno said nothing directly about contagion.59 The Salernitan physicians of the twelfth century, however, came to see leprosy as easily passed from one person to another. A prose version of the Salernitan Questions, compiled circa 1200, compared leprosy to scabies, an infestation of tiny parasites that was renowned for how easily it moved from one individual to the next. Even modern hospitals have problems in controlling an infestation of scabies. This same version of the Salernitan Questions also repeated the warning found in Archigenes’s treatise, that one could contract Elephant Disease simply by speaking with a leper.60 As we saw in chapter 3, the twelfth-century translation of Avicenna’s Canon reinforced the idea that leprosy was highly contagious since the famous Muslim physician also warned against approaching lepers.61 Avicenna underscored the danger of contagion regarding Elephant Disease, even though Islamic religious writers had condemned the notion of contagion as violating the sovereignty of God’s will. Building on the observations of Avicenna and of the Salernitan Questions, many of the original medical treatises written by Latin physicians of the thirteenth century emphasized how easily healthy people could catch leprosy. Circa 1250, Gilbertus Anglicus included a long section on leprosy in his Compendium medicine in which he warned people not to inhale the breath of lepers.62 As we saw in chapter 3, so did the contemporary Breviarium Practice of Italy. Not all Western physicians, however, considered Elephant Disease contagious. Following the tone of Galen’s observations, neither Theodoric of Cervia nor Taddeo Alderotti, two of the leading medical experts of thirteenthcentury Italy, ever suggested that a healthy person could catch leprosy by approaching a leper.63 A contemporary of Theodoric’s and Alderotti’s, Lanfranc of Milan, took the middle road. (Leprosy) passes from one person to another and from father to son, but not always, because sometimes a healthy person who lives with a leper does not become leprous, and a leper can give birth to someone who will not be leprous.64

By the thirteenth century, however, the physicians who warned that leprosy was highly contagious began to influence the organization of leprosariums in

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Western Europe. Some of these institutions drafted detailed rules (regula) that included clauses to ensure that lepers had minimal contact with healthy people. According to the rules of the leprosarium of Lille, issued in 1239, the leper residents were not allowed to cross the plaza in front of the leprosarium to the houses on the opposite side. If they wished, however, they could go for walks in the opposite direction, which led into the fields belonging to the institution. Although the rules do not state specifically why the residents could not stroll into populated areas, it is clear that the fear of spreading Elephant Disease lay behind this restriction.65 The rules of the leprosarium of Brives, drafted in 1259, more clearly stated the reasons for restricting the activities of lepers in its charge. At Brives, the lepers were not allowed to touch the altar or anything belonging to the sanctuary. In fact, they were forbidden to enter the sanctuary of the chapel and were to say their prayers beyond the sanctuary gate. This restriction, however, had nothing to do with lepers’ ritual impurity; the text stated specifically that this clause had been included to prevent the spread of leprosy from sick residents to healthy staff members.66 The rule of Brives added other restrictions. The lepers were to eat in their own refectory, separate from healthy staff members, and they were never to enter the kitchen when food was being prepared. Moreover, they could not pass through workshops where healthy workers were performing their tasks.67 Most humiliating of all, literate lepers and clergy with the disease were not to touch any books belonging to the institution except for one breviary reserved for their use.68 The rules of Brives had special standing throughout Europe because they had been approved by Guido, bishop of Le Puy, in 1259. Five years later, in 1264, Guido was elected bishop of Rome and took the name Pope Clement IV.69 People in France expected leprosariums to isolate lepers from the healthy. In a sermon given in the mid-thirteenth century, Cardinal Eudes de Châteauroux criticized the staffs of leprosariums for their laxity in carrying out their duties. According to the cardinal, if attendants, through their own fault, allowed lepers to escape from their leprosarium, they would be guilty of a sin worse than deliberately setting fire to their neighbors’ homes.70 In 1278, Philippe de Beaumanoir, a well-known expert on canon law, pointed out that asylums for lepers were founded for two reasons: out of charity to assist those stricken with leprosy, and out of prudence to separate the victims of leprosy from the healthy.71

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Although no regulations from Greek leprosariums have survived, we cannot rule out the possibility that precautions were taken at the Zotikos Leprosarium similar to those at Brives to isolate lepers from healthy society. We can state definitively, however, that no text openly asserted that leprosariums were intended to isolate lepers. All the references that we have collected mention the need to alleviate the suffering of the sick as the motivating force in founding asylums for lepers. One story from the legend of Saint Zotikos, however, shows that leprosariums were sometimes used to enclose people by force. One of the Zotikos miracle tales from the eleventh or perhaps the twelfth century described a Khazar Jewish woman who was struck with leprosy. Her brother, now a Christian, tried to convert her to Christianity, but with the moral support of her Jewish husband she successfully resisted her brother’s repeated efforts. After many rebuffs, the brother went to the head of the Zotikos Leprosarium and convinced him to send a detachment of men to remove the woman from her home by force and to keep her imprisoned at the Zotikos. There, free from the support of her husband, she converted to the Christian faith and agreed to be baptized. She emerged from the baptismal waters not only cleansed of her sins but cured of her leprosy.72 For our purposes here, we should note, first, that the head of the leprosarium had a squadron of men under his command who were capable of using force to bring lepers to the Zotikos asylum. Second, we should emphasize that the Zotikos Leprosarium was set up in such a way that residents could not easily leave. In the words of the miracle tale “(the brother), bringing the Khazar woman to the holy enclosure, locked her in.”73 Leprosariums thus served two functions both in the Byzantine Empire and in the West: to assist the victims of Elephant Disease and to isolate them to some degree from the healthy. Byzantine sources, however, never articulated the second goal, as we have shown in previous chapters. The Greek fathers claimed that the fear of contagion was the root cause of cruelty toward lepers. Christians must not be influenced by such fears. Gregory of Nyssa went so far as to deny that elephantiasis could pass from one person to another.74 The funeral oration delivered in honor of John Chrysostom in 407 presented perhaps the strongest moral condemnation of the contagion theory in Byzantine literature.

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For in addition to these other evils, the Demon who hates the human race sowed among all people a suspicion against these wretched brothers (the lepers), a suspicion that believed that the sickness was contagious and that it could transfer to those who came close to it.75

As we saw in chapter 3, under the influence of Greek patristic thought, Byzantine medical writers ceased to make statements about the contagious nature of leprosy. In the West, on the other hand, medical authors increasingly emphasized how contagious leprosy was, a view that led preachers such as Eudes of Châteauroux to consider an escaped resident of a leprosarium more dangerous than a raging fire. Clearly the Latin medical writers helped create an atmosphere of fear regarding Elephant Disease, whereas Byzantine physicians did not. Latin medical writers of the thirteenth century also added a new symptom of leprosy to distinguish it from other skin diseases, a symptom that Galen and Aretaios had not mentioned: a loss of sensation especially in the hands and the feet. Modern medicine has confirmed the accuracy of these observations by medieval physicians because modern Hansen’s disease does, in fact, damage the nerves in an infected person’s limbs, a process that causes numbness in the legs below the knees and in the hands and arms. In describing leprosy, Taddeo Alderotti, a physician who taught at the medical school of Bologna during the thirteenth century, emphasized the lack of feeling in the hands and feet as the primary symptom of leprosy. He precisely described where to look for this numbness. Alderotti observed that a victim of leprosy lost sensation in the little finger and then in the finger next to it. This insensitivity also ran up the muscles from the little finger as far as the elbow and, in some patients, even as far as the shoulder. The same numbness occurred in the toes and the muscles of the leg as far as the knee.76 At the end of the thirteenth century, Arnold of Villanova, who taught medicine at the medical school of Montpellier, devised an elaborate test for verifying the lack of sensation in cases of leprosy. He recommended that the patient be blindfolded. Then the physician should carefully prick the patient’s hands and feet with a needle and ask the patient to indicate where exactly he or she had felt the sharp point. Arnold also advised tricking the patient by not pricking him or her and then asking him or her to point to the place where the needle was felt.77

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Although neither Galen nor Aretaios referred to insensitivity in the limbs as a sign of leprosy, Byzantine physicians may have known about it. Gregory of Nyssa, who had studied medicine formally, made a veiled reference to the anesthetizing effect of leprosy in his sermon counseling charity toward the victims of Elephant Disease.78 It is therefore possible that Latin doctors learned of this symptom through contact with Byzantine medicine in southern Italy or through some Arab texts, or they might have discovered it by observation. William of Tyre, the twelfth-century crusader bishop, served as the tutor for Baldwin IV, the future king of Jerusalem. William noticed that as a boy Baldwin felt no pain in his arms and legs when he and his playmates were pinching one another to see who would cry out first. William maintained that this was the first indication that the young prince was infected with leprosy.79 More interesting questions are why did Latin physicians focus on the anesthetizing effects of Elephant Disease, and why did Arnold of Villanova devise such complicated methods to test for it? Western physicians seem to have been striving to eliminate any error in their diagnosis because the results of having leprosy had such momentous legal and social consequences. In places still using the Lombard law, a local magistrate could order that a leper be expelled immediately from his or her home and community. In the thirteenth century, the Lombard city of Lodi expelled all lepers who were not natives.80 As we noted earlier, English common law deprived a “convicted” leper of all legal rights except possession of his or her property.81 Although in France no law code or universal royal ruling required the isolation of lepers, we know from many sources that both secular lords and church officials forced people with elephantiasis to leave their homes and live either in leprosariums or in isolated places. During the reign of Louis VII (1137– 80), the bishop of Clermont told how a wealthy knight had come down with leprosy. The clergy and people of Clermont forced him to leave his wife and home and to reside in isolation. After visiting the shrine of Saint Thomas of Becket, the knight claimed to have been cured. The bishop of Clermont, however, ordered the knight to appear again before the clergy and people to prove that he did not have leprosy. When the knight refused, the bishop and a prominent local count suspected that his illness had in fact returned.82 By the fourteenth century, many towns in Western Europe had established formal examinations of suspected lepers before special panels that

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included lepers from leprosariums, local representatives, and eventually physicians. There even existed elaborate methods of appealing a sentence of leprosy. Arnold’s careful needle pricking test was obviously designed for such quasijudicial proceedings.83 Byzantine medical texts, on the other hand, have left absolutely no trace of such careful diagnostic methods, nor do Byzantine legal codes or records of court decisions mention any rules about removing lepers from the community and isolating them. The one example of force against a leper that has come down to us is the case of the Khazar woman, discussed previously. In that example, however, her brother requested her incarceration in the Zotikos Leprosarium. In connection with this case, we should recall the sixthcentury text from Palestine where the master of a leprous slave had the power to decide whether to care for his sick bondsman at home or entrust him to a leprosarium.84 In other words, the pater familias determined whether a slave and presumably any other member of the household needed to leave the home or not. Even the decision to divorce a leprous spouse, allowed by the law of the Ecloga, was essentially a family decision. It appears, therefore, that in the Byzantine Empire, state and church never needed precise criteria to determine who suffered from elephantiasis because this decision was left to the pater familias or a family council, methods within the traditional framework of Roman law. In Ell’s article on leprosy in the Dictionary of the Middle Ages, he mentioned religious impulses, fear of the disease, and social attitudes as reasons for the isolation of lepers in Western Europe. As we have indicated, this isolation finally erupted in the French Leper Massacre of 1321. One cannot claim that religious impulses were responsible for the mistrust and isolation of lepers because the same religious impulses influenced orthodox Christians in Byzantium and Catholics in the West. Our research, on the other hand, does confirm that there was greater fear of the disease in the West. Some Latin medical texts did emphasize that Elephant Disease spread easily from person to person. In making these statements, the Latin physicians were repeating observations made by ancient Greek physicians who followed the pneumatist theory of health and illness. Byzantine physicians, on the other hand, although they had access to the same pneumatist theories, repressed any suggestions that leprosy was contagious because such views came to be considered unethical and even inspired by Satan.

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Our research has also confirmed that social attitudes, reflected in legal codes and customary practices, played perhaps the central role in placing victims of Elephant Disease “outside the camp” in some regions of Western Europe. These legal codes, however, all had their origins in Germanic customary law, not the Roman law tradition. Because Charlemagne incorporated the Lombard rule to isolate lepers from healthy society into his capitularies, local customs even in France sometimes required lepers to leave their homes and communities. It is interesting to observe that in the Liber Augustalis, drawn up by Emperor Frederick II Hohenstaufen in 1231 for his kingdom of South Italy, there is no mention of isolating lepers. Frederick, however, was deeply concerned about health issues because he included a detailed regulation about keeping the air pure from improper burials of humans and even animals and about relocating polluting industries away from populated areas.85 In this regulation one would expect something about isolating lepers, but there is no trace of such a regulation. We can explain this only by noting that many areas of Frederick’s kingdom of South Italy used Roman Byzantine law, a system that did not allow for any expulsion or quarantine of lepers by the state.

Chapter 6

Leprosariums in the Latin West

Medical historians and medievalists have long known that leprosariums became common in Western Europe during the High Middle Ages. However, when, and why, Latin Christians founded so many of them has given rise to controversies. Some scholars have claimed that leper hospitals suddenly appeared in the early twelfth century as soldiers returned from the First Crusade; others have argued that such institutions had existed since Merovingian times. Another group of researchers has claimed that Church authorities first established leprosariums, but still others have maintained that they emerged spontaneously from the desire of lepers to live together and support one another. Many other questions concerning leprosariums remain unanswered. Were lepers in an organized leprosarium considered members of a religious community similar to monks, or were they prisoners in an institution of confinement? How were these medieval leper asylums financed and administered? Since the leper residents of these institutions often met in chapter meetings just like monks, did they also have a role in governing their group homes? Finally, since most leprosariums had both male and female patients,

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did women with Elephant Disease stand beside male lepers as equals in the chapter meetings of the residents? In this chapter we briefly discuss these controversies regarding Western leprosariums, where possible in the light of the information concerning similar institutions in the Byzantine world. As always, such a comparative approach helps resolve some questions, but it also raises others, especially regarding Byzantine asylums for victims of Elephant Disease.

The Leprosy Epidemic Since the eighteenth-century Enlightenment, historians have noted the rapid increase in the number of leprosariums following the First Crusade (1095– 1100). In the article devoted to leprosariums in the famous Encyclopédie of Diderot and D’Alembert, Louis Jaucourt first popularized the idea that leprosy arrived in Western Europe as warriors of the First Crusade returned to their homes. After the Christians had established new principalities of brief duration, depopulated the world, ravaged the earth, and committed horrible crimes, connected with both glorious as well as infamous deeds, they finally brought back leprosy as the fruit of their efforts.1

Reflecting the prejudices of many eighteenth-century philosophes, Jaucourt used powerful rhetoric to condemn the medieval crusading ideal in particular and medieval Christianity in general for having unleashed a bloody conflict on the Middle East. The author implied that an epidemic of leprosy accompanied the returning Crusaders and subsequently spread throughout the lands of Western Europe as just punishment for such unprovoked violence. Moreover, the author condemned Western Christendom’s leprosariums as miserably poor, filthy, and ineffective in combating the disease. In Jaucourt’s opinion, the harsh legislation to isolate lepers from society, issued by the Lombard king Rothari in 643, had been more effective in ridding early medieval society of the scourge of elephantiasis than were the leprosariums of the twelfth and thirteenth centuries. Jaucourt’s Encyclopédie article firmly established the belief in a leprosy epidemic following the First Crusade. During the nineteenth century, however,

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historians began to collect evidence that cases of leprosy and even leprosariums had existed in Western Europe long before 1100. In 1907, the Catholic medievalist Godefroid Kurth published a short, but effective, monograph that argued against a leprosy epidemic in the High Middle Ages by marshaling the many sources that referred to lepers and to leper asylums prior to 1100.2 In 2002 Piers Mitchell also dismissed the leper epidemic as a myth, basing his argument on medieval sources, but also, to a great extent, on bioarchaeological evidence. By examining skeletal remains from early medieval burial sites for the marks left on the bones by Elephant Disease, paleopathologists were able to prove that the malady had been widespread prior to 1100. Mitchell, therefore, concluded that the many leprosariums founded after the First Crusade resulted from a new form of Christian piety, not from an actual increase in the number of people with leprosy.3 A decade earlier, however, in 1988, Françoise Bériac had pointed out that twelfth-century observers in France definitely thought that cases of leprosy were increasing in their lifetime. The monks of the Abbey of Saint-Pierrele-Vif in Sens stated that “the number of lepers has increased so much that it is absolutely intolerable for us and our townsmen.” Bériac found similar complaints in two other documents from the reign of King Louis VI (1108– 37). She also demonstrated that in the same period the number of leprosariums, mentioned in the records, increased in France from five to eighteen. By the end of the twelfth century, some cities such as Toulouse had as many as eight leper asylums.4 Other scholars have confirmed that following the First Crusade leprosariums also began to appear in Italy. By the mid-twelfth century, every major Italian city north of Rome had a leper hospital.5 In 1153, documents mentioned an already existing leper community at Genoa.6 To the north of France, the cities of Belgium also opened leprosariums during the twelfth century. Lüttich founded one in 1117, Gent in 1146, and Brussels in 1150.7 The situation in twelfth-century Italy, France, and Belgium resembles in many ways that of fourth-century Asia Minor. Just like the monks from the Abbey of Saint-Pierre-le-Vif, Gregory of Nyssa was convinced that cases of leprosy were increasing rapidly in Cappadocia.8 Moreover, many local bishops from Eustathios of Sebasteia to Basil of Caesarea were building leper asylums.9 Was this building program in Asia Minor only a new form of Christian piety, or did it meet a growing need?

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Most historians now believe that leprosy did indeed increase suddenly in frequency in the twelfth century as it apparently had done in fourthcentury Anatolia and other Byzantine provinces.10 The dramatic increase in cases of Elephant Disease during the twelfth century, however, resulted not only from the Crusades but from growing trade connections and increasing urbanization. As Bériac stated the paradox, the leprosy “epidemic” in twelfthcentury Europe was a sign of economic progress as it had also been in the provinces of the Byzantine Empire during the fourth through the sixth centuries.11

Dark Age Leprosariums Although cases of leprosy did increase in Western Europe after 1100 and the number of leprosariums rapidly multiplied during those years, this does not mean that leper asylums did not exist earlier in the Latin world, as Kurth correctly observed. Bériac also acknowledged that one could find examples of leper asylums before 1100, but according to her, they were much fewer in number and formed spontaneously from the desire of the lepers themselves to provide one another mutual support.12 Bériac maintained that these institutions had few resources and little support from the Church or the secular powers. Only in the twelfth century did leper hospitals assume any organized form. Indeed, we have evidence of leprosarium regulations only after 1100. The first extant rule was drafted in England circa 1130 for the hospital of Saint Mary Magdalene at Dudston.13 Twenty years later, the bishop of Montpellier and the local count approved a rule for the leprosarium in their southern French town.14 Thereafter, many such documents were written. In his collection of French hospital regulations, Léon Le Grand has published thirteen leprosarium rules from the late twelfth through the fourteenth centuries.15 Although Bériac is correct in maintaining that leprosarium rules survive only from the period after the First Crusade, leper hospitals had indeed been organized in the West much earlier. The first had opened many centuries earlier in Rome around 400, clearly modeled on Byzantine institutions. Saint Jerome described how an aristocratic woman named Fabiola founded a hospital for lepers in the Western capital. Jerome called this institution a

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nosocomium, a Greek word that was occasionally used to identify leprosariums in Byzantine sources.16 Jerome never mentioned that the patients at this institution suffered from either lepra or elephantiasis, but his description of the sick whom Fabiola searched out in the streets and piazzas of Rome leaves no doubt that they were lepers. Jerome described the sick at the hospital as having truncated noses, sunken eyes, shriveled and burned feet, and withered thighs—in fact, symptoms of modern lepromatous Hansen’s disease. Jerome also referred to the turgid blood of these patients—a reference to the supposed cause of leprosy. Greek physicians who followed Galen believed that when an excess of black bile poured into a patient’s veins, this humorial imbalance produced a thick blood and sometimes Elephant Disease. Despite his pneumatist doctrines, even Aretaios referred directly to the blood of lepers as muddy.17 Jerome probably avoided using the term lepra or the Greek medical term elephantiasis because there was still confusion in Latin as to the correct name of Elephant Disease.18 The next well-financed leprosarium mentioned in Western sources was opened in the Gallo-Roman town of Chalon-sur-Saône. According to Gregory of Tours, Bishop Agricola had built this institution for lepers outside his town sometime around 550 AD. Gregory used another Greek term, xenodochium, to describe this asylum. Agricola had built a large church as part of this leprosarium, large enough to hold an important liturgical event attended by abbots and other clergy.19 Bishop Agricola had also attended a synod of Gallic bishops held at Orleans in 549. At this assembly, the bishops voted that each diocese should provide food and clothing for those lepers who came from the local area.20 The canons of the Orleans synod did not mention leprosariums, but the example of Bishop Agricola’s large institution suggests that at least some bishops constructed leper asylums to meet the requirements of the Orleans council. A fascinating document from the seventh century provides additional evidence that a system of leprosariums existed in Merovingian Gaul. Adalgisel Grimo, a cleric attached to the church of Verdun and also a member of a powerful Frankish family, wrote a last testament in which he gave most of his property to the Monastery of Saint Agatha. He made three legacies, however, to groups of lepers. He left one legacy to the church of Saints Peter and Vitonus at Verdun, “where the lepers reside,” a second to the lepers at Metz,

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who were to receive the properties into their own power, and a third to the lepers at Maastricht, who exercised their own “potestatem.”21 The testament of Grimo did not explicitly mention leprosariums, but it referred to a church associated with lepers at Verdun, and to two groups of lepers, one at Metz and one at Maastricht, which had some collective identity with legal power to own and administer property. In view of what we know about the leprosarium at Chalon-sur-Saône, it seems that Grimo had left his property to three leper asylums. The bishops of Merovingian Gaul appear to have established a network of assistance for lepers. At their synod of Lyons in 583, they reiterated their requirement that each bishop feed and clothe lepers. They also forbade victims of Elephant Disease to wander from place to place.22 Although much of this episcopal program in Gaul followed what the bishops of Asia Minor had established in their cities in the fourth century, their attempt to limit the movement of lepers from place to place and their requirement that each bishop provide only for the sick in his own diocese had no parallel in the Greek East. In fact, when Chrysostom began to build his new leprosarium in the suburbs of Constantinople, he intended it not for residents of the capital but primarily for lepers who had arrived in his city from Bithynia and other regions of Asia Minor.23 The founder of the Carolingian dynasty, Bishop Arnulf of Metz, was also associated with a leprosarium. Arnulf served as shepherd of the church at Metz for fourteen years, but in 629 he laid aside his episcopal office to live as a hermit near the monastery of Remiremont, founded by Arnulf’s friend Romarich. As part of this ascetic life, Arnulf served a group of lepers. He would regularly wash their feet, prepare their beds, and even cook their meals. Arnulf was obviously working in some kind of leprosarium. Unfortunately, we do not know if this institution belonged to Remiremont or was an independent leper community created by the sick themselves. Arnulf’s example, however, helped establish a strong link between the practice of monastic asceticism in the Frankish world and the charitable labors to relieve the pains of leprosy.24 Circa 720 Abbot Othmar, the founder of the famous monastery of Saint Gall near Lake Constance, built a hospital for lepers (hospitolum in the text) not far from the principal buildings where the monks lived. He made sure to separate the leprosarium both from the monks’ quarters and from a hospice where healthy poor persons received assistance. Othmar provided the

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lepers with food and palliative care. Probably inspired by Arnulf, he himself frequently washed their sores.25 In Italy, the city of Naples also took some measures to assist lepers. The ninth-century Life of Saint Athanasius of Naples mentioned that the lepers, along with other destitute people, lived in a particular place where the citizens provided them with everything they could want. Thus the victims of Elephant Disease did not need to wander around Naples to beg in the streets. There is no indication, however, that victims of elephantiasis received any special care at this institution.26 From the tenth and eleventh centuries, however, we have found no additional references to organized leprosariums. Then, at the very beginning of the twelfth century, the charismatic preacher and hermit, Robert of Arbrissel, founded his monastery at Fontevrault in the Loire River valley. Robert’s ascetic community was remarkable for the leading role it assigned to women, but Robert also included a leprosarium at Fontevrault. He built a church, dedicated to Saint Lazarus, for the lepers, many small cottages for them, and a cloister apparently for the nuns and monks who were assigned to care for the residents of the leprosarium.27 As long as he lived, Robert regularly visited the residents. When he died, he asked to be buried next to “his dearest leprous men and women.”28 In addition to organized leprosariums, founded by Gallo-Roman bishops such as Agricola or Carolingian abbots such as Othmar, many spontaneous leper communities also existed, as Bériac correctly maintained. At the end of the sixth century, Gregory of Tours recounted the following story about Saint Romanus, a monastic leader from the Jura Mountains near the city of Geneva. Romanus was traveling through some wild, uninhabited mountains. As dusk fell, he finally came upon a little hospital where nine lepers were dwelling. All of them welcomed the traveling monk. Romanus asked them to heat some water so that he could wash their sores. Then he had them prepare a sleeping area large enough for all of them to lie down. Romanus did not hesitate to sleep near lepers. During the night, the monk kept vigil and sang psalms. While he was singing, he touched one leper who then awakened to find himself healed. The first leper touched the second who also woke to find that he too had been miraculously cleansed. Each one of the lepers touched the next until all were restored to health.29 Gregory of Tours was obviously familiar with the spontaneous forms of leprosariums. In Gregory’s account, no episcopal official or nearby abbot fi-

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nanced or administered this leprosarium. Rather, these nine lepers, expelled from surrounding villages, had either built a residence for themselves or occupied an abandoned building. The nine lived together for material support: to find or produce sufficient food, to search for firewood, and to prepare their meals. Finally, they were ready to assist the weakest among them as they approached their death.30 According to Bériac, before Robert Arbrissel founded Fontevrault, circa 1101, and established a leper asylum as an integral part of his new monastic complex, leprosariums had emerged through a spontaneous drive on the part of the lepers to form a community just as the sick had done in the hospital that Romanus had visited.31 Even an advanced urban community such as Genoa did not have an organized leprosarium until the mid-twelfth century. Genoese documents first mentioned a city leprosarium in 1150 when a prosperous layman named Bonmartino requested a grant of public property from the town’s four consuls (annually selected leaders of the Genoese republic) to build a church and dormitory for the lepers in Genoa. An unstructured community of lepers, however, had already been living together in the area on a small promontory called Cape Faro, just west of the city. Although Bonmartino provided the money to build the facilities, the lepers themselves petitioned the city government again in 1153 regarding a legal dispute with the nearby parish church of San Teodoro.32 After Bonmartino’s initial grant to begin construction, many other Genoese left legacies to the leprosarium of Cape Faro or donated money during their lifetimes. In fact, this leper asylum received more legacies than any other philanthropic institution in Genoa except for the Hospital of Saint John, administered by the Hospitallers of Jerusalem.33 Bonmartino himself was the first master of the leprosarium for whom we have any information. Before his foundation, however, the lepers no doubt had some sort of organization, but we have no information regarding their customs, which were probably never committed to writing.

Leprosarium Regulations After 1100, the number of leprosariums increased everywhere from Italian towns to the cities of Belgium and even to rural England. Moreover, these asylums began to organize and expand their facilities. At Fontevrault, the

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stimulus came from a monastic leader, but at Genoa it was generated through the initiative of a prosperous layperson and the active cooperation of the existing leper community. One significant result of this remarkable development was the drafting of rules for the lepers who lived in these communities. Unlike the patients of a regular hospital who entered these institutions with acute diseases and either died there or recovered, leprosy victims might remain in a leprosarium for many years until they died, usually from secondary infections. Thus the leper patients formed a permanent community similar to monks in a monastery. The twelfth century saw many new monastic communities form, each with its own religious mission and distinctive administrative rules and regulations for daily life. Thus it is not surprising to find similar regulations composed for the many communities of lepers. As we observed earlier, the oldest of these leprosarium rules to survive came from the small institution of Mary Magdalene at Dudston, near the English town of Gloucester. The extant version of the rules was probably composed around 1130, but, according to the introduction, the famous intellectual and bishop, Ivo of Chartres, had originally written these regulations for the English leprosarium sometime before 1115.34 Ivo also founded the wealthy leprosarium of Beaulieu for his own city of Chartres. Together with the leper asylum at Fontevrault, Ivo’s institution at Chartres served as an inspiration for many later leprosariums throughout France and also in Norman England.35 Although Ivo’s rules for Beaulieu probably inspired those at Dudston, the English institution made some changes. Whereas the residents at Beaulieu regularly received wine to drink with their meals, the lepers at Saint Mary Magdalene received a mug of beer as their normal beverage. The founders of Dudston house no doubt made other adjustments to Ivo’s original rules.36 Despite the views of historians such as Gunther Risse and Sheldon Watts, leprosarium rules prove that these institutions were not designed as prisons to separate lepers from society. At the Dudston leprosarium, if residents repeatedly broke the rules, they were forced to leave.37 Most other leprosariums had similar regulations. If a leper came from a noble or wealthy family, expulsion meant that the sick person had to find some isolated cottage for a residence, as the illustrious knight Heinrich did in the

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twelfth-century German romance Der arme Heinrich.38 For a poor person, however, expulsion could mean a life of begging on the byways of Europe. Thus economic realities did wall in the poorer residents of leprosariums, but the regulations at leper hospitals definitively disprove the notion that these institutions were designed to incarcerate the victims of Elephant Disease. The leprosarium regulations also demonstrate that leper residents were to live lives like those of monks. At Dudston, the lepers were to practice the three monastic virtues—personal poverty (i.e., all property was held in common), obedience to the superior, and chastity. The Dudston lepers were also supposed to display the Christian virtue of patience. Moreover, the lepers at Dudston received some sort of habit because they were forbidden to have additional pairs of clothes made of multicolored cloth.39 The revised rules at Ivo’s leprosarium at Chartres stated explicitly that the leper residents were to wear only the undyed clothing issued by the institution.40 Like monks, lepers were to pray for the benefactors of their institutions and for the residents who had died. The rules of Montpellier (1150s) required the lepers to pray seven “Our Fathers” each day for the salvation of those who had contributed to the community. Moreover, at the death of one of the members of the leprosarium, the literate lepers were to read the entire Psalter.41 Also following the rules of monks, lepers were to be obedient to the master or prior of the community. As we shall see, in some leprosariums the lepers elected their master. They also held chapter meetings, as did the monks. We discuss these chapter sessions again in examining how leprosariums were governed. Finally, just like monks and the thirteenth-century friars, leper residents who left the leprosarium for any reason were to go two by two, not alone.42 Medieval clerics themselves classed residents of leper hospitals together with monks. Circa 1210 conservative canonist Robert of Flamborough wrote a treatise at Paris in which he listed those whom he considered religious (i.e., people who lived a community life according to a series of rules or regula inspired by Christian principles). He listed first the monks and canons; second the Templars and the Hospitallers of Jerusalem; third the lepers who lived in leprosariums; and finally the religious brothers and nuns who cared for the sick in general hospitals and hospices. It is important to notice that Robert considered the lepers themselves members of a religious order, not only the healthy men and women who worked in leprosariums.43

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Not everyone agreed with Robert’s analysis, however. An anonymous treatise known as the Summa Pastoralis, also written in Paris circa 1250, argued vehemently against classifying leper residents in institutions as monks. This author argued that the lepers’ promises of celibacy, obedience, and poverty were not true canonical vows. Second, he stressed that lepers were too weak to keep monastic fasts. Third, he faulted them for paying money to enter their leprosariums because this was the sin of simony. Finally, he accused leper residents of drinking too much.44 In his detailed study of leprosy in the ecclesiastical province of Sens, François-Olivier Touati has cited the Summa Pastoralis as evidence of a change in attitude toward lepers that he detects in the writing of French clerics from the later thirteenth century.45 The tone of the Summa Pastoralis is negative, and in many ways unfair. Leprosarium rules required that lepers fast, but because of their disease they were allowed to follow less rigorous rules. Leniency regarding fasting in the case of the sick, however, was a longstanding principle of Benedictine monasticism. The lepers did often pay for admission to a leprosarium, but this too was an old tradition of organized leprosariums, as we shall demonstrate. Finally, the charge of excessive drinking probably stemmed from the large rations of wine allowed for both male and female lepers at the more affluent institutions.46 The strident tone of the Summa Pastoralis does betray a negative attitude toward lepers, but it also indicates that the author thought he had to present a strong argument to convince many who still considered lepers monks. Other writers of the twelfth and thirteenth centuries had asserted that lepers were especially blessed because God was testing their virtue. Gregory of Nazanzus had expressed this same idea in his Oration XIV, where he compared the effects of Elephant Disease to the sufferings of Job.47 The rules of the leprosarium at Lille, written about ten years before the Liber Pastoralis, considered lepers to have been marked by God with a sign of his special love.48 This seems to imply an even higher status than monks. It is curious that the author of the Liber Pastoralis failed to mention how leprosariums did indeed differ strikingly from monasteries. With a few exceptions, leprosariums accepted both men and women. Of the 170 leprosariums that Bériac studied in Aquitaine, all of them had male and female residents living in the same institution.49 Although they resided in separate dormitories, they prayed together in church and usually ate together in the same refectory. The leprosarium rules all stressed that women and men

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should not meet together in the storage cellars or other suspicious retreats and should not enter the dormitory for the opposite sex, but together they constituted one community.50 Moreover, there is good evidence that the two sexes worked together in governing their communities, as we shall demonstrate. Despite the significance of leprosariums organized along monastic lines with an established rule, it is important to remember that many leper asylums never adopted any formal regulations and remained spontaneous associations of the sick, such as the community of nine lepers that Saint Romanus supposedly visited at the end of the fifth century.51 Such informal leprosariums survived into the High Middle Ages. In fact, most lepers of the twelfth and thirteenth centuries probably lived in such associations. According to Bériac’s study of leprosariums in the dioceses of Cahors and Poitiers, 80 percent of the institutions there seem to have had no formal organization.52

Finances From the beginning, bishops provided resources to support the asylums for those with elephantiasis. With regard to the first leprosariums in northern Asia Minor, circa 350, Epiphanios emphasized “that the bishops of these churches financed the ptochotropheia to the best of their ability.”53 Led by the same philanthropic principles as these Byzantine bishops had followed, the Christian shepherds in sixth-century Gaul took the initiative in assisting lepers, and as part of this program, some bishops built leprosariums. In the same tradition, Ivo, Bishop of Chartres, founded the Grand Beaulieu in the early twelfth century and set an example for many bishops throughout France and England.54 In the West, as we have stressed, monastic leaders such as Othmar at Saint Gaul and Robert of Arbrissel also supported hospitals for lepers. Private benefactors also played an important part in building the many new leprosariums that appeared throughout twelfth-century Europe. Earl Roger of Mowbray founded Burton Lazars, which he surely intended to serve as a leprosarium, when he returned from the Second Crusade in 1150, and Bonmartino helped build a new institution for lepers at Genoa.55 Leprosariums not only received large land grants from private founders, but

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their original endowments were continually augmented by smaller gifts from local knights or wealthy townspeople, as in the case of Saint Lazarus in Paris. At the leprosarium of Brives in southern France, the residents often received additional donations or legacies in money or food supplies.56 Both in the Byzantine East and in the medieval West, episcopal support and private endowments were methods of financing all institutional charities, from hospitals to orphanages. In Western Europe, however, leprosariums had other unique sources of income. At the leprosarium in Montpellier, the victims of Elephant Disease were to hand over to the institution all their money that they carried with them. After a nine-day trial period, the newly arrived residents had to decide whether they were going to remain at Montpellier or leave. If they stayed, the institution claimed their movable wealth.57 Lepers also had to pay entrance fees at German leprosariums. At the large hospital for victims of elephantiasis at Cologne, each sick person made a contribution upon entering the facility. Since the Cologne leprosarium could house one hundred residents, this source of income was significant.58 At Trier, the lepers paid a fixed amount; at Strasbourg, it was a percentage of each sick person’s total wealth.59 The requirement at most French leprosariums that the sick make some sort of payment upon admission lay behind the charge against lepers that they practiced simony and could not be considered monks.60 Another source of income for leprosariums were the testaments by the lepers themselves. At Montpellier, the lepers were required to make their last wills in the presence of two or three witnesses and to have the administrators’ permission. The rules at Montpellier did not state specifically that the residents had to leave some of their estate to the institution, but surely they were under some pressure to do precisely that.61 At Brives, the regulations stated precisely that a sick resident with no heir should leave all of his or her property to the leprosarium, while one who had sons and daughters should consider the institution as a coheir with the children.62 Family members of the leper residents did not always agree with the terms of these testaments. In the early thirteenth century, the family of Jacques the leper refused to hand over the share of Jacques’s estate, which he had promised to the Paris leprosarium of Saint Lazarus. The administrators had to sue Jacques’s heirs in court, and after ten years of litigation, they were ultimately forced to accept a compromise annual cash payment instead of the whole estate.63

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Leprosariums also required lepers to bring some of their own supplies to the asylum. Saint Lazarus in Paris made an agreement with the Abbey of Sainte Geneviève that if any of their monks were stricken with leprosy and needed to enter the Lazarus Leprosarium, the monastery would provide their clothing, an annual cash grant, and a supply of wheat and wine.64 In 1193, the villagers of Nailly promised the leprosarium at Sens that if lepers from their community entered the asylum, these sick would provide their own clothing, a bed with proper sheets and covers, and a cash donation.65 The rules for the leprosarium at Noyon, composed at the end of the twelfth century, required the lepers to bring with them a bed with sheets, blankets, and pillows. They also had to supply some drinking goblets and kitchen pots and pans, as well as some long sheets of cloth. At Noyon, however, the lepers did not need to bring with them any food supplies.66 Some leprosariums also ran taverns for profit. The large leprosarium at Cologne operated an alehouse along the road to Aachen, which enjoyed an exemption from the normal sales tax on beer. As a result, the tavern attracted many patrons, since the leprosarium’s beer cost less than that of competitors.67 At Brives in France, the reformed rules of 1259 forbade the leprosarium from opening a tavern to sell its wine unless the institution’s vineyards began to produce a significant surplus.68 In the twelfth century, the Parisian leprosarium of Saint Lazarus enjoyed the revenues of an annual fair, which was held November 3–11.69 Some of these revenue sources unique to leprosariums had precedents in earlier Byzantine institutions. The two monastic advisers, Barsanouphios and John, told the wealthy landowner of sixth-century Palestine not to care for his leprous slave at home but to put him in a leprosarium and provide his clothing, food, and bedding.70 At first reading, these instructions seemed to contradict the whole tradition of Christian philanthropic care, but almost the exact same set of requirements—providing clothing, food, and bedding—reemerged in the leper hospitals of the West. Apparently Christian opinion both in the Greek East and later in the Latin West was that lepers who had sufficient resources should help pay for their institutional care. With regard to the Western medieval system of demanding some payment from lepers themselves or their families, it is interesting to recall the method that Chrysostom devised for financing his proposed leprosarium at Constantinople. He planned to require that fathers with substantial property

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give the institution the child’s share in the family inheritance.71 We should notice here that the same concept regarding inheritance shares was expressed in the rule of Brives—that is, that the institution had a claim on the leper’s family property equal to that of a surviving heir.72

Governance Leprosariums also differed from hospitals, hospices, and orphanages in how they governed themselves. Unlike patients in a hospital, guests in a hospice, or children in an orphanage, leper residents played the leading role in administering and governing their institutions. As Bériac observed, in many leprosariums the sick elected their masters who had to be lepers themselves.73 Moreover, residents frequently held chapter meetings where they corrected one another’s behavior flaws but also advised the master on administering the leprosarium. The rules of Saint Mary’s at Dudston stated almost nothing about administration. They stressed that the lepers ought to obey the master, but they did not mention how he was chosen. Perhaps the superior of Llanthony Priory appointed the master because the leprosarium had close ties to that religious community. The rules, however, did state that the lepers held chapter meetings in the institution’s chapel at which time “they discussed business.”74 The regulations from Montpellier (circa 1150) also did not mention how the several officials in charge were chosen. The few clauses regarding governance referred to administrators—apparently a committee in charge of the leprosarium.75 The rules at Lille (1239) also did not explain how the prior was chosen, but they required that any new regulations for the institution should be approved “by the common consent of the brothers (the lepers).”76 The rules of Brives (1259), however, provided more precise information on administration. They stated that the lepers should elect one of their own as the master to govern the institution.77 The master had to take an oath before the lepers to protect them and the resources of the house. Moreover, the master could not alienate property without the consent of the lepers assembled in what the rule referred to as the collegium, and he had to give periodic reports on the financies of the institution before the assembled collegium.78 Individual lepers could also have the collegium review the mas-

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ter’s orders if these seemed too burdensome.79 The rules even provided for an impeachment process by which the lepers could remove a master for incompetence, wastefulness, or physical incapacity if his leprosy worsened.80 The regulations at Brives were unusual in specifying clearly how the leprosarium was to be governed. Most regulations focused on daily routines such as fasts, penalties, and prayer obligations and ignored governmental matters that were left to custom. For example, the revised rules of Beaulieu at Chartres (1264) only dealt with reforms in the daily discipline of the lepers and made only a few statements about administrative issues. Only from reading the cartulary of the leprosarium can one discover how the assembly of lepers actually governed together with the institution’s prior. The entry for April 23, 1257, described how the prior met that day along with all the brothers and sisters who were interested and who were physically able to come to the meeting to deal with the institution’s affairs. That the brothers and sisters had to be strong enough to come to the meeting made it clear that the participating members included the leper residents themselves, not only the healthy staff members.81 At the leprosarium of Cape Faro in Genoa, the lepers consistently asserted their right to elect their own prior subject to the confirmation of the bishop. They also had the right to approve all decisions made by their prior in chapter meetings.82 When in the fifteenth century the city government tried to impose priors on the community without the lepers’ consent, the residents appealed directly to Pope Nicholas V, who in 1450 restored the right of the lepers to elect their chief administrator without interference from the local commune.83 Byzantine leprosariums may also have allowed the victims of Elephant Disease to participate in governing their institutions, although the evidence for this is limited. In the miracle tale about the Khazar woman, an official called the epitropos (guardian) of the brothers in Christ (the lepers) dispatched a group of men to arrest the Khazar woman.84 About the same time this miracle tale was composed, Emperor John II Komnenos wrote his rule for the Pantokrator Monastery. He referred to an official at the Zotikos Leprosarium as “supervising (oikonomountos) the care and governance of all the suffering brothers.”85 In neither of these two documents, however, is there any indication how this administrative chief was selected. The ninth-century Treatise of Philotheos specified that the orphanotrophos supervised the secretaries in charge of the Zotikos Leprosarium’s finances,

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but neither this treatise nor any other sources stated specifically that the orphanage director appointed the supervisor at the leper asylum.86 That the orphanotrophos oversaw the administration of the Zotikos institution, however, suggests that the orphanage director also appointed the asylum’s chief administrator. A lead seal of the twelfth-century from the Zotikos Leprosarium, on the other hand, referred to the leper residents as a group. The seal’s inscription reads: “Seal of the brothers of Saint Zotikos.”87 Whoever used this seal did so in the name of all the lepers—what the Latin rule of the leprosarium of Brives called the “collegium” of the lepers. Was such a representative of the sick residents at the Zotikos elected by these same people? If he was elected, did this association of lepers also have the right to discuss matters of interest to their institution as did the residents of many Western leprosariums? To understand better how the Zotikos asylum was governed, it is useful to consider the Saint Lazarus Leprosarium at Candia on Crete. After the Venetians subdued Crete in 1211, they attempted to fuse Byzantine and Venetian institutions to reduce friction between the Western colonizers and their Greek subjects. For example, the Venetian government adopted the Byzantine cult of Saint Titus as an expression of Creten identity, and more significantly, it retained some Byzantine administrative and legal practices in landholding regulations and inheritance laws.88 After the Venetians established the Lazarus Leprosarium, it rapidly evolved into one of the best-endowed philanthropic institutions on the island and received gifts and legacies from both Greeks and Venetianst.89 Its dedication to Saint Lazarus followed Western traditions, but some of the administrative terms and organizational features at the Candia hospital resembled features of the Zotikos Leprosarium.90 An official called a “procurator” administered the Lazarus Leprosarium on Crete. In Greek documents from Crete this official’s title was often translated as epitropos, the term used in the miracle tale at the Zotikos Leprosarium for the official in charge of the men who arrested the Khazar woman.91 The Venetian colonial government appointed this procurator but often chose Orthodox Greeks to fill this post. Leonardo Dellaportas, the renowned Greek poet from Crete, served as procurator of Saint Lazarus from sometime before 1411 to his death in 1420.92 In addition to the procurator who represented the Venetian government, the institution’s documents also referred to officers chosen from among the leper residents of the Lazarus asylum. These representatives accepted gifts

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and legacies in the name of the lepers and were responsible for distributing the benefits fairly to their constituents. These representatives of the collegium of lepers were probably elected, as they were in many leprosariums in Western Europe.93 The leprosarium at Candia thus had an administrator appointed by the government and representatives responsible to an association of leper residents. Some such arrangement may well have been in place also at the Zotikos Leprosarium. Italy also provides examples of dual leadership—a leprosarium official appointed by an outside authority and leaders elected by the lepers. A fascinating document from the archives of the leprosarium at Verona, dated 1146, mentioned a fight between the rector, appointed by the bishop and supported by the lay leaders of the commune, and the lepers who claimed the right to control, administer, and divide “the goods which God and men have given them.”94 The residents of the Verona asylum were thus demanding the very rights exercised by the leper representatives who accepted gifts and distributed them to the residents at the leprosarium of Candia.95 Lepers in Western leprosariums were aware of a tradition of participating in governing their group homes, even in Verona, where the bishop was trying to suppress their administrative activities. In fact, this tradition probably had its origins in the oldest leprosariums because the seventh-century Testament of Grimo referred to the collective legal power of the lepers at Metz and Maastricht.96 On Crete, the residents of the leper hospital elected representatives and probably asserted the same independence as the residents of Western leprosariums. We also have evidence from the Lazarus hospital on Crete that women residents not only attended the chapter meetings but also actively participated in governing the institution. On December 29, 1411, the person who accepted the cash gift in the name of the lepers of Candia was named Irene Ambelakianes.97 In how many other leprosariums did women participate alongside male lepers in governing their institutions?

Women Most leprosariums in Western Europe received both men and women as residents. The small leprosarium at Dudston, England, cared for both sick

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brothers and sisters during the twelfth century. They also met together in chapter meetings, but we have no evidence from Dudston that the women actively participated in debates, though the rules did not specifically exclude them.98 At Chartres, the rules of 1264 required weekly chapter meetings but did not state whether the women participated in debates. As we have seen, however, a document from the leprosarium’s cartulary, dated 1257, mentioned that both men and women patients were summoned to chapter meetings. Moreover, this passage stressed that the men and women who attended took an interest in discussing the institution’s business affairs.99 Another fascinating document from the leprosarium of Verona, however, provides conclusive evidence that women took their place alongside male residents in voicing their views about managerial issues. This document recorded an inquest conducted over several months in 1235. It recorded the testimony of lepers as well as healthy witnesses regarding a complicated dispute between the prior Rodolfo of the principal Veronese leprosarium of Saint Giacomo and the prior of a smaller church and former leprosarium of Saint Agatha outside of Verona. The city government and bishop of Verona had been trying to close smaller leprosariums such as the Saint Agatha institution so that all lepers would reside in one large facility at Saint Giacomo, just outside of Verona’s walls. According to the testimony presented in the document, the lepers of Saint Agatha, both male and female, had approved this action and willingly participated in transferring themselves and their belongings to the new, more spacious institution. The lepers at Saint Agatha, however, had vehemently opposed some of the policies of Prior Rodolfo of Saint Giacomo. A leper woman named Briana gave the longest testimony. She had resided at Saint Agatha and had moved to Saint Giacomo, but she stated that all the lepers, both men and women, of the collegium of Saint Agatha, had met and expressed their opposition to Rodolfo’s plan to lease some of the buildings at Saint Agatha, including the mill, to a community of nuns. Briana and the women lepers with whom she lived had told Rodolfo that they did not want him to lease the property. Rather, the buildings should have been torn down and their contents transferred to Saint Giacomo, while the mill should have been reserved for the use of all the lepers in the newly constituted hospital of Saint Giacomo. Briana further stated that Rodolfo had punished a male leper named Enrico and a female leper named Pecana for speaking out against his project by making them fast on bread and water.

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Briana had also spoken out against the prior according to her testimony, but she was not punished. Briana described men and women lepers working together to stop Rodolfo’s rental schemes. According to her testimony, both male and female residents had repeatedly opposed Rodolfo in chapter meetings and in other venues. Not only had the lepers spoken out against him but the healthy serving staff as well.100 We do not know the outcome of this inquest, but Briana’s testimony clearly showed that the leper residents expected the prior of a leprosarium to obtain the approval of both male and female residents before conducting business regarding the institution’s endowment. Records from the Genoese leprosarium also depicted women as actively engaged in management decisions for their institution. One document described a chapter meeting held on October 22, 1408. Only seven lepers attended—three men and four women. This meeting took place in the early fifteenth century, a time when the number of lepers was rapidly declining throughout Europe. One of the female lepers named Petrina, however, was so weak that she could not walk to the meeting. Nevertheless, she insisted on participating. According to the document, the chapter meeting moved from its usual site and reassembled next to Petrina’s bed in the dormitory for female patients so that she could express her views.101 After reading the Verona and Genoese documents, one is no longer surprised to find the Greek woman Irene Ambelakianes acting as the representative of the lepers at Saint Lazarus on Crete. Irene was not the only woman who appeared in such a capacity at this leprosarium. In the sixteenth century, three more women were mentioned in the cartulary as accepting donations from benefactors and distributing the gifts to the resident lepers.102 Perhaps the most extraordinary example of women lepers who helped govern leprosariums came from South France at the time of the Leper Massacre of 1321. As we explained in chapter 5, a leper named Guillaume Agasse had been arrested at Pamiers in connection with his role in the leper conspiracy. He testified on June 4, 1321, that he had been the commander of the leprosarium of Lestang.103 His title of commander possibly indicates that Agasse supervised a leprosarium that belonged to the military order of Saint Lazarus, also known as the Knights of Saint Lazarus, originally centered in Crusader Jerusalem.104

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During his testimony, Agasse mentioned that he had sent two lepers from his community to the leprosarium in Toulouse, where these representatives found out about the poisoning plot and were given some powder to throw into town fountains. On their way to Toulouse, the two lepers had spent the night at a leprosarium in Auterive, where the commander was a woman named Galaube.105 Agasse’s story about a female commander would be hard to believe if we did not have two other examples of women who presided over leprosariums with both male and female residents. One of the victims of Elephant Disease burned at Uzerche (Lemousin) during the Leper Massacre of 1321 was identified as a major matrona (the chief matron) of the leprosarium of Coursières. A woman with the title of perceptrix was supervising the leprosarium of Thémines in 1343. These two examples, combined with Agasse’s story, demonstrate that at least in southern France women lepers occasionally rose to the post of master (mistress?) of their communities.106 In view of Briana’s testimony from Verona and the evidence of the female officials at the leprosarium at Candia, women apparently were able to rise to positions of responsibility in leper hospitals in other areas of Europe as well. Women played a part in governing Western leprosariums both by participating in chapter meetings and by holding offices, but we have no evidence that they played a similar role in Byzantine institutions for the victims of Elephant Disease. We have seen that some Byzantine leprosariums admitted women. We have examples of institutions at both Antioch and Alexandria that accepted female lepers. The story about the Khazar woman at the Zotikos Leprosarium shows that women lepers could stay at this central hospital in Constantinople. The lead seal of the brothers of Saint Zotikos also reveals some organization for the leper residents there. We have found no statement, however, that women participated in any administrative activities in Byzantine leprosariums other than the example of Candia, but this leprosarium reflected Italian practices as well as those in Byzantine institutions.

Chapter 7

The Knights of Lazarus

During the twelfth and thirteenth centuries a new Western order of fighting “monks” gradually took shape in Crusader Jerusalem, an order known as the “Knights of Saint Lazarus” (or the “Lazarites”). This organization apparently began as a group of ascetic men who served the victims of Elephant Disease in a leprosarium outside the walls of Jerusalem, but less than one hundred years later these ascetics had taken their place alongside the more famous Templar and Hospitaller warriors in battles against the forces of Islam.1 No institution of Western Catholicism was more alien to the orthodox Byzantine worldview than the military orders— organizations of fighting monks whose religious vocation was a commitment to warfare. Byzantine subjects had been shocked that Catholic bishops actually wielded weapons in the First Crusade. How much greater was their rejection of fighting monks, even if those ascetics were shedding the blood of Muslim Turks who had seized much of the empire’s lands?2 Despite the radically “un-Byzantine” vocation that the Knights of Saint Lazarus ultimately adopted, there are

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indications that they first began by serving lepers in what originally had been a Byzantine institution. Scholars have recently devoted considerable attention to the history of the Knights of Saint Lazarus. In 1998, a thorough study of the Knights by Kay Peter Jankrift was published in German. Several years later, in 2003, David Marcombe wrote a major study on the order’s activities in England from 1150 to the Reformation, when Henry VIII disbanded them. Also in 2003, Rafael Hyacinthe completed a thorough study of the order in French.3 In addition to these major works, several important articles have also appeared describing the order’s military and charitable activities.4 In this chapter we summarize the information in these secondary sources to provide a short history of the Lazarus order. During this process, we emphasize the aspects of the Knights’ organization that conformed to practices in other leprosariums in Western Europe as well as indicate features unique to the Lazarites. After this brief review of the Lazarus Knights’ history, we reexamine the order’s origins in twelfth-century Jerusalem and its possible connection to earlier Byzantine efforts to assist victims of elephantiasis. Finally, we investigate how the Knights of Saint Lazarus fit into the wider program of care for lepers in the countries of Latin Christendom. This discussion will lead us back to the Leper Massacre of 1321 in France.

History The origins of the Knights of Saint Lazarus are shadowy due to a lack of primary sources. First, no copy of the original rules of the order has survived. Historians have been forced to use a set of regulations from an obscure convent of the order at Seedorf in Switzerland. Although this document was prepared in the fourteenth century, it did include some of the original regulations from the Jerusalem leprosarium. In the Seedorf redaction, however, the twelfth-century regulations do not survive in the original Latin but have been translated into the local German dialect.5 Second, the archives of the Lazarus Knights were destroyed by a fire at Boigny, France, in 1441. These records had been transferred there from the Crusader lands after the triumph of Islamic forces in 1299. Fortunately, some of the oldest documents had been copied into a manuscript, known as the Turin Cartulary, which has survived in northern Italy until the present day.6

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The first reference to the order’s central leprosarium in Jerusalem is found in a document dated 1142 from the Turin Cartulary. It mentioned a convent for those sick with leprosy and a church dedicated to Saint Lazarus. An anonymous description of Jerusalem, written at about the same time, located the Lazarus Leprosarium outside of the walls of Jerusalem between Tancred’s Tower and the Gate of Saint Stephen, the principal northern entrance to the city. Several other twelfth-century descriptions confirm the location of the Lazarus Leprosarium as standing on the left side of the Gate of Saint Stephen as one departed Crusader Jerusalem. A description of Saladin’s siege of the Holy City in 1187 mentioned two separate dormitories at the leprosarium, one for men and another for women.7 The Livre au Roi, a collection of laws from the Kingdom of Jerusalem, collated circa 1200, required knights throughout the Crusader kingdom who fell ill with leprosy to leave their military fiefs to join the Knights of Saint Lazarus. This regulation provides the first piece of evidence that the brothers of Saint Lazarus had become a military organization. Apparently the Lazarus order now served as an acceptable haven for leprous nobles who, on the one hand, needed to separate themselves from healthy society but, on the other hand, were still obligated to fight for the Crusader kingdom.8 Additional evidence for the militarization of the brothers of Saint Lazarus comes from the thirteenth-century redaction of the Rule of the Templars. According to these revised regulations, if a Templar warrior contracted Elephant Disease, he was required either to withdraw from the Templar convent and live in isolation or to leave the Templars altogether and become an active member of the Knights of Saint Lazarus. From that time on, he would wear the habit of the Lazarites and fight with them in battle. The Templars, however, would pay for the food and other expenses of their former comrade as long as he lived with the Lazarus Knights.9 This Templar obligation to support former members after they had joined the Lazarites followed standard practices back home in Western Europe. As we emphasized in the previous chapter, French monasteries promised to provide food, clothing, and bedding for monks of their communities if any of them fell ill with Elephant Disease and had to take up residence in a nearby leper asylum.10 The Templar Rule and the Livre au Roi not only prove that the Knights of Lazarus had become a fighting order, but they also show how many Latin Crusaders were contracting leprosy in Palestine.11 The famous case of King Baldwin IV (1174– 83) also strengthens the argument that Elephant Disease

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was common among Latin settlers in the Holy Land. Baldwin had developed leprosy early in life while still Bishop William of Tyre’s pupil.12 Baldwin went on to rule the Kingdom of Jerusalem for nine years with no criticism from his peers, at least with regard to his having leprosy. That so many Crusaders suffered from leprosy, including one of only seven kings who ruled in twelfth-century Jerusalem, provides additional support for the argument that the increase of elephantiasis in twelfth-century France, Italy, England, and the Low Countries might indeed be linked to warriors returning from the Holy Land. During the thirteenth century, the Knights of Saint Lazarus suffered tremendous losses in battles against the Muslims. A letter of the Latin Patiarch of Jerusalem, dated 1244, stated that a great number of Lazarite knights, both leprous and healthy, had been killed in a single battle. A ruling of Pope Innocent IV in 1253 allowed the Knights to elect their master from among healthy members of the order because so many sick brothers had perished in combat during the Seventh Crusade (1248–53) that not enough leprous knights survived to form an adequate pool of candidates for the high office of master.13 Innocent’s ruling demonstrates that before 1253 the Knights had always selected their master from among the brothers afflicted with leprosy. Several scholars have expressed surprise that the Knights of Saint Lazarus ordinarily elected a leper as their master; some have even attributed this to a more liberal attitude toward victims of Elephant Disease in the Holy Land, supposedly due to Islamic influence.14 In fact, we have seen that some Western leprosariums also selected their priors from among leprous residents. The rules of the leper asylum at Brives in France, drawn up by the future Pope Clement IV in 1259, required that the leper residents always elect a fellow leper as master.15 Moreover, Agasse, the commander of the leprosarium of Lestang in southern France, also was a leper, and he identified several other leprous masters, including one from Toulouse, in the testimony he gave in June 1321 concerning the supposed leper plot.16 From Italy comes additional evidence that the masters or rectors of leprosariums were often themselves lepers. The records of a small twelfth-century leper asylum near the Lombard town of Voghera demonstrate that the residents always selected a fellow victim of Elephant Disease to govern their community.17 The twelfth-century rules of the Jerusalem convent required that the master of the Lazarites make all of the important decisions with the advice

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of the chapter. We have seen that the leper residents of most leprosariums in the West exercised the same right. The earliest extant rule for leper asylums— the one from Mary Magdelene at Dudston, England—recommended weekly chapter meetings of the lepers to help the master administer their group home.18 At the leprosarium in thirteenth-century Verona, Briana described the boisterous chapter meetings where residents openly opposed the decisions of their prior.19 In many other ways, the Lazarus convent and leprosarium in Jerusalem followed procedures common to most Western leper hospitals. What marked the Lazarus Knights as a unique institution was their role as warriors. Why would a leprosarium have any connection with fighting? To answer this question, Shalamith Shahar suggested in 1982 that the Crusaders’ desperate need for warriors, combined with their elevated susceptibility to Elephant Disease, forced the Lazarus Leprosarium to develop a fighting wing. In other words, so many knights from Western Europe were contracting leprosy in twelfth-century Palestine that Crusader society concluded that it could not afford to let these trained fighting men languish in a regular leprosarium. Despite their illness, they needed to be combat ready. The Templar Rule adds additional support to Shahar’s suggestion.20 As in the secular world, so too with the Templar order many men were falling victim to elephantiasis. The healthy Templars refused to live and fight next to a brother who had contracted what all believed to be a dangerously contagious disease. On the other hand, the Templars did not want the Christian kingdom to lose the services of a Templar warrior—one of the elite fighters of the Crusader state. By transferring their leprous brothers to the Knights of Saint Lazarus, the Templars provided these sick men with the proper physical and psychological support in their illness but also gave them an opportunity to continue fighting as long as their strength held out. We should emphasize that Elephant Disease did not immediately debilitate its victims. The telltale symptoms could appear without at first significantly affecting a man’s strength.21 The leper knights who joined the Lazarus community spent some time in caring for those Lazarites with more advanced leprosy, but they also had opportunities to train for combat. As their condition worsened, they were allowed to withdraw from active military service and eventually entered the infirmary, where stronger brothers now assisted them in their final days. The Knights of Saint Lazarus also accepted healthy knights who fought alongside their leprous colleagues. Some of these healthy warriors joined as

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full members; otherwise, in 1253, Pope Innocent IV would never have made them eligible as candidates for the office of master of the order. Other healthy knights joined as temporary members, a custom that the order of Saint Lazarus adopted from the Templars and the Hospitallers.22 The Knights of Saint Lazarus also accepted guest lepers among whom were women, since one description of Saladin’s siege mentioned a dormitory for female patients at the Lazarus Leprosarium. It seems that such guest lepers were not considered members of the order and did not participate in chapter meetings. They did, of course, receive care from the Lazarite staff. Jankrift has suggested that some of these guest lepers were too poor to pay the entrance fee to join the order.23 If this is true, then such a custom also differed from those in force in Western leprosariums where people with Elephant Disease who were too poor to contribute to their own maintenance were nevertheless integrated into the community and presumably participated fully in chapter meetings with the other lepers.24

Origins Like the Knights of Saint John (the Hospitallers), the Lazarites told many fanciful tales about their origins. As early as the twelfth century, the legend circulated that Hyrcanus, the Hasmonean king of Judah (135–104 BC), had founded the Lazarus Leprosarium more than one hundred years before Christ’s birth. By the fourteenth century, some of the Knights of Lazarus claimed that the fourth-century Pope Damasus had established their house and others thought it to be the Arian emperors Valens and Valentinian. Still others more reasonably claimed that the leper king of Jerusalem, Baldwin IV, had founded the leprosarium in the twelfth century. Most often, however, those Lazarites who attempted to write the history of their order identified as their founder Saint Basil of Caesarea, one of the fourth-century fathers of the Greek (Byzantine) Church.25 Why would members of a Western military order imagine that a Byzantine bishop had any connection to their origins? One answer, of course, was Basil’s reputation for having founded one of the first Christian leprosariums outside the gates of Caesarea in Cappadocia. The Lazarus Knights had surely heard of Basil’s devotion to the victims of Elephant Disease and thus claimed him as a founder. There is also evidence, however, that the Lazarus Lepro-

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sarium had a more direct connection to Byzantine philanthropic institutions, specifically with a leprosarium built by the empress Eudocia in Jerusalem, shortly before her death in 450.26 Many fifth-century sources mention that the empress Eudocia constructed a large church in honor of Saint Stephen the First Martyr. These same sources agree that she built this basilica outside the northern gate of the city, close to the walls of Jerusalem. As we saw in chapter 4, she was also well known for having sponsored several philanthropic institutions in and around Jerusalem.27 According to Nikophoros Kallistos Xanthopoulos, her philanthropic foundations included a large leprosarium in association with her Church of Saint Stephen.28 As we observed in chapter 4, however, Xanthopoulos wrote his chronicle almost nine hundred years later in the fourteenth century. Eudocia’s basilica of Stephen became one of the most famous monuments in Jerusalem. In the sixth century, Byzantine writers began to refer to the Holy City’s northern entrance as the Gate of Saint Stephen because of its proximity to Eudocia’s splendid church.29 The seventh century, however, brought destruction to Jerusalem and Palestine. In 614, the Persians laid siege to Jerusalem and in the process destroyed Eudocia’s church, which was located outside the walls of the city.30 Because leprosariums were also placed outside city walls, they were often destroyed during sieges. From Western Europe comes the example of the large leprosarium at Cologne, which the forces loyal to Emperor Frederick II Hohenstaufen leveled sometime prior to 1243.31 Eudocia’s church was never restored, but the patriarch Sophronios of Jerusalem (634–38) did manage to build a much smaller church on the same site to preserve Saint Stephen’s relics. This much more humble structure survived the Arab conquest of Jerusalem in 638 and was still standing in the early ninth century.32 No description of the Church of Saint Stephen from the prosperous sixth century mentions a leper asylum, nor do any of the seventh-century notices concerning the church’s destruction and Sophronios’s reconstruction program. In 808, however, a pilgrim from the Latin West visited Jerusalem and prepared a short description of the Holy City’s sacred shrines, a description that included valuable information about Saint Stephen’s Church. With regard to this sacred building, the Latin-speaking pilgrim wrote: “In the Church of Saint Stephen where the saint was buried, [there were] two priests and fifteen lepers.”33 This short entry includes a statement that corroborates

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Xanthopoulos’s claim that a leprosarium was associated with the empress Eudocia’s church dedicated to Saint Stephen. Of course, the size of the leper community had shrunk since the sixth century, but such a reduction in residents reflected the rapid decline in the number of Palestinian Christians during the seventh and eighth centuries. As additional support for the existence of a leprosarium next to Saint Stephen’s Church, we should consider the location of Eudocia’s foundation beyond the walls of Jerusalem. By building the church and its adjoining leprosarium just outside the fortifications, the empress was closely following Basil’s example of establishing his ptochotropheion a short distance from the gates of Caesarea in Cappadocia. Let us return now to the Knights of Saint Lazarus. As we observed at the beginning of this chapter, twelfth-century Crusader sources all agree that the leprosarium of the Knights was located beyond the walls of Jerusalem, on the left side of Saint Stephen’s Gate, that is, in a location very close or identical to the place where the empress Eudocia had built her famous basilica and presumably her leprosarium. In addition to the location of the Lazarus Knights’ original leprosarium, we have evidence that a community of lepers had existed at this site from the earliest days of the Crusader Kingdom of Jerusalem before any source indicates that a true order of Saint Lazarus had formed. Before he became Latin bishop of Laodicea near Antioch, a French ascetic named Gerard wrote a treatise on fellow Westerners who were pursuing the ascetic life in the Crusader lands.34 Among these men, Gerard described three Frenchmen who had chosen to devote their lives to serving victims of Elephant Disease and were living in a community just outside the walls of the Holy City. The first was a great feudal lord named Radulf who had arrived from France with seventy knights to fight the forces of Islam. Eventually, Radulf put aside his role as crusading warrior to serve the lepers living in what Gerard called a domus (a religious house). Gerard described a second man named Albericus who fed and bathed the lepers at this same institution. He even carried the weakest patients from place to place on his shoulders. A third man named Bartholomew first joined the Templars, but subsequently he left this famous military order to imitate Albericus’s labors on behalf of the lepers.35 All of Gerard’s descriptions date from the reign of King Baldwin II (1118–31), that is, more than ten years before the earliest document registered in the Lazarus order’s cartulary.36

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Gerard’s information provides the link between a preexisting leprosarium and the later Lazarus institution. At first Latin ascetics began to serve lepers at an older charitable facility for lepers outside the city’s walls, near the ancient Church of Saint Stephen. They carried water, prepared food, and washed the lepers’ sores. Gradually, these Latins formed a religious order on Western models and took control of the preexisting leprosarium, the heir of the community with fifteen lepers and two Greek priests described by the ninth-century Latin pilgrim. In his recent book on the Knights of Saint Lazarus in England, David Marcombe mentioned the leper foundation of the empress Eudocia but rejected any connection to the later Crusader institution. As we have argued, there are good reasons based both on the location of the Lazarus Leprosarium as well as on the consistent testimony of sources over several centuries to believe that indeed the Lazarites had begun as a group of Westerners who had consecrated themselves to serve the victims of elephantiasis living in an ancient Byzantine philanthropic institution. Such an evolution would explain why later historians of the order believed that Saint Basil of Caesarea originally founded their religious community.

The Knights of Saint Lazarus in the West How many leprosariums did the Knights of Saint Lazarus operate in the lands of Western Europe? Historians have had difficulty answering this simple question because medieval sources often describe leprosariums without including any information on who administered these institutions. For example, writing in 1938, Emilio Nasalli-Rocca assumed that almost all the twelfth- and thirteenth-century leprosariums in Italy belonged to the Lazarus Knights because these institutions were dedicated to Saint Lazarus.37 At the other extreme, David Marcombe has claimed that the order might not have cared for any victims of Elephant Disease in their English houses. Marcombe developed his suspicions regarding the Knights of Saint Lazarus after a careful study of their principal English convent, Burton Lazars.38 Upon returning from the Second Crusade in 1150, Earl Roger of Mowbrey donated an extensive tract of land at Burton Lazars to the Lazarus order, apparently so the Lazarites could establish a leprosarium for England’s growing number of lepers, an institution similar to the one that Earl Roger

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had seen outside of Jerusalem.39 Marcombe, however, has shown that both the documents from Burton Lazars and the archaeological evidence do not show that any lepers were ever given care at this convent. Rather, Burton Lazars served as the administrative hub for the order’s substantial property holdings throughout England.40 Marcombe also assembled more damning evidence regarding the Lazarites’ behavior in the case of the Saint Giles Leprosarium at Holburn outside of medieval London. King Henry I’s first wife, Matilda, had founded this leper asylum in the early twelfth century. The institution thus enjoyed a close relationship with the monarchy but also with London because it primarily accepted lepers from that city. Saint Giles Holborn subsequently expanded to become a large leprosarium designed to care for forty residents. Maintaining services at the leprosarium became a fiscal burden for King Edward I (1272–1307). At the beginning of the fourteenth century, therefore, King Edward decided to give control over Saint Giles to the Knights of Saint Lazarus. Twenty years later, the city government of London complained that the Lazarites were using Saint Giles to house members of the order and were refusing to admit lepers from the city. The Knights finally agreed to care for fourteen lepers, but they later complained about providing services for even that small number.41 As a result of his research, Marcombe finally came to the conclusion that the Knights of Saint Lazarus were using the image of the suffering lepers to extort money and property grants from gullible Englishmen and were assisting few victims of Elephant Disease. The French historian Rafael Hyacinthe also maintained that the Lazarus Knights played only a limited role in caring for lepers in Western Europe. Their primary goal in the West was to maintain a network of estates that provided money for their crusading activities and their leprosariums in the Middle East.42 In this practice, the Lazarites were simply following the organizational plan of the Templars and the Hospitallers.

Pope Clement IV and the Lazarus Knights Pope Clement IV’s bull of August 5, 1265, presents the strongest evidence against Marcombe’s thesis.43 According to this papal order, Clement expected that the Knights of Saint Lazarus would not only assume care for lepers from

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a regional capital such as London, but that they would take custody of all the victims of Elephant Disease in Catholic Europe. Clement, in fact, commanded that all the archbishops and bishops of Christendom cooperate with agents of the Lazarites to transfer all lepers—male and female, clerical and lay—to leprosariums of the order. The pope also commanded that the lepers transfer to the Knights of Saint Lazarus all their movable and immovable property.44 The text of Clement’s order leaves no doubt that the pope envisioned a great enclosure of all those with elephantiasis in leprosariums administered by the Knights. Clement justified his radical program by citing the injunction of Leviticus 13, that all lepers should be removed “outside the camp.” Strangely, Clement’s bull escaped the notice of Watts, Risse, Porter, and Brody, as well as many other scholars who have claimed that the medieval Catholic Church was primarily concerned with isolating lepers as sinners rather than assisting them as those whom God had marked for heaven. Clement surely wanted to isolate lepers, but to ensure public health, not to punish victims of leprosy for their supposed sins. Historians of the Lazarus order such as Jankrift and Hyacinthe, however, have interpreted Clement’s plan primarily as part of a papal effort to rescue the Knights of Saint Lazarus from serious financial trouble. With the fall of Jerusalem to Saladin in 1187, the Knights had lost many revenue-producing estates in Palestine. As Muslim forces scored more victories over the Crusaders during the thirteenth century, the order’s resources continued to dwindle in the East. The same scenario afflicted the Templars and the Hospitallers, but the larger crusading orders had greater resources in the West to supplant their losses in the East. In their efforts to revive the crusading movement in general, popes of the mid-thirteenth century initiated a number of policies to assist the Knights of Lazarus. In 1234, Pope Gregory IX granted indulgences to all those who donated to the order. Pope Innocent IV (1243–54) commanded bishops to cooperate with agents of the Lazarites who were collecting funds in their dioceses. Pope Alexander IV (1254– 61) pledged to hand over to the order fines levied on those who had promised to go on Crusade and had subsequently broken their vow. Clement’s order to transfer all lepers and their property to the custody of the Knights was thus the final move in a consistent papal policy to rescue the order from financial ruin.45 It seems to us, however, that Clement’s bull should also be examined in light of his reform of the Brives leprosarium, a plan he had executed while

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still serving as bishop of Le Puy in south-central France from 1256 to 1259. Bishop Guido (Clement’s baptismal name) drafted one of the most detailed set of leprosarium regulations found in Le Grand’s collection of French hospital rules. Bishop Guido’s rules, in fact, resemble a written constitution aimed at guaranteeing the rights of leper residents.46 As we explained in the previous chapter, Guido’s “constitution” stipulated that the lepers had the right to elect their own superior from among the sick residents of their house; required that the superior’s major decisions be approved by all the lepers meeting in chapter; insisted that all financial dealings be revealed in quarterly reports to all the lepers; and, finally, instituted a method of removing superiors for incompetence or dishonesty. On the other hand, Guido’s “constitution” included strict rules to separate the leper residents from healthy people. Bishop Guido aimed at protecting the rights of lepers to self-government but also at ensuring public health by limiting the spread of leprosy. If one compares Guido’s regulations for the Brives leprosarium with his bull of 1265, it appears that the French bishop’s concern as pope was primarily to contain what he believed was a highly contagious disease by centralizing control of leprosariums under the Knights of Saint Lazarus and by forcing all lepers to enter these institutions. The regulations issued by Charles of Anjou, king of Sicily from 1266 to 1285, confirm this interpretation. Pope Clement IV and Charles of Anjou, the young brother of King Louis IX of France and Count Alphonse of Toulouse, were closely tied even before Guido was elected pope at Perugia on February 5, 1265. Once pope, Clement sealed the alliance between the papacy and Charles, an alliance that led directly to Charles’s victory over the Hohenstaufen family in Italy and his successful conquest of the kingdom of Sicily.47 In 1269, less than a year after his decisive victory over the Hohenstaufen at the Battle of Tagliacozzo (August 25, 1268), Charles issued an order to all his officials to assist agents of the Lazarites in collecting the lepers of the kingdom and relocating them to the order’s leprosariums. Charles gave as his reason for issuing this order that leper residents of some leprosariums (apparently those not belonging to the order) were disobedient.48 In a second order, issued a year later, in 1270, he described these unruly lepers as those who wandered through the towns of the realm begging from the generous.49 Charles stated that he was undertaking this program because he wanted those with leprosy segregated from the healthy population.50

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In 1272, Charles issued a third proclamation regarding lepers. The king repeated his order that all lepers be placed in institutions belonging to the Knights of Saint Lazarus, but he added that when they entered these leprosariums the sick were to surrender all their movable property to the Lazarites.51 The wording of this last decree leaves no doubt that Charles was endeavoring to implement Pope Clement’s plan in his new kingdom. In his second decree of 1270, King Charles mentioned that many people, including family members of lepers, opposed his centralization policy.52 Nevertheless, there are some indications that Charles and Pope Clement succeeded in their efforts. The leprosarium of Saint Agatha at Messina on the island of Sicily seems to have been an independent institution in the twelfth century, but by the 1270s it was controlled by the Knights of Saint Lazarus.53 Court documents from Naples also mention a leper who claimed that he had been miraculously cured of his ailment, and he was now seeking to reclaim his property from the Knights of Saint Lazarus.54 Outside the kingdom of Naples, however, there is little evidence that Clement’s program had any effect, but that Pope Clement conceived such a scheme and that King Charles I of Sicily actually implemented the plan demonstrate that the Knights of Lazarus did care for victims of Elephant Disease in some countries of Western Europe on a large scale, though apparently not in England.

The Leper Massacre of 1321 We have already discussed the Leper Massacre of 1321 in chapter 5, but we shall reexamine it here in the context of the Knights of Saint Lazarus and Clement’s plan to enclose victims of leprosy in the order’s leprosariums. As Malcolm Barber has shown, the records of the inquisition at Pamiers in southern France under Bishop Fournier have contributed some revealing details concerning the leper conspiracy.55 Guillaume Agasse, identified in the court records as superior of the leprosarium of Lestang at Pamiers, testified three times before the Pamiers inquisition during 1321. His testimony seems to be describing a conspiracy of lepers within the Lazarite order. According to the court records, Agasse’s official title as superior of his leprosarium was commander, a rank used by the Knights of Saint Lazarus to designate the head of an

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individual community of the Knights with or without a leprosarium attached to it.56 During his second and third appearances before the inquisition, Agasse described how Jourdan, the preceptor of a large leprosarium at Toulouse, had ordered him to travel immediately to Toulouse to discuss important matters. “Preceptor” is another title used by the Knights for a regional officer who supervised the individual commanders in his province. That Jourdan expected Agasse to obey immediately reflects the command structure of a hierarchical religious order such as the Knights of Saint Lazarus.57 Agasse also testified that, when he had first arrived at the leprosarium in Toulouse, he participated in a meeting of between forty and fifty lepers, many of whom were commanders and preceptors from various regions of southern France. In addition, Agasse maintained that the meeting had been summoned to gain the support of all the commanders for the plot to poison fountains, wells, and streams throughout Christendom. According to Agasse’s testimony, this plan had been approved in advance “by our superiors.”58 All the details of Agasse’s account suggest a highly structured group of leprosariums under a central command, not a collection of independent leper hospitals founded and supported by local bishops, monasteries, and wealthy lay lords, or organized by the leper residents themselves. Agasse also claimed that the emir of Granada and the sultan of Baghdad (at the time there was no sultan ruling in Baghdad) had instigated the poisoning scheme. Agasse embellished his tale by mentioning that these Muslim potentates required the lepers to renounce Christianity and to spit on the cross as a sign to seal their commitment to the conspiracy.59 Agasse linked the leper plot to rejecting Christianity and to conspiring with the Muslim enemies of Europe. Indeed, Agasse’s stories seem to have borrowed many details from the accusations fabricated by the French royal government ten years earlier against Jacques de Molay and his Templars. Both Barber and Jankrift have pointed out this correspondence.60 In view of the similarities between the charges against the Templars and those made by Agasse against the leper conspirators, the suspicion arises that the Leper Massacre of 1321 may have been the result of another attack, orchestrated by the French royal government, on an international crusading order. King Philip IV had succeeded in crushing the Templars and seizing some of their assets in 1314. In the period 1320–21 did Philip V utilize the same tactics against the Knights of Saint Lazarus? If this, indeed, was

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Philip’s plan, the king’s attack on the Lazarites misfired and ended in a mass uprising against all lepers rather than in a successful confiscation by the French government of Lazarite leprosariums and their resources.61 Agasse’s testimony about Muslim support for the leper conspiracy to poison the water supplies was obviously false. Moreover, some of his statements about individuals he named in his first deposition were also fabrications because he later retracted them.62 Did Agasse also lie when he was describing a network of leprosariums in Languedoc under the control of the Knights of Saint Lazarus? Most historians of the order would agree with Marcombe that Lazarite houses in the West did not maintain many leprosariums. Should one, therefore, reject everything that Agasse claimed in his testimony before the inquisition? We suggest that in fact Agasse was telling the truth regarding the organization of leprosariums. First, the details about the leprosarium commanders and preceptors served as background information. If Agasse had painted a false picture of leprosarium organization in southern France, no one would have accepted his outlandish claims about a conspiracy to poison the waters, a plot that he claimed had been inspired by Muslim potentates. Second, there are reasons to believe that Pope Clement’s policy to centralize the care of lepers under the supervision of the Knights of Saint Lazarus was not only implemented in the Kingdom of Sicily but also in Languedoc. As we noted earlier, before becoming pope, Guido had served as bishop of Le Puy. In 1259, however, he was elected archbishop of Narbonne. During Guido’s time as archbishop of this city from 1259 to 1261, both Toulouse and Pamiers—the two principle locations in Agasse’s description of the network of leprosariums—were within Guido’s metropolitan jurisdiction. Moreover, Guido also had close ties with Count Alphonse II of Toulouse, the greatest feudal lord at the time in Languadoc and the brother of Charles of Anjou. It is our opinion that Guido, with the support of the count of Toulouse, instituted a program to transfer to the control of the Lazarites all leprosariums within the ecclesiastical province of Narbonne in Lanquedoc. This would account for the highly organized network of leprosariums described by Agasse in his testimony of 1321.63 Charles of Anjou simply imitated his brother Alphonse’s policies regarding leprosariums when Charles began to implement Pope Clement’s (Guido’s) plan in the Kingdom of Sicily. Such a scenario would account for the network of hierarchically organized leper hospitals that Agasse described in his court testimony.

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A document dated August 24, 1268, provides additional evidence that the leprosariums in the ecclesiastical province of Narbonne had been organized into some sort of a federation during the time Alphonse II held the county of Toulouse. According to the document, several ministri (officials) of leprosariums in Toulouse appeared before Count Alphonse to ask that he order his officials to cease collecting market dues and transit fees for food and clothing that the leper hospitals purchased for their own use. These ministri represented not only their own leprosariums but all of the leper hospitals in the diocese of Toulouse.64 Another document from 1306 reveals a similar organization of leprosariums around Toulouse. In that year the leprosariums of the diocese took common action against the city government of Castelsarrasin, a modest town northwest of Toulouse. Two lepers representing the city of Toulouse, along with one leper from the leprosarium of Montauban and one from the leprosarium of Montcuq, joined the commander of the leprosarium of Castelsarrasin to oppose the elected officials of that town. Bériac has found other examples of leprosariums working together in joint missions and assemblies. In fact, she compares their coordinated activities in Aquitaine to those of the mendicant orders.65 What was the nature of this association of leprosariums? Neither of these documents mentions that the leprosariums of the diocese of Toulouse formed part of a network of houses belonging to the Lazarus order, but in view of what Pope Clement IV decreed in 1265 and the legislation initiated by King Charles of Anjou in the kingdom of Sicily after his victory at Tagliacozza in 1268, one is tempted to see the organization of leper hospitals in and around Toulouse as part of the same program. If indeed the leprosariums of the diocese of Toulouse and of other cities in the ecclesiastical province of Narbonne had formed some sort of a permanent organization or had been integrated into the order of Saint Lazarus, it is perhaps easier to understand the fear that underlay the Leper Massacre of 1321. An organization of all the leper hospitals around Narbonne and Toulouse would have controlled considerable resources, especially if this organization formed part of the Lazarus order. That leprosarium officials organized coordinated legal actions against their opponents to protect their interests could easily have generated distrust and fear among the healthy toward leprosariums and their residents.

Conclusion

When Pope Clement IV issued his order in 1265 to enclose all of Europe’s lepers in leprosariums under the control of the order of Saint Lazarus, he envisioned a far-reaching campaign to remove those sick with Elephant Disease from contact with healthy society. As we stressed in the previous chapter, he justified his efforts with the statement of Leviticus 13:46, that those with leprosy should “live outside the camp.”1 Pope Clement’s decree is evidence to support what Roy Porter maintains in his history of medicine “[Lepers] were segregated in special houses outside towns—following the injunction in Leviticus that the ‘unclean’ should dwell beyond the camp.” Clement’s decree might even provide some justification for Foucault’s vivid description of medieval leprosariums as “cities of the damned” that supposedly sprang up all over the face of Europe.2 How, then, do the plans of Pope Clement fit the new scholarship of experts studying medieval leprosy and leprosariums who have stressed that medieval society did not segregate victims of elephantiasis but, rather, revered them as those marked for heaven? Answering this question is even

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more crucial for a proper understanding of medieval ideas about leprosy if, as we have argued, Clement’s plan to organize leprosariums under the order of Saint Lazarus played an important role in generating the profound distrust of lepers in southern France that erupted in 1321 as the infamous Leper Massacre. We have attempted to resolve this problem by comparing medieval Greek ideas about Elephant Disease and Byzantine institutions to assist lepers with views expressed in Western writings and with institutional features of leper hospitals founded in the Catholic Christian world. Central to our study of medieval leprosy is the view that the Latin culture of Western Europe was always closely tied to the Greek world of Byzantium. According to this interpretation, a common Christian culture, enriched by classical Greco-Roman learning, united the Eastern provinces with those of the West. Moreover, the Latin world remained in continual contact with Hellenic culture centered in the Byzantine capital of Constantinople throughout the Middle Ages. It is indeed revealing of this common Christian heritage that Saint Basil in Caesarea and Saint Martin in Gaul, despite the vast distance that separated these two men and the difference in their cultural heritage, stooped to kiss a victim of leprosy at almost the same time during the fourth century. In both the Latin West and the Greek East, these spiritual leaders were shaping a new ethical imperative to accept lepers as suffering brothers in Christ, not to reject them as ritually impure or as objects of divine punishment.3 During the fifth and sixth centuries, Franks, Goths, Vandals, and Lombards took possession of the Latin provinces and permanently separated the West from the East. Despite these major political shifts, Pope Gregory I, circa 600, was still able to recount a detailed story about a contempory monk of Byzantine Asia Minor who had seen the Lord Jesus in the guise of a wandering leper. As late as the ninth century, Bishop Athanasius of Naples supervised both Latin- and Greek-speaking congregations within his diocese.4 Our study of Byzantine legislative history and Western canon law has demonstrated the same close connection. When the Byzantine emperors of the eighth century began to recognize leprosy as grounds for a legal divorce, popes expressed the same opinion in the West. In the late ninth century, however, when Pope Nicholas I reversed this position and declared that no physical disease could annul a marriage, the Byzantine emperors Basil I and

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Leo VI soon affirmed this same opinion and reversed the decrees of their predecessors.5 With regard to medical learning, we have seen how influential in the West were the two Latin translations of Oribasios’s medical encyclopedia, translations carried out somewhere near Ravenna in the sixth century. It is possible, however, that other Greek texts, conserved in Byzantine libraries, had a direct impact on medieval Latin physicians, although visible traces of their effects have been obscured by the accidents of manuscript survival. As we explained in chapter 3, the thirteenth-century Italian physician Taddeo Alderotti maintained that lepers suffered from an abnormally strong sexual drive. In Alderotti’s own words, “Lepers are especially desirous and burn for intercourse and (then) they feel themselves weaker than normal.” 6 Despite the views of some Western medievalists, we have found no parallel for this observation in the Latin translations of Arabic medical sources. In recounting the symptoms of Elephant Disease, however, the Greek text of Aretaios describes a symptom of leprosy in a manner closely resembling Alderotti’s observations. According to the Greek text of Aretaios, “There is a raging desire of Aphrodite, and spontaneous periods of weakness.”7 Obviously Alderotti did not translate word for word Aretaios’s almost poetic description of the sexual desire felt by lepers, but the Italian physician’s text captures the essence of Aretaios’s symptom description: elevated sexual desire, followed by an abnormal feeling of exhaustion. Although no medieval translation into Latin of Aretaios’s On Acute and Chronic Diseases has so far been discovered, we believe that Alderotti somehow had access to the Cappadocian physician’s comments on leprosy, perhaps through a catena of excerpts from Greek medical texts translated into Latin. We know that many Greek manuscripts of such catenae were copied in southern Italy, and that some of these were translated and incorporated into Latin collections of excerpts from medical texts. We should also not rule out the possibility that Alderotti had learned Greek, or even that he had studied medicine in Byzantine territory, as did the famous Italian physician Pietro d’Abano at the beginning of the fourteenth century.8 From the early Middle Ages comes surprising evidence that for many centuries Aretaios’s description of Elephant Disease had been available in some form to people living in the former provinces of the Western Roman Empire. A Latin antidotarium was composed at the Monastery of Lorsch during the reign of Charlemagne (768–814).9 This “Medical Book of Lorsch”

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included a section on leprosy that presented the various reasons people often called this disease “elephantiasis.” Whence comes the name for those with elephantiasis? According to some the name comes from the great size of the elephant animal because Elephant Disease is so much greater than other diseases just as the elephant is greater than all other animals. It is also called Elephant Disease because the color of these elephants is similar to the surface of the body (of those sick persons) described above, both on account of the roughness of the skin and also on account of the black color of the blemishes. . . . Elephant Disease is stronger in power than other diseases and is malignant.10

As we stressed in chapter 1, only Aretaios’s On Acute and Chronic Diseases discussed at length why people called leprosy the “Elephant Disease.” Moreover, Aretaios mentioned both of the reasons repeated by the Lorsch antidotarium: the strength of the elephant and the animal’s rough and black skin.11 Because of this shared Greco-Roman religious and intellectual tradition, it is not surprising that Byzantine and Western leprosariums displayed many similar organizational features. Historians of charity have long understood that the philanthropic institutions organized in the Byzantine Empire set the pattern for later hospitals, hospices, and orphanages in the West. During the early Byzantine centuries (the fourth through the sixth), bishops founded philanthropic institutions by assigning episcopal revenues to support these charities or by transferring ownership of shops or landed estates to these institutions. Both emperors and wealthy private doners imitated the example of bishops. Emperor Justinian (527– 65) enshrined these methods of supporting charitable foundations in his Corpus juris civilis, a text that scholars have long known shaped later Western philanthropic foundations.12 With respect to Byzantine leprosariums, we have shown that institutions belonging to this category of charitable facility differed from all other charitable foundations in the Eastern Empire in that they required recipients of their philanthropic services to contribute to their own maintenance by providing for their food, clothing, and bedding, or by assigning their family inheritances to their new institutional homes. As early as circa 400, John Chrysostom expected that fathers would set aside the inheritance of their

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leprous children as gifts to those leprosariums that were willing to care for their sick children. In view of the parallel development of Byzantine and Latin culture, it is not surprising that we have found the very same methods of financial support, unique to Byzantine leprosariums, in the records of thirteenth-century French asylums for the victims of Elephant Disease.13 Our research has also underscored one striking feature of Western leprosariums that many previous studies have failed to emphasize. In some of these institutions, leper residents exercised a large measure of control over their communities and their endowments. Moreover, female lepers participated as equals in the chapter meetings where residents elected their priors, approved major administrative decisions, and even amended the written regulations that governed their communal lives. Because no rules or archival records survive from Byzantine leprosariums, we cannot know for certain that the victims of elephantiasis enjoyed the same rights of self-government in Eastern leprosariums, but because of the common Christian and classical culture of the Greek and Latin provinces of the former Roman Empire, it is certainly possible that they did. That the leper residents of the Zotikos Leprosarium possessed a lead seal suggests that these patients had formed a legally recognized corporation.14 If they had such an organization, they probably exercised some of the same rights of self-government claimed by lepers in Western institutions. Not all Byzantine ideas and institutions concerning Elephant Disease had an impact on the West. Paul of Aegina’s acute observation that leprosy had an ultimately fatal manifestation and a less severe form—what modern physicians call “lepromatous and tuberculoid Hansen’s disease”—lived on in the medical literature of Byzantium but never influenced Western physicians. With regard to classifying types of leprosy, some doctors of the Catholic Middle Ages followed the distinctions of Arab physicians, a system based on the theory of the four humors, not on the observed severity of the disease’s effects on the human body.15 Although the West shared a common Christian classical tradition with Byzantium, the invasions and subsequent Germanic settlements in the Latinspeaking provinces did introduce new ideas, institutions, and attitudes, markedly different from those of Eastern Christianity. The warrior ethos of the Germanic aristocracy no doubt lay behind the glorification of war, which ultimately led to the Crusades and even to the formation of military orders such as the Templars and the Knights of Saint Lazarus.

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The Germanic peoples also introduced their own customary law to the former Roman provinces. As Germanic laws were written down to form legal manuals, these new collections of laws sometimes contained harsh regulations against lepers, rules that banished the sick from society and deprived these lepers of their legal rights. We have suggested that the rules against lepers in Germanic law codes and even in the customs of English common law may well have been responsible for a popular distrust of lepers, which does seem stronger in the Latin world than in the Byzantine Empire.16 Following some of the ideas presented by Françoise Bériac and Saul Brody, we have also referred to the negative attitude toward lepers in Western medieval romances. We have discussed two versions of the “Tristan Legend,” the German poem “Poor Henry” and the French romance The Quest of the Holy Grail, but we have made no attempt to survey all the Western romance literature to evaluate how lepers were portrayed. We also did not deal with the issue of how victims of leprosy were depicted in the secular romances that Byzantine authors began to write in the twelfth century. One fruitful area for future research on medieval leprosy would be to expand on Saul Brody’s study of the disease in medieval chivalric tales by including Byzantine romance literature. If Byzantine romance writers dealt with lepers and leprosy, did their images of the disease and its victims differ from those of Western writers? Such a study would not only serve to shed more light on attitudes toward Elephant Disease in the Middle Ages, but it would also provide new insight into a much-disputed question about Byzantine literature. To what extent did the Byzantine romance writers draw inspiration from Greek literary tradition, rooted in the Hellenistic period? Or, were they influenced more by contacts with the chivalric society of the West, especially after 1300?17 Another direction for future research would be to locate and publish more primary sources describing how leprosariums operated in the West. Léon Le Grand made available the most useful evidence for reconstructing how medieval leprosariums functioned when he published the community regulations for thirteen French leper hospitals. Carlo Marchesani and Giorgio Sperati have revealed important details concerning leprosarium government by summarizing documents from the archives of the Genoese leper hospital, although so far no edition of this institution’s archival documents has been published. Moreover, French scholars have been preparing editions

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of leprosarium archives for a century. In 1909, René Merlet and Maurice Jusselin published the archives of one of the oldest leper hospitals in France, the Grand-Beaulieu at Chartres. In 2005, Simone Lefèvre completed an edition of 247 documents from the Saint Lazarus leprosarium in Paris, acts drawn up between 1124 and 1254.18 In Germany, G. Klövekorn based his study of the leprosarium in Cologne on his reading of still-unpublished documents from that institution’s archives. Publishing a full edition of these records would offer a wide range of scholars a chance to evaluate directly the evidence from Cologne. These documents from the largest leprosarium in Germany surely offer additional clues as to how lepers governed themselves and how their institutional independence was viewed by the wider world of healthy people. Indeed, scholars meeting at Göttingen and Rouen in 1995 emphasized the need to collect and publish additional archival materials from all regions of Europe.19 Annamaria Rossi Saccomani has made available the most valuable single document for this present study of leprosariums in her excellent edition of seventy-eight documents from the archives of the leper hospitals in medieval Verona. Her document no. 78, recounting the deposition of several witnesses in 1235, has made available the lively testimony of the female leper Briana and of two other leper residents of the San Giacomo alla Tomba leprosarium just outside of Verona. This testimony has been invaluable in showing, first, how active women were in the governance of leprosariums and, second, how the leper residents vehemently resisted any infringement of their rights to govern their community. Briana mentioned the frequent meetings to discuss the policies of the prior Rodolfo, while the male leper Ordericus described a food riot that ended with the lepers’ attack on the institution’s store of supplies.20 In her edition of the Verona document no. 78, Saccomani included the marginalia. At the beginning of Briana’s testimony, an anonymous annotator, apparently a notary with legal training, added a comment in the left margin that this woman was not testifying to what happened at chapter meetings but spoke “from the abundance of the heart,” and therefore her words should be discounted. Was the annotator adding some detail from personal knowledge about Briana or simply making a misogynist comment concerning women’s supposed emotional instability? In another marginal comment at the very beginning of document no. 78, the annotator discounted the assertion in the text that the leper residents

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formed a legal collegium or corporation. The annotator firmly rejected the notion that eating together or electing its own prior established the leper community as a true collegium. Does this marginal comment represent the opinion of one notary, or does it reflect the views of a wider element in the nascent Italian communes, an element that rejected the idea that lepers had any legal standing as a collegium? When we take this comment together with the observation about Briana’s emotional instability, did our annotator also object to the role women were playing in governing leprosariums? To answer these and many other questions concerning the nature of the leper collegia, researchers need to locate and publish documents from other Italian leprosariums. To assemble the seventy-eight documents from Verona’s several leprosariums, Saccomani had to comb through eight present-day archival collections, including the Secret Archives of the Vatican.21 Given the rich collections of medieval documents housed in both private and municipal archives throughout Italy, local historians and archivists in other Italian cities might have the same success in finding a significant number of leprosarium documents as did Saccomani. Such archival research is an absolute precondition for understanding how thirteenth-century Catholic Europeans viewed lepers and their various political organizations. If the annotator’s comments regarding Briana’s testimony and his rejection of the Veronese lepers’ claims to be a self-governing collegium were more than personal opinions, then the growing suspicion of lepers that scholars have detected during the High Middle Ages might not only be based on the fear of contagion but also on a mistrust of the lepers’ concept of participatory governance. Only a thorough study of surviving archival materials can prove that some elements in the medieval world were not only afraid of walking corpses but also of the new concept of the body politic taking shape in the leper hospitals of Europe.

Appendix 1

Aretaios of Cappadocia, On Acute and Chronic Diseases (Books IV.13 and VIII.13)

Translators’ Introduction Aretaios of Cappadocia wrote the most detailed description of Elephant Disease to have survived from the corpus of ancient Greek medical literature. His description of leprosy symptoms appears in Book IV of his only extant treatise, On Acute and Chronic Diseases, and his recommended treatments in Book VIII of the same work. The modern editor of Aretaios’s treatise, Karl Hude, has organized this text as a single opus of eight books. We have used the short title, On Acute and Chronic Diseases, for this work. Previous editors and translators divided Aretaios’s composition into two or four separate treatises. As we explained in chapter 1, modern scholars do not know exactly when Aretaios was active. He was rarely quoted by other physicians in later generations, and scribes did not frequently recopy his writing. As a result, few manuscripts survive that contain the text. Greek physicians of the Byzantine era no doubt found his Ionic dialect difficult to understand. Nevertheless,

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Paul of Aegina was inspired by Aretaios’s discussion of Elephant Disease when he wrote his medical compendium in seventh-century Alexandria. Moreover, the recently edited Therapeutics of the Physician John suggests that Aretaios had more influence on later medical writing than the small number of surviving manuscripts has led us to believe.

English Translation Book IV.13 (pp. 85 to 90 in the Hude edition) (p. 85) 13. Concerning the Elephant (Elephant Disease) There are myriad similarities between the ailment called elephant and the elephant animal, similarities in general appearance, in skin color, in strength, and in its way of life, but the animal has no similarities to any other animal, nor the ailment to any other ailment. As a beast the elephant especially excels [all others], primarily regarding its great size and its great weight (thickness). Regarding the size (height) of this animal, it is as big as when you would put one animal on top of another to form a tower. The elephant is also the heaviest as when you would put together several heavy animals. In shape, however, the elephant is not at all like anything else. With respect to skin color, elephants are all a deep black and over the entire body. [In the case of horses], however, one horse is white such as the Thracian horses of Resos; others are white-footed such as the white-footed Podargos of Menelaus; † others are blond (bay) such as [ . . . ], † a hundred-fifty; others are a dark bluish-black (as in the passage) “taking the shape of a dark haired horse, he lay [beside her] (Iliad 20.224). And so it is regarding cattle and dogs, and whatsoever other creeping creatures or animals thrive throughout the earth. Only elephants are black, dusky in skin color, resembling / (p. 86) night and death. In regard to its form, the elephant has a shapeless head and countenance, unclear in form, on a short neck so that the head seems to sit on the shoulder, and thus is not distinct. The ears are large, flat, and wing-like, [extending] as far as the collar bones and the chest area so that these ears conceal the neck with the shoulders as ships [are concealed] by their sails. The elephant has marvelously white horns against its very black color. Some people call these horns teeth. These horns alone are of such whiteness; nothing of

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any other animal, not even of a white animal, [is of such whiteness]. These horns do not grow above the forehead and temples as they do on animals that have horns, but at the mouth and the upper jaw, going not exactly straight forward, but curving upward a little so that it would be possible to meet with and lift up a heavy object from a standing position with these upwardly curved teeth. These teeth on average measure about six feet in length, but others are much larger than these, as much as two times this length. The upper jaw also has a long protrusion from the upper lip; this protrusion has no bones, is winding and reptile-like [in nature]. There are twin holes at the tip of the protrusion, and nature has bored these holes all the way through to the lungs just like a double flute. The animal uses this protrusion for breathing like a nose, and also like a shepherd’s pipe, but even like hands so that the elephant can take up a Laconian drinking vessel with the protrusion if he wishes. The elephant can hold the cup tightly [with the protrusion] so that no one can take the vessel away from the animal by force except another stronger elephant. With this protrusion, the elephant also searches out grass to feed on. With his small teeth and his mouth, the animal cannot tear apart meat. [He uses this protrusion to eat,] because his especially long legs keep the animal far above the earth, and also his neck is short as I have said. Thus, the elephant is never able to graze the earth with his mouth, and the growth of horns in front of his mouth also prevents the mouth from taking hold of the grass. Thus, the elephant draws up a great load with its protrusion and binding it together with its protrusion in the manner of a sheave-binder, he puts a great deal into his mouth for his stomach. The earliest [writers] appropriately called this organ a proboscis (for feeding) because, projecting in front of the animal, the organ provides food [for the elephant]. Nor is it physically possible for the elephant to drink from a lake or river because of the very same reason. Rather, if the elephant is thirsty, it places the nose tip of its proboscis into the water, and then, as though inhaling, / (p. 87) the elephant draws up a great quantity of water in place of air. When it has filled its nose [with as much water as] a Laconian drinking vessel holds, it pours the water into its mouth like a river. Then, it again draws up the water and again pours it in until it has filled up its stomach like the hold of a freight vessel. Its skin is rough and very thick, having tuberous fissures in it like long furrows. While other hollow and very deep grooves go in one direction, others crisscross these grooves, the whole surface resembling a trice-ploughed fallow

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field. While the hair on other animals is by nature flowing, on the elephant it is a fine down. There are many other differences between elephants and other animals. The leg bends backward at the knees as is the case in man, and the elephant has its breast nipples at the armpits as do women. It is not necessary, however, for me to write these matters down now concerning this animal, but only that which the disease and the elephant possess which is distinct from others and such similarities as the appearance of one suffering from the ailment [under study] has with the natural form of the elephant. Some people also call the disease (Elephant Disease) the lion because of the similarity of the skin above the brow [with that of a lion], which I will describe later. Or they call it satyriasis because of the red coloring of the cheeks and because of the ungovernable and disgraceful drive for sexual intercourse. Still [others] call it herakleion for nothing is greater or stronger than this disease because this sickness is great in strength, and it is far more able to kill than all other diseases. Moreover, it is a disease which is both especially ugly to look at and fearful to see just as the elephant [is] a fearsome beast. It is impossible to escape the disease because it is born from death as its cause. The disease is a significant chilling or a freezing of the innate heat as in the case of one great winter storm when water is turned to snow or to hail, or to sleet or ice. This [chilling] is the common cause of both death and of this disease. The beginning of the disease, however, does not have any clear symptom, nor does any strange discomfort visit the person. Neither does anything appear on the surface of the body so that [it would be possible] immediately to recognize it and to begin to ward it off. Rather, it hides in the internal organs like an unseen fire and smolders for some time, and having taken hold of these inner regions, it breaks out on the surface, and especially the evil fire first becomes visible from the face as though from a watch tower. In other people, however, it first appears at the tip of the elbow, or of the knee, or at the knuckles of the hands and feet. On account of this [progression], men have no hope of a cure since the physician cannot make use of his art at the beginnings of the disease when it is weakest and because those suffering the illness ignore it and are ignorant of its dangers. / (p. 88) Indeed, as in the case of a temporary condition, the patients are sluggish, drowsy, quiet, and suffer dryness in the intestines. Such signs are not at all uncommon among healthy people. As the disease increases, however, the breath becomes foul-smelling from the internal rise of pneuma.

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It seems that some kind of air or something else from outside causes the disease. Urine becomes thick, white, and muddy, like the urine of a donkey. An assimilation of raw and undigested † Aphrodesian † elements [is present], but there is no perception of these things [in the patient], nor any concern. They have no knowledge of this, even if they do not digest [the elements]. Both digestion and lack of digestion are similar. This is not the normal digestion for the useful and natural end in these patients, but a rapid absorption as the disease forcefully pulls [everything] to nourish its own elements. Through this action, the disease dries the lower intestines. Tubercles rise up, one after the other, never continuous, but thick and rough. And the space between the tubercles is cracked just like the skin of the elephant. The veins are enlarged, not because of an excess of blood, but because of the thickness of the skin. In a short time, the seat of the disease becomes clear since everything is stirred up to [form] the same tubercle. In every part of the body, the hairs die first on the hands, the thighs, and the shins, then among the pubic hairs; hair on the chin becomes scarce, as does the hair on the head. [The patients have] very premature graying of their hair and suffer sudden baldness. In a short time, the pubic hair and the beard become sparse. If any hairs remain, these appear less suitable than if they had all fallen away. The skin of the head becomes deeply cracked. There are continuous, deep, and rough wrinkles. There are hard and sharp tubercles on the face, sometimes white at the top, but a grass-green color toward the base. The pulses are weak, heavy, and sluggish as though moving with difficulty through mud. The veins of the temples are raised as are those under the tongue. The excrement is bile-colored and the tongue rough with a rash of small granular bumps. It is not unusual for the whole body to be covered with such a rash; and especially in victims with a poor balance of humors, the flesh is full of eruptions resembling hail. If the disease rises in great quantity from the internal parts and appears on the extremities, there are moss-like markings (lichens) on the tips of the fingers, and itching affects the knees. The patients scratch their knees with pleasure. Sometimes, the moss-like outbreak encircles the chin. The cheeks become red with a moderate swelling. The eyes [of patients] become cloudy and bronze-like, and their eyebrows jut forward / (p. 89) and become thick, but with sparse [hair] and are weighed down like a tubercle with the area between the eyebrows drawn together. The color [of the face] is livid or black. The skin of the

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eyebrows grows large and is pulled down to obscure the eyes in the manner of angry lions (cf. Iliad, 17.136). For this reason the disease is also called leonteion (the lion disease). The countenance is not only like lions or the elephant, but like darkest night (Iliad, 2.463). The noses become jagged with black masses. There is a thick protrusion of the lips, and the lower lip becomes livid. The noses are prominent. The teeth are not white, but appear [colored] with black from the rest of the body. The ears are reddish-black, broken, and elephant-like so as to appear of greater size than normal. There are ulcers at the bases of the ears and a flow of thin liquid ichor; the ears are itchy. [The patients are] shriveled-looking over the whole body with rough wrinkles. Moreover, there are deep grooves of skin like black furrows of a field. From this appearance, the name of the disease is Elephant. There are cracks on the sole and heel of the foot up to the middle toe. If the malady grows stronger, [the patients] develop ulcerous tubercles, and the ulcers on the cheeks, chin, fingers, and knees become malodorous and will not heal. Other ulcers break out on top of others, while still different ulcers are closed up on top of others. Sometimes at this point, some of the members of the patient—the nose, the feet, the genitals, and all parts of the hands—begin to die to the point of falling off. The malady does not kill a person to release the patient thereafter from a disgraceful life and horrible sufferings, but rather his limbs are severed by the disease. The illness is long-lived as is the elephant [among] animals. If the ailment especially causes pain in the limbs, it attacks [the patient] with even greater severity, moving from place to place. There is no unseemly appetite for food; eating and drinking have no taste sensation or enjoyment; rather, there is a hatred of food due to a general annoyance at everything. There is present a raging desire of Aphrodite, and spontaneous periods of weariness. Each member [of the body] seems heavy †and a burden† for the patient, even the small members. Indeed, the body is vexed by everything. [The patient] takes no pleasure in bathing, or not bathing, in eating or abstaining, in exercise or rest. The disease has set upon all parts [of the body]. Sleep is light, but lack of sleep is worse because of what the patient imagines. There is great difficulty in breathing, and choking as though from strangulation [occurs]. Thus, some end their lives sleeping a deep sleep into death. Who would not flee people with such ailments or who would not by repelled even if the victim should be a son or a father, or / (p. 90) happen to be

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a brother. There is fear of the contagion of the disease. As a result, many have placed their dearest relatives in the desert or have brought them to mountains. Some relatives help the sick for a time in their hunger, but others do not assist them at all because they wish that these people would perish. There is an account that one of these lepers who went into the desert saw a viper crawling out of the ground, and burdened by the pressing need of hunger or by his suffering, he ate the snake live in the hope that he might exchange one evil for another. He did not die after that before all his flesh had rotted, and his limbs fell away. According to this same account, another leper saw a viper crawling into a jar of sweet wine. The viper drank the sweet wine to the full and then spit it out and a quantity of poison spilled into the sweet wine. When the animal had drowned in the wine, the man drank a huge quantity of the sweet wine, seeking release from life and his suffering. When he had drunk to the full and was intoxicated, he lay down on the ground right away as though to die. When he awakened from his torpor and his drunkenness, first his hair fell out, then his fingers and nails, then everything became emaciated, but since the life force was still present in the seed, nature reshaped the man as though from birth. He grew new hair and nails, and clean flesh, and he put off his †old skin† just as a serpent sheds his shin. He was called back to a full life, just like any other man. This myth is not completely credible, but also not completely unbelievable because it is believable that evil can be countered by [another] evil. To believe that nature can revivify a man from the embers of life is not so difficult as to believe in some monstrous shape.

Book VIII.13 (pp. 167–70 in Hude’s edition) (p. 167) 13. Treatment of the Elephant (Elephant Disease) In order to cure sickness, it is necessary that the cures be stronger than the diseases. What medical treatment could be victorious against such a malady as the Elephant Disease? This sickness, then, does not attack one part or organ, or only infect the insides of the body or the outside. Rather, the illness dwells within all [internal parts] of the patient / (p. 168) and takes hold of all his exterior parts. It is distasteful and fearful to look upon because it has the appearance of a wild animal, and there is fear no less than

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with the plague (loimos) of living and cohabitating [with the disease] because a rapid infection through respiration occurs to spread [the disease]. What remedy from medicine, therefore, could one find which would be capable of conquering this disease? All medicines, however, are of necessity beneficial together with proper diet, the hot irons, and fire. If you apply these to [Elephant] Disease while it is still in its early stages, there is hope of healing. If, however, the disease has reached the acme of its development and has established its seat in the organs, and especially when it has advanced to the facial features, the sick person has no hope. Therefore, cut the veins at the elbow on both sides, and cut those at the ankle, but not on the same day. An interval of time is better both for a greater flow of blood and for the restoration of strength [in the body]. For, it is necessary that much blood flow and often, since it is the nourishment of the disease. There is, however, a little useful blood in the patient, the nourishment of nature. It must be taken into account that when one draws off the bad, the natural element is also dissolved together with it. [One must draw off the blood] to the point where the disease disappears due to lack of nourishment, because the fresh nourishment, mixed into the body over a period of time, destroys the old [mixture]. Then, make the patient drink the potion hiera (a laxative consisting of many ingredients), not just once, but let it be much and often on account of absorption and elimination. Let there be other purgings with other medications in the food. There should be the purging used for the hip joint which I have already described. The patient should drink much un-separated milk for defecation. The milk should hold a fifth part of water so that all the milk runs through [the body]. Induce the patient quickly to vomit, first after fasting, then after eating, and then with radishes. Let all these therapies be administered often and continuously. Introduce the patient to hellebore at any season, but especially give hellebore in spring and fall, early each day, and again [administer it] the next year. If the disease has strengthened, have the patient drink as many medicinal drinks as anyone knows because it is good to administer many helpful medicines. I will note down as many as I know. Give one ladle of juniper (Cedar of Lebanon, Cedrus libani). Mixing in two ladles of cabbage, give another [measure]. Another remedy [is composed of ] one ladle of juice of iron wort (Sideritis), one ladle of treacle clover (Bituminaria bituminosa), and two ladles of wine and honey. Another remedy [is] a drachma of filings from an elephant’s tooth / (p. 169) with two ladles of

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Cretan wine. In addition, the flesh of vipers—reptile animals— can be formed into small loafs and swallowed down. It is necessary to cut the head and tail from each viper, measuring four inches back. Then boil the snake until [the flesh] separates from the backbone. Forming the snake meat into small loafs, cool these in the shade. Then give these small loafs to swallow down like squill (Urginea maritima). These snakes can also be a dish at dinner, but it is necessary to prepare them just like fish. If the complex medicine [derived from] vipers should be available, drink it instead of all these other [preparations] because it has the strength of all [preparations] together. Clean the body [of the patient] and smooth down the tubercles. Use the myriad other medicines of the Celts who are now called Gauls, spheres made of sodium carbonate with which these Gauls clean their linens, what is called soap. With this [soap] it is best to clean the body in a bath. In addition, purslane (Portulaca oleracea) and evergreen with vinegar clean well, as does a decoction of the roots of monk’s rhubarb (Rumex patientia) with unfired brimstone (Sulfur). [Use] also a mixture of ground bastard sponge (Alcyonium) with sodium carbonate, bitter new wine heated over a fire, unfired brimstone, divided alum, spice root (Saussurea costus), iris bulb, and pepper. It is necessary to mix all these ingredients for each patient, proportionate to the power of each element. Sprinkle this evenly everywhere and rub it in. Anoint the tubercles on the face with the ashes of grapevine branches, mixing this with some fat of wild animals— of a lion, a leopard, or a bear; or if none of these [are available], with the fat of the Egyptian goose. It is best to have similar with dissimilar such as monkey with man. Also perfume of ammonicum gum (from Dorema ammoniacum) with vinegar and the juice of plantain (Plantago major) or knot-grass (Paspalum distichum) are helpful, as are hypocistis (Cytinus hypocistis) and lyceum (Lycium barbarum). If, on the other hand, the flesh is livid, first scarify [the surface] to express fluid. But, if you wish to soothe sections of the skin where the scabs have been stripped away by sharp discharges, a decoction of fenugreek (Trigonella foenum-graecum) is helpful or a mild cleaning agent of peeled-barley juice, or also grease made from roses or from mastic. Frequent baths are helpful for moisturizing and for exhalation of bad humors. Nourishment should be pure, with a good balance of humors, easy to digest and simple. There should be a well-ordered daily routine in everything: in sleeping, in taking walks, and in places where the patient resides. There

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should by gymnastics, running, twisting stretches / (p. 170) and throwing exercises with a leather bag, all done with proper intensity without reaching the point of exhaustion. There should also be vocal exercises and exercises in breathing according to the seasons. The clothing should be clean, not only because it looks better, but because dirty clothing causes itching of the skin. Give the patient wine of wormwood (Artemisia absinthium) on an empty stomach. Bread from barley is best and good salted fish and bitter tree mallow (Lavatera arborea) or [a] half-boiled section of cabbage with a cumin sauce. For dinner [serve] carrot root and porridge and a mixture of wine and old honey together with seafood as much as loosens the stomach [such as] sauces of small shellfish, oysters, sea urchins, and rock-dwelling fish. From terrestrial wild animals, rabbits or swine [are good]. From among birds [serve the patient] all types of partridges, ring doves, domestic doves, and whatever is best from what the territory supports. The ripest of hard-shelled fruits [are good], and sweet wines are better than the natural grape juices. Baths should be in naturally heated, sulfurous water. Life is long by the waters, both by the sea and on board ship. Treatments with hellebore: white hellebore (Veratrum album) is a purgative of the upper digestive track; black hellebore (Helleborus niger), on the other hand, is a purgative of the lower track. White hellebore is not only an emetic, but it is also the most powerful of purgatives, not through the quantity and variety of the excretion (such as cholera produces), nor by the retching and the force of vomiting (with regard to this, traveling on a ship at sea has a greater effect) but with a force and a quality not negligible by which it makes those sick healthy, even by means of a little purging and a little vomiting. In view of the fact that all chronic diseases are firmly rooted, if all other remedies fail, this is the only medicine because white hellebore resembles fire in its powers. Whatever blazing fire accomplishes, white hellebore accomplishes when it penetrates within, producing easy breathing in place of difficult breathing, good coloring in place of paleness, and healthy flesh in place of emaciation.

Appendix 2

Gregory of Nyssa’s Oration, Regarding the Words “As much as you have done for one of these, you have done for me” (Matt. 25:40)

Translators’ Introduction Gregory of Nyssa gave this speech during Lent, probably in 372 AD. It is usually cited by a short title in Latin, De pauperibus amandis II. The page numbers that appear in the following translation in parentheses refer to pages of the critical edition of the Greek text edited by Adrian van Heck (see Bibliography under Gregory of Nyssa, Pauperibus). Because van Heck did not break up the text of the oration into smaller numbered units, we have marked his paragraph breaks with the paragraph symbol (¶). We have added additional unmarked paragraph spacing, based on our understanding of the text (but not identified as paragraphs in the Greek text), to make it easier for the reader to follow the arguments presented. Surprisingly, Gregory’s De pauperibus amandis II had not been translated into English before 2000, despite its importance both for the history of Christian charity and for the study of medieval leprosy. In 2001, however, Susan Holman provided an English translation of this oration in an appendix to

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her monograph The Hungry Are Dying (see Bibliography under Holman). We have included our own translation of De pauperibus amandis II here because this text was so important both in the development of Christian attitudes toward leprosy and in the subsequent history of leprosy in the Byzantine Empire. We believe it will be helpful for readers to have at hand this text as they follow the arguments we have presented.

English Translation ¶ (p. 111) I am still standing before the vision of the fearful advent of the King which the Gospel records. My soul still crouches in fear at what has been said as it contemplates in what awesome manner the heavenly King sits upon his throne of glory, as the reading states. The soul contemplates this magnificent throne which at one moment holds in itself what is boundless, the infinite myriads of angels which surround the King, and that great and awesome King himself who from inexpressible glory looks down upon human nature. The King gathers to Himself the entire race of men who have lived from the time when human beings were first created until this awesome advent, and according to the worth / (p. 112) of their deeds in life renders judgment to each. As [the scripture] has said, he grants the right side to those who have sought out the right choice, but to the dark and rejected ones he assigns the sentence appropriate to their deeds. He addresses each group; to one group [comes] that sweet and good sound “Come, Blessed ones,” and to the other the fearful and dreaded condemnation “Depart, you cursed ones!” (Matt. 25:34, 41). ¶ Because my soul is moved to such fear of what has been read that it seems to be close to these events and to perceive none of the present elements, my mind spends no time in looking at any other of the details presented to analysis and in pondering them logically. These issues, however, are not small or worthy of only a little discussion: that is, to understand how one always present can have an advent, because Christ says, “Behold, I am with you always” (Matt. 28:20). If it is a matter of faith that He is with us now, how can it be proclaimed that He will come, as though not present now? If, as the Apostle says, “In Him we live and move and have our being” (Acts 17:28), no trick of the one who has grasped after all things (the devil) can

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separate in space those who hold fast to Him so that either now He is not present with those embraced [by Him] or in some later time He would expect to be again present with them. I shall also postpone [the question] as to what is the throne of the incorporeal or how there is a circumscription to that which is boundless because these are too great for the present moment. On the other hand, in order that I might not be pushed into the ranks of those who have been rejected [by the Lord] / (p. 113) to the best of my ability I will turn my discourse to the issue (proposed above) for the common benefit. ¶ Too much, my brothers, too much have I, when faced with this threat, been terrified, and I do not deny the suffering of my soul. I would wish that you not hold these fears in low esteem. For he is blessed who fears all because of reverence. The word of wisdom somewhere says that he, who holds a serious matter in contempt, will be held in contempt by God (Prov. 28:14). Therefore, let us consider before the time of these evils how not to suffer the trial of these miserable ones (rejected by the Lord). ¶ What brings release from such fears? Choosing that way of life which the Word has just shown us, the truly fresh and living way. And what is this way? “I was hungry, I was thirsty, I was a stranger and naked, and sick, and in prison.” “As much as you have done for one of these, you have done for me.” And because of this, He says, “Come, blessed of my Father” (Matt. 25:35– 40). And what do we learn from these words? That attention paid to the commandments is a blessing, but indifference to the commandments is condemnation. Let us love the blessing and flee the curse. It is for us on our own authority to choose or not to choose one of [these paths]. We will be in that place to which we incline with our will. Therefore, let us make the Lord of blessing our own Lord, the one who counts concern for those in need as concern for Himself. We should do this especially now when the commandment takes much more substance according to the present condition of life when many are in need of necessities, but many are also in need regarding their own bodies, people who have been wasted away by this terrible disease. Thus, in concern for these victims, let us fulfill for ourselves the good command of love. I shall now speak clearly concerning these people mutilated by this difficult disease. As much as / (p. 114) this disease is greater in these victims, so much more is the blessing clearly greater for those who carry out the labors of the commandment.

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¶ What is to be done? Not oppose the command of the Spirit! That command is not to alienate ourselves from those who share our nature nor to imitate those who are condemned in the Gospel. I mean the priest and the Levite who without sympathy passed by the man who needed mercy, the one left half dead by the robbers according to the narrative (Luke 10:30ff.). If [the priest and the Levite] are guilty because they did not return to the swollen wounds on the man’s naked body, how are we not responsible who imitate these guilty men? Was it indeed much more to gaze on the one who had fallen among robbers compared to gazing on those who have been seized by this malady? You see a man transformed by this terrible disease into the shape of a four-legged creature. In place of hooves or claws, he takes up wooden sticks with the palms of his hands and leaves behind marks on the ground, novel tracks for human pathways. Who would know from such tracks that a human being impressed such marks by his passing? Man, upright in stature, looking toward the heavens, having hands from nature for the service of his labors, is bent down to the ground and becomes a four-legged creature that differs little from an unreasoning animal. With a rough and painful breath from deep within his internal organs, his voice is rasping; he is even more miserable than the animals, if one must dare to say this. Animals / (p. 115) maintained their character from birth in everything as much as possible, and nothing of these attributes was altered to any other characteristic because of any sort of misfortune. This man, on the other hand, as though his nature has been altered, appears as something different, not the living being he was accustomed to be. His hands have taken up the function of feet; his knees have become his supports [on the ground]. The supports given him by nature (his feet) and his ankles have either fallen away completely or are hanging haphazardly and are dragged along according to the situation in the manner of small boats, pulled along by the side [of a larger ship]. Thus, when you see a man in such circumstances, do you not feel regard for your common relationship? Do you not have mercy on a being of your own race, or do you feel revulsion at his misfortune, and hate the supplicant and flee his approach as though it were the assault of a wild beast? And yet it would be well for you to consider carefully that an angel has taken hold of you, a man; and that [this] angel, though without a body or any material nature, felt no disgust at one who was mixed with flesh and blood.

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Why do I speak of angels? The very Lord of angels, the King of heavenly blessedness, became man for your sake and put on Himself this foulsmelling and filthy flesh, bound up together with the soul within it, so that He could heal your sufferings by means of His own touch. You, however, being the same in nature with the sick person, flee from one of the same race. Brother, let this evil counsel in no way at all be acceptable to you. Consider who is deliberating concerning whom, a man concerning a man. [Consider] that you possess no quality of your own alien to your common nature. Do not make rash predictions about the future. Whenever you condemn this disease when it has already appeared in some other body, you make an unlimited judgment against all nature. You have a share in this nature alongside of all the others. Therefore, let this speech be about an issue common to everyone. ¶ How is it that no sorrow at these images overcomes you? / (p. 116) You see men wandering like scattered cattle in search of nourishment. They have rags for clothing, pierced all around with holes. Their staffs in their hands are their weapons and their mode of conveyance. They cannot grasp the staff with their fingers, but they bind it to their palms with straps laced cross-wise. [They have] a ragged sack and a morsel of moldy and rotting bread. Their sack is for them their hearth, house, mattress, bed, treasury, table, every contrivance of life. How, then, should the one in these circumstances reckon himself? [He should consider himself] a man, the one created in God’s image, established to rule over the earth, holding under his control the service of all the animals. This person has come to such a point of misfortune and of change that his appearance causes doubt since he neither bears clearly on his person the distinct marks of a man nor those distinguishing marks of some other animal. If you compare him to a human being, the human characteristics stand opposed to his shapeless form; if you turn to compare him to the animals, these do not offer any similarity to his appearance. Such people as these [victims of Elephant Disease] alone look only to one another and flock together with each other because of the similarity of their sufferings. They have become repulsive to all others, but out of necessity they are not repulsed by one another. Driven out from everywhere, they flow together to form their own people (demos). Do you see these joyless dancers and their mournful, distressing dance? Do you see how they walk in procession with their misfortunes, how they make a theater of their own

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deformed nature? Like some performers, they display the great variety of their ailments to those who gather about them. They are poets of sorrowful melodies, inventors of dark tales, composers / (p. 117) of these painful songs, tragic poets of this new ill-fortuned tragedy, making no use of various tragic narratives to add to their sufferings, but filling the stage with their own evils. What scenes [they present], what tales! What is it, then, that we hear them say? How, without having committed any unjust deed, they were rejected by those who bore them; how they were driven out of cities, driven out of common associations, of feasts, and of festivals, like some murderers or those who kill their own fathers, condemned to perpetual flight. But they are far more unfortunate than these [criminals]. Indeed, it is possible for murderers to migrate somewhere else and live among men. These people, however, alone of all others, are rejected everywhere as though declared to be common enemies to all men. They are considered worthy of no shelter, of sharing no common table, of using no [common] implements. And this is not the worst suffering. Springs of water, used commonly by other men, do not well up for them. Nor are rivers trusted to strip off any pollution of their disease. If a dog laps up some water with his blood-seeking tongue, the water is not considered to have become polluted because of the animal. If a sick person (with leprosy) should approach the water, it is immediately declared unapproachable because of the man. They endure such situations; they suffer such things. Because of all this, these wretched persons must throw themselves before men and beg from everyone who passes by. Often I have cried over this dark scene; often I have experienced despair regarding nature. Now I am confused in my memory. I have seen this miserable suffering; I have seen this scene full of tears. Dead men are placed along the paths of passersby, but not really men, but the / (p. 118) wretched corpses of those who once were human, who lack any signs or identifying markings to confirm [their human nature]. They have no physical characteristics by which they can be recognized as men. Among beings they alone hate themselves. They alone commemorate their birthdays with curses because they hate this day which began for them such a life. They are men who are ashamed to call themselves by this common term so that they might not insult this common nature by their sharing this common name. They live always with lamentations because they have an unceasing reason for their sorrows. As long as they see themselves, they always have something

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to arouse their sorrowing. They are at a loss whether that which they no longer have of their bodies or that which remains to them gives them more pain. [Are they distressed over] how much the disease has already consumed or over what the disease has left to them? Are they distressed because they can see such things about themselves or because they are not capable of seeing since their eyesight has been darkened by the disease? [Are they distressed] because they have such tales to relate concerning themselves or because they are unable to recount their sufferings since they have been deprived of their voice by the disease? Are they anguished because they have need of such nourishment or because they cannot easily take in food since the disease has destroyed the parts surrounding the mouth and thus has hindered eating? [Are they distressed] because in their feeling they suffer the misfortunes of the dead or because they have been deprived of their sense perceptions? Where is their sense of sight? Where is their sense of smell? Where is their sense of touch? Where are their other senses which, as the disease progresses, its corruption consumes little by little? Because of these things, the sick wander through all places like animals migrating to more abundant pastures. They carry around their misfortunes as their provisions for purchasing food, and to all / (p. 119) they display their disease in place of begging, having need of men to guide them because of their sickness and supporting each other because of their profound need. Each one of the sick according to his own ability becomes a support for the other; they make use of the limbs of one another in place of their own missing limbs. They do not appear singly, but their misery brings something wise regarding the meaning of life so that they desire to be seen with one another. Each one of them is by himself pitiable, but to make men more sympathetic, they add their own misfortune to those of others and thus make their own ill-fated contribution to the common goal. From some other misfortune, each one collects mercy for himself. One presents hands that have been cut off, another an inflamed and swollen stomach, another a damaged face, and still another a rotting leg. Each one, laying bare whatever part of the body happens [to be afflicted], has displayed in that part his suffering. ¶ What then! Is it enough that such a violation against the law of nature be for naught and that there be this tragic account of the sufferings of nature, [an oration] describing the disease rhetorically and presenting with passion a memorial in words? Or is there a need for some deed on our part

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to show our sympathy and affection toward such as these? As landscape paintings are to things in their reality, so are speeches distinguished from deeds. For the Lord does not say that salvation is in speaking, but in performing the deeds of salvation. Thus, it is necessary for us ourselves to take up this command regarding [such sick persons]. Let no one say that it is sufficient to provide food to those who have been removed to the farthest border lands, distant from our lives. Such a view does not make any display of mercy or sympathy, but is a specious plot to drive out completely / (p. 120) these people from our lives. Are we not then ashamed of our lifestyle, if we have pigs and dogs living with us under the same roof? The hunter often does not ban the puppy from his own bed. The farmer knows to greet his calf with a kiss. And [if ] this were not much, the traveler washes the legs of his donkey with his own hands and lays his hand upon the animal’s wounds and cleans up the manure and takes care of his bed. Should we treat one of our own family and race with less respect than these animals? Let this not be so, my brothers! Let this charge not be confirmed against men! ¶ It is fitting to recall who we are and who are those about whom we deliberate, that this is a case of human beings who discuss human beings, people who have in themselves no individual characteristic against their common nature. “For all there is one entrance into life” (Wisdom 7:6). There is one way of sustaining life for all—food and drink. There is a similar way of working in life. There is one constitution of the body and one conclusion of life. Every complex structure comes to its dissolution. Nothing that has been put together has a solid constitution. For a short while our body is stretched out by the spirit like a bubble, and then we are extinguished leaving no trace in life of this temporary inflation. Even those memorials on steles and stone tablets and in inscriptions do not last forever. Recall what the Apostle said, “Do not be arrogant, but be afraid” (Rom. 11:20). It is unclear whether or not you are formulating a charge of cruelty against yourself. Do you tell me that you flee the sick person? What charge do you have against the man? [Are you accusing him] because the moist element has been corrupted within him, and some rotten humor has been distributed by the blood because the black bile has been poured into the moist element? This is to listen to the doctors discoursing on the nature of diseases. What injustice has this person done, if his nature is in a state of flux and instable / (p. 121) and has slipped into the form of disease? Do you not see that even

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in healthy bodies, a person sound in all else, has often suffered from a boil or a dark carbuncle or some other ailment of this kind? [This occurs] because the moist element in this section [of the body] has been heated beyond what is necessary and because of this suffers an inflammation and redness and a certain emaciating disorder. What, then? We do not fight against the sick part of the flesh, do we? Just the opposite! We turn every healthy part of the body to treat what has fallen sick. The sickness is not repulsive. Or, if this [sick] part were to cause us harm, the healthy part would cease from the treatment of the sick part. What is the reason, then, that alienates us from these sick people? What is it? Not fearing the threat of the one who says “Depart from me to everlasting fire”; “As much as you have not done for one of these,” and He says, “you have not done it for me” (Matt. 25:41– 45). If people thought that this were the case, they would not hold such an opinion about these sick so that they push them away from their persons and consider concern for these wretched people a pollution of our life. Therefore, if we consider the one who spoke these words worthy of trust, we must take hold of these commands without which it is impossible to be considered worthy of what we hope for. [The victim of leprosy] is a stranger, is naked, is in need of food, sick, and in prison—he is everything to you which has been mentioned in the Gospel. He goes about as a naked vagabond, sick and lacking necessities because of the poverty resulting from his illness. Because [the leper] has nothing from home and is incapable of becoming a hired person, he is of necessity completely lacking in the basic supports of life. He is bound like a prisoner by the disease. Thus, you have the complete fulfillment / (p. 122) of the commandments fulfilled in these people, and you hold the very Lord of all things in your debt because of your philanthropy to this sick person. Why do you struggle against your own life? For a person not to desire the God of all as his very own companion is nothing else than to have a powerful enemy against oneself. Just as God becomes a resident [with us] through the commandment, He is in the same way driven away by cruelty. He says, “Take upon yourselves my yoke” (Matt. 11:29). He identifies the labor of these commandments as the yoke. ¶ Let us heed the one who gives the command. Let us become the draught animal of the Lord by binding ourselves with the yoke straps of love. Let us not shake off this yoke; it is useful and light and does not chafe the neck of the one who goes under it, but [the yoke] smoothes it down. As

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the Apostle says, “Let us sow bountifully so that we might reap bountifully” (2 Cor. 9:6). The stalk which shoots up from such a seed has a great yield. Deep is the standing crop of the Lord’s commands. High are the fruits of His blessing. Do you wish to learn to what height the increase of his fruits stretches? It reaches to the very heights of heaven. As much as you do for these people, you harvest for the heavenly treasuries. Do not lose hope in what has been said, and do not consider the love for such as these [lepers] something contemptible. The hand has been mutilated, but it is not too weak for an alliance. The foot is useless, but it is not hindered from running to God. The eye is melted away, but it sees with the spirit the invisible riches. Do not then consider the ugliness of the body. Wait a little while, and you will see something more unbelievable than any miracle, not so much what has occurred in the realm of nature, always in flux, but that which lasts forever. Whenever the soul has been freed from its connection with the perishable and earth-bound, then it is dazzling with its own beauty. Here is the proof [of what has been said]. / (p. 123) That rich pleasure seeker did not find the hand of the poor man repulsive in the afterlife, but he asked that the finger of the poor man, formerly decomposed, become for him the conveyance of a drop of water, desiring to lick the moisture from around the poor man’s finger with his own tongue. He would not have desired this, if he had seen the unsightly quality of the body in the character of the soul. How fitting it was that in vain the rich man repented in the afterlife? How much did the poor man bless the harshness of his life? How much did the rich man condemn his own lot as destructive to his soul, his lot apportioned to him because of his wealth? If it were possible to return again to life, with whom would the rich man choose to live? Would he choose to be among those fortunate according to this life or with the unfortunate? It is perfectly clear that he would prefer the lot of the unfortunate since he asked that there be some guide from among the dead for his brothers so that they might not be injured by the arrogance of wealth in the extravagance of the flesh, and because of the slippery quality of pleasure, slide down and be taken into the same chasm of Hades (cf. Luke 16:19–31). Why are we not rendered prudent through stories such as these? Why do we not engage in the virtuous business enterprise which the divine Apostle recommends? He says that your abundance should be for their lack so that their excess of relief (from suffering) in the life hereafter will be sufficient

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for your salvation (cf. 2 Cor. 8:14ff.). If, then, we wish to take something useful, let us be first in making an offering. If we wish to be taken in hereafter, let us give shelter now. If we wish to be received by them into the eternal abodes (Luke 16:9), let us receive them now into our homes. If we wish to be healed of the wounds of our sins, let us ourselves do this for the bodies of those who are suffering. “Blessed are the merciful, for they shall receive mercy” (Matt. 5:7). ¶ / (p. 124) Perhaps, however, someone will say that this command is good for later, but right now he must be wary of some contagion and of the infectious quality of the disease. So that he might not suffer something unwanted, he thinks that he must flee the approach of such as these. Such are his words, excuses, and inventions—some specious coverings for his indifference regarding the commands of God. This, however, is not the truth. No fear attaches to carrying out this command. Let no one treat evil with evil. How many can one see among those who from youth to old age are employed in caring for these sick and have not at all weakened the natural sound constitution of the body because of such efforts? Nor is it likely that this would be the case. Whenever these types of [apparently contagious] diseases occur such as epidemic humoral fluxes or other diseases of such a type that they depend on some outside cause such as corrupt air or water, many people suspect that the diseases cross over from those already seized by the sickness to those who draw near. I, however, think that in this situation the ailment does not induce disease in the healthy person from contagion, but rather that a common flux of humors is responsible for the similarity of the disease in many cases. These others, however, believe that [this] disease has its origin by crossing over from those already stricken to other people. This ailment, however, is marked out in the patient when the internal structure of such a disease is established and the blood suffers a certain contamination by the admixture of corrupting humors. It is possible to learn that [what I have outlined above] is the case from the following fact. Does any contagion of the stronger nature ever occur from those of good health to those who are sick, even if the healthy are most heavily involved in caring for them? This is not the case. It is thus not likely that in the contrary direction the ailment would transfer from those who are sick to those who are healthy. If, on the other hand, there is / (p. 125) so much gain from the commandment that the kingdom of heaven is prepared

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by fulfilling it, and on the other hand, there exists no harm to the body of the one who cares [for the sick], what is it, then, that prevents this command of love from being realized? ¶ You say, however, that it is burdensome to force yourself to such physical labors when the condition of many sick people is loathsome. Fine, then. I agree with this statement that it is difficult. Will you identify any other work of virtue which is not painful? The divine law required much sweat and toil for the hopes of heaven and showed that the road of life for human beings is hard to travel, and this law made it narrow on all sides by requiring more difficult and rough tasks to perform. “Narrow and straight” He says, “is the road that leads to life” (Matt. 7:14). What, then? Because of this [difficulty] are you going to neglect this hope of such good things because it is not possible to attain them through laziness? Let us ask the youth if prudence does not seem burdensome or if freely to enjoy the passions does not seem more desirable than a self-disciplined way of life? Are we, then, on account of this, going to uphold [this voluptuous form of living] because it is sweet and easy and, in addition, shun the difficult way to virtue? This does not seem good to the Law Giver of life who blocks the wide and broad, downward-directed path for leading this [earthly] life. For He says, “Go through the narrow and compressed gate” (cf. Matt. 7:13). Therefore, let us legislate here this one [rule] for those things completed successfully through hard work, that we make the distasteful command a habit of life, and let us cure the physical aversion of those who are healthy with the persistence of active labor. Indeed, through persistence habit can make it possible to carry out what seem to be the most difficult [chores]. / (p. 126) Therefore, let no one say that this task is burdensome, but rather that it is helpful to those who seek its fulfillment. Moreover, since the reward is great, one must look past the labor for the sake of the reward. In fact, with time what is now difficult will become sweet through habit. ¶ If it is necessary to add something to what has been said, [that would be] that sympathy for the unfortunate is also helpful for the healthy throughout this present life because, for those who possess intelligence, it is good to show mercy in the midst of others’ misfortunes, for such behavior makes provision of the future. In view of the fact that all humanity lives with one nature and that no one has any certain security of a continually prosperous life for himself, it is proper always to remember the Gospel com-

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mand which advises that whatever we wish that men would do for us, we should do [for others] (cf. Matt. 7:12). As long as you sail in safety, stretch out your hand to the one who suffers shipwreck. The sea is common to all, as are its little waves, and the great confusion of its [mighty] waves. Dangers, hidden beneath the waters, rocks, and promontories, and all the other evils which cause the destruction of life awaken in mariners the same fear. As long as you remain free of suffering, as long as you sail the sea of life free of danger, do not pass by without mercy the one who has fallen. Who stands as surety for you that you will always have a fortunate voyage? You have not yet put in at the harbor of rest; you have not yet stood beyond the waves; a life of stability has not yet come to you. As a seafarer, you are still carried through life. You will ready for yourself sea companions of the quality you yourself will show yourself to be toward a person in distress. Would that we all might arrive at the harbor of rest through the Holy Spirit and enjoy calm during the voyage of life which lies before us. Would that the practice in these commandments and the rudder of love be present within us, commandments through which we, set on our course, might attain the land of / (p. 127) the promise in which stands the great city whose builder and creator is our God to whom be glory and power unto the ages of ages. Amen.

Appendix 3

Selection from The Funeral Oration in Praise of Saint John Chrysostom (Chapters 60.17 to 67.1)

Translators’ Introduction A section of this oration in praise of John Chrysostom (paragraph 60, line 17, to paragraph 67, line 1 in the edition by Wallraff and Ricci) describes in detail how Chrysostom, while serving as bishop of Constantinople, tried to construct a leprosarium, probably on the Asiatic shore of the Bosporos. We, the authors, published the Greek text of this section together with an English translation in Rivista di Studi Bizantini e Neoellenici, n.s., 42 (2005): 33– 43 (see Bibliography under Miller and Nesbitt). As this partial edition was in press, Martin Wallraff and Cristina Ricci published the entire Greek text of this oration along with an Italian translation (see Bibliography under PseudoMartyrius). In preparing their edition, Wallraff and Ricci discovered that the French scholar Michel Aubineau had found a previously unrecorded copy of this oration in the Athos monastery of Koutloumousiou (Koutloumousiou 13, fols. 227r–261r). This manuscript proved to be the most reliable witness to the

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text of this oration. It had been unknown to Florent van Ommeslaeghe, a Belgian scholar who had spent a lifetime studying this oration. Because of the many ambiguities in the text that Ommeslaeghe had established on the basis of two less reliable manuscripts (Parisinus Graecus 1514 and Marcianus Graecus VII.34), he never felt ready to publish an edition of the Greek text of the oration. The discovery of Koutloumousiou 13, however, resolved many of the textual problems that had plagued Ommeslaeghe’s tentative edition. With the new readings from Koutoumousiou 13, Wallraff and Ricci were able to publish their Editio Princeps in 2007. Unfortunately, our Greek text and its accompanying English translation were based only on the two manuscripts that Ommeslaeghe had used. Nevertheless, we have decided to reproduce in appendix 3 our original translation, with a few changes, based on the better Greek text of Wallraff and Ricci. In the following English translation, these changes are enclosed in boldface square brackets [ ], as are the paragraph numbers introduced by Wallraff and Ricci in their edition. Simple slashes in the translation indicate pages in the Paris manuscript (Parisinus Graecus 1514) on which this translation was based. The edition by Wallraff and Ricci provides the actual page numbers of the Paris manuscript. Wallraff and Ricci are confident that this anonymous oration was delivered soon after the death of John Chrysostom in 407. As a result of the tireless efforts of Ommeslaeghe and the work of Wallraff and Ricci, scholars now consider this text a primary source for the study of Chrysostom’s ecclesiastical career in Constantinople (398– 404).

English Translation [chapters 60.17 to 67.1 in the Wallraff and Ricci edition] [60.17] Our speech will surely be stretched to a great length. Now, however, it is time for us to show what eagerness he (Chysostom) had for the love of the poor, [a virtue] especially dear to Christ. Moreover, our preceding section demands this. We will move on in our narrative of events to reveal the madness [of those who opposed Chrysostom]. [61] Among all the poor, then, [Chrysostom] saw some who were fed from the resources of the church, but others who had no share in this assistance. Some of these had other sources of income because they still possessed

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youth and bodily strength, unless they wished to live in idleness. Some with ulcers or illnesses or amputated limbs bore the yoke of poverty with greater difficulty. With these [conditions] they induced all those who passed by to be generous toward them; their natural sympathy pushed those who saw [these suffering poor] to give them support so that their bodily misfortune provided the necessary relief of their poverty. While he (Chrysostom) allowed all of these to remain and to present an opportunity of salvation for those who nourish the Church, he himself emptied out, so to speak, all his feelings of care toward those who were stricken with what is called the holy disease. I believe that this disease has acquired such a name because it surpasses all human misfortunes and pain. For it is truly the worst of diseases, a disease at the same time inspiring pity and hatred. It draws even the soul as hard as a diamond to pity, but it also drives away the most philanthropic soul, whenever it might be necessary to touch the afflicted body. This disease dissolves the bond of family relationship and overturns the law of friendship; this disease deprives those taken by it of the joy of life and of the repose of death. On the one hand, this disease makes living something odious, and on the other hand, it makes death long. This disease demands very many things for its treatment, but at the same time deprives [the victim] of everything. For in addition to these other evils, the Demon who hates the human race sowed among all people a suspicion against these wretched brothers, a suspicion that believed that this sickness was contagious and that it could transfer to those who came close to it. Thus, all of those people who dwell in homes and cities forbade that those with the disease should enter their houses or agoras, baths or cities. Even if someone has a son [with this illness], he decrees these same [restrictions] against the one he sired, even though the son is still living. / Even if the victim is his brother, his friend, or his constant companion, once the disease has begun, he approves the same restrictions for him as for all the other [sick] people, and this occasion for sympathy thus extinguishes the flame of loving affection which nature has enkindled. [62] When the blessed one (John Chrysostom) saw many among these sick stricken [with these symptoms] abandoned along the roads in the land of the Bithynians—unburied corpses, moving cadavers, creeping bodies, rational beings who sent forth inarticulate sounds, who displayed only so much of their [natural] character that those who saw them knew that at one time they had been human beings—the saint moistened his cheeks with streams

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of tears, and said, “What must one do for his fellows if he would lighten such a misfortune for these brethren?” Some people said that they gave a little silver to these people, but that they had to free themselves from the sight of these stricken ones. The saint, however, said that people of ordinary character would do such a thing, but he turned his thoughts to building houses / for those without hearths and to devising for them the comforts of those who dwell in the city. On account of the size of the building project and the great number of those gathered together—for the number of those sick with this disease was in the thousands—the saint said that he wanted to build a dwelling and make room not only for as many as one could calculate, but [also so that there would be no more] of those in the land who were wrestling with this misery. [He said] that he planned sufficient revenues for all these afflicted ones for all time through the possession of fields and [that he planned] to allocate the possessions of the fathers for those expelled from their paternal homes on account of the burden of the body. [He said that he would do this] not only for those sick at that time, but in case any other person was ever seized by the shackles of this disease so that that person would have a place to flee to as to his own refuge. By chance, he managed to purchase what was the goal of his plan, banishing from his mind every delay. He carried out the first step / of his labors by finding a place for sale which was most especially suited for this use. This place happened to possess the lightest air and a river flowing past which would be useful for the sick in cleaning the filth from their wounds. As soon as he purchased it and began the foundation, [63] a war awaited him within because the Devil, [seeing that those who were fighting with Chrysostom had relaxed their efforts a little], worked myriad evils so that the saint could not stand the blow. Those who happened to be the owners of fields which were near to this location made accusations that they had suffered an injustice, as though the disease had already passed to them; the river which previously made the land [fertile] for them, now was suspected of bringing the infectious ruin of these sick persons even to the [landowners]. Cowardly because of their suspicion, deserving of pity because of their cowardliness! [These landowners] ought to have acknowledged thanks to God that / they have been established only as observers of others’ misfortunes and that they have never tasted the experience of such suffering themselves. They, however, have both hated the water and also fled from [that

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same water which washed the wounds of those human bodies, water which was not confined in one place but by the current of its flow was able both to show and to hide from onlookers what was offensive]. While he softened the anger of these men with words concerning hell and the kingdom of heaven, he allowed those who wished not to be persuaded to do and to say whatever they might wish. He, however, moved every skilled hand to the work [64]. When, in fact, the construction was pressing on toward the second floor, the Demon moved those who shared his thoughts to hasten to destroy the one who was constructing these things. No sooner did they etch in the last letter than they sent messengers to the office of violations and commanded that work cease and that [those involved in the construction rapidly repay the money to those (who had begun the legal action)]. And now the house stands without a roof. It leaves those who see it with open mouths for two reasons: to praise and proclaim the one man for his philanthropia and to curse the others for their love of money. [65] Is there anyone of you who still doubts that these men who do not spare such money have raised up war against Christ, or that they have not heeded Christ when he says that “whatever you do to the least of my brothers, you do to me?” (Matt. 25:40). They not only have not done this, but they have seized the things of the one who has done it, and they assume the role of enemies and warriors against the one who has done it. How have they not launched [arrows] against the very heavens or rather against their own heads, those who, through their own money, have brought back upon themselves these diseases of the brothers, / just as Gehazi [brought upon himself] the leprosy of Naaman. In this way the fire of Gehenna might have been more bearable for them. Although Gehazi sought false payment for the healing grace, he paid the penalty (2 Kings 5). These people, however, have taken away the very therapeutic treatment from those who are suffering. Because of this, they would have suffered a far more just punishment than did Gehazi, if they had suffered, but since they have escaped for now this punishment, let them await a more severe fire there [66]. Nor will I willingly hide the guarantee of the Lord’s anger against what has taken place. When these [landowners] had crossed over to the city in pursuit of such trophies against piety and praised in song the victory monuments [erected] against the truth, the philanthropic God, the savior of all and guarantor of the just one, / did not wish the death of the sinner so much as that the sinner turn around and live. Because of this [mercy], He always holds the bow taut

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and ready for the conversion of such men. Knowing that the root of all evil had been hidden in the woman in power, He let loose his hand and the [arrow flew] and took hold of her wretched womb; God reminded her by saying, “O Woman, in pain will you conceive children from your womb.” Sending forth her child for the tomb and winding together the final burial sheets with the first swaddling cloths, in one instant, she was both mother and childless, [67] and indeed, her barrenness bore fruit. For on the next day, giving commands to her spear bearers, she drove away those who frequented the porticos of the emperor and who received the woman’s words as though they were some oracle, with lashes of the whip and verbal threats. She also ordered her horse soldiers to pursue him (Chrysostom), and she brought him back and intended to take away the church as rapidly as possible.

Abbreviations

AB

Analecta Bollandiana

ActaSS

Acta Sanctorum

CMG

Corpus Medicorum Graecorum

CSHB

Corpus Scriptorum Historiae Byzantinae

DOP

Dumbarton Oaks Papers

GCS

Die griechischen christlichen Schriftsteller der ersten Jahrhunderte

JCod

Corpus juris civilis. Vol. 2: Codex Justinianus

JGR

Jus Graecoromanum

JNov

Corpus juris civilis. Vol. 3: Novellae

LCL

Loeb Classical Library

MGH

Monumenta Germaniae Historica

ODB

Oxford Dictionary of Byzantium

PG

Patrologia cursus completus. Series graeca

PL

Patrologia cursus completus. Series latina

REB

Revue des Études Byzantines

SC

Sources Chrétiennes

TheoCod

Codex Theodosianus

Notes

Introduction 1. In her influential work, Illness as Metaphor (1978), Susan Sontag made a similar point in comparing society’s reactions to those who suffered from tuberculosis with its feelings about the “alien nature” of cancer. 2. For a modern scientific description of leprosy, see the standard medical handbook Harrison’s Principles, pp. 1021–27. For a less technical discussion of symptoms, see Brody, The Disease of the Soul, pp. 21–33. For the term walking corpses, see the anonymous sermon in honor of John Chrysostom (Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ” pp. 38–39). Cf. Gregory of Nazianzos’s description (Gregory of Nazianzos, Oratio XIV, 10 [col. 869]). 3. Thomas of Celano, Vita secunda S. Francisci Assisiensis, 9, pp. 14–15. 4. See Newstead, “The Origin and Growth of the Tristan Legend,” p. 124, and note 1. 5. The Quest of the Holy Grail, chap. 12, pp. 245– 49. 6. Brody, The Disease of the Soul. 7. During the 1980s the AIDS epidemic stimulated a wave of publications that compared the medieval belief that lepers were suffering a divine punishment for their sins with contemporary responses to AIDS victims. See Moore, The Formation of a Persecuting Society, which views medieval Christianity’s attempt to place lepers in charitable

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institutions as the first stages in forming a society ready to persecute outsiders. Anthropologists have also compared medieval approaches to lepers and leprosariums with witch hunts. An influential article by Mary Douglas, published in 1991, maintained that some African tribes in what was the Belgian Congo prior to 1960 used accusations of witchcraft to eliminate political enemies or economic rivals. Douglas claimed that the medieval Catholic Church and secular powers used a diagnosis of leprosy for similar ends. In 1997 the historian Sheldon Watts, developing Douglas’s argument, maintained that very few lepers in the medieval period actually suffered from the dreaded disease. According to Watts, church and civil officials used a charge of leprosy to imprison undesirable members of society in leprosariums. 8. See Bériac, Histoire des lépreux au Moyen-Âge. Bériac undercut some of the extreme views expressed by Moore and refuted in advance much of what Watts would later assert. 9. See Touati, Maladie et société au Moyen Âge. Touati’s book has been especially effective in dispelling erroneous but widely held views concerning the persecution of medieval lepers. 10. Bruno Tabuteau, in his “Historical Research Developments on Leprosy in France and Western Europe,” pp. 41–56, recounts the history of studies on medieval leprosy in Europe during the past twenty years; see especially pp. 49–51. See also Demaitre, Leprosy in Premodern Medicine, esp. pp. 45–51. Demaitre’s detailed study of leper trials from the late medieval and early modern periods revealed that these trials were not hasty show trials devised to rid society of undesirables but were carefully conducted medical exams employing methods that even today would be valid for diagnosing true leprosy. 11. See, especially, Touati, Maladie et société, pp. 27–58, esp. pp. 47–58; also see Rawcliffe, Leprosy in Medieval England, pp. 1– 43. 12. See Touati, Maladie et société, pp. 47– 49, and note 81. 13. See Foucault, Madness and Civilization, p. 3. 14. See Porter, The Greatest Benefit to Mankind, p. 121. Other textbooks still used in courses on the history of medicine make statements similar to Porter’s. See, for instance, Conrad, Nive, Nutton, Porter, and Wear, The Western Medical Tradition, p. 188. 15. Byzantium is frequently given short shrift in accounts of the medieval Christian world. In part, this is because Byzantine (Orthodox) and Latin (Catholic) Christians of the Middle Ages came to see one another as distinct cultures and, after the beginning of the Crusading movement, as enemies. It is also true that modern academic institutions tend to treat Byzantine history and medieval history as separate subjects, thus limiting the gaze of many medievalists to France, England, Italy, and the other heirs of Latin Christendom. 16. Our book is certainly not the first to examine leprosy and leprosariums in the Byzantine world. Two important articles by Armin Hohlweg and Paul Gläser appeared in a comprehensive study sponsored by the German Medical Museum, Aussatz, Lepra, Hansen-Krankheit. Ein Menschheitsproblem im Wandel. Teil II: Aufsätze (1986). See Hohlweg, “Zur Geschichte der Lepra in Byzanz,” pp. 69–78; Gläser, “Der Lepra-Begriff in der patristischen Literatur, pp. 63–67.” Also see Sidéris, “Lèpre et lépreux à Constantinople,” pp. 187–207. None of these excellent articles, however, makes any attempt to link the Byzantine experience to that of Western Europe.

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17. Because our study focuses primarily on the Christian response to leprosy, we do not devote much space to leprosy’s impact on the world of Islam. We have, however, included some information concerning Arab medical writers who were influenced by ancient Greek and Byzantine physicians and in turn had a profound effect on Latin doctors both in eleventh-century Salerno in southern Italy and later in Toledo in Spain. One cannot discuss Latin physicians such as Taddeo Alderotti or Arnold of Villanova without referring to Arab medical texts. 18. Galen, De usu partium, Book 1, pp. 1– 64. 19. Galen, Ad Glauconem, 2.12, pp. 139– 44. 20. Rawcliffe, Leprosy in Medieval England, p. 23. 21. Brody, Disease of the Soul, pp. 21–33; Manchester, “Tuberculosis and Leprosy in Antiquity,” p. 167. 22. Riddle, “Research Procedures in Evaluating Medieval Medicine,” pp. 3–5. 23. Manchester, “Tuberculosis and Leprosy,” pp. 167– 68. 24. For Germany, see Schmitz-Cliever, “Zur Osteoarchäologie der mittelalterlichen Lepra (II),” pp. 182–200; for Denmark, see Møller-Christensen, Bone Changes in Leprosy, pp. 44– 46; for England, see Farley and Manchester, “The Cemetery of the Leper Hospital of St. Margaret, High Wycombe, Buckinghamshire,” p. 87, and the comments of Rawcliffe, Leprosy in Medieval England, pp. 3– 4, and esp. note 10 for additional excavations of English leprosariums. For a summary of ongoing archaeological projects in France, see Tabuteau, “Historical Research Developments,” pp. 47– 48.

Chapter 1 1. See Watts, Epidemics and History, pp. 43– 44, but especially see Manchester, “Tuberculosis and Leprosy in Antiquity,” p. 168. 2. Rostovtzeff, The Social and Economic History of the Hellenistic World, vol. 1, 386– 89; Casson, The Periplus Maris Erythraei, pp. 12, 36. 3. Manchester, “Tuberculosis and Leprosy in Antiquity,” pp. 167– 68. 4. The Greek text of Rufus is preserved in Oribasios, Oeuvres d’Oribase, 45.28 (4:63– 64). For an English translation, see Grmek, Diseases of the Ancient World, pp. 168– 69. 5. Rufus of Ephesus, in Oribasios, Oeuvres d’Oribase, 45.28 (4:63– 64). 6. Lucretius, De rerum natura, 6.1114–15, pp. 522–23. 7. Apotelesmatica, 1.53–55. The text is cited and reproduced in Gascou, “L’ elephantiasis en Égypte gréco-romaine (faits, répresentations, institutions),” p. 261. This passage also mentions festering sores and the loss of fingers, all symptoms of the modern Hansen’s disease. The Apotelesmatika is an instructional poem on astrology. Unfortunately, its date is uncertain. 8. Pliny the Elder, Natural History, 26.5, pp. 270–71. 9. Plutarch, Table Talk, book 8, question 9.1 [731 A–B], pp. 186– 87. 10. Galen, Ad Glauconem, 2.12, p. 142. 11. Ibid., 2.12, pp. 142– 44. 12. Rowlandson, Women and Society in Greek and Roman Egypt, doc. 268, p. 341. 13. Aretaios, Aretaeus, 4.13, pp. 85–90; 8.13, pp. 167–70.

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Notes to Pages 14–24

14. For a thorough discussion of Aretaios and the problems of dating his work, see Oberhelman, “On the Chronology and Pneumatism of Aretaios of Cappadocia,” in Aufstieg und Niedergang der römischen Welt, pp. 941– 66. 15. For a discussion of Aretaios’s practice of pathological anatomy, see Weber, Areteo di Cappadocia, pp. 9–21; for pathological dissections during the Justinianic plague, see Procopius, Wars, Books I and II, in Procopius, 2.22.29, p. 460. 16. Oberhelman, “On the Chronology and Pneumatism of Aretaios of Cappadocia,” pp. 959– 66. 17. Aretaios, Aretaeus, 4.13.1– 8, pp. 85– 87. 18. Plutarch, Table Talk, book 8, question 9 [731–34], pp. 186–203. For an excellent discussion of this passage, see Nutton, “The Seeds of Disease,” pp. 11–13. 19. Thucydides, History of the Peloponnesian War, Books I and II, 2.47, p. 342. 20. Aretaios, Aretaeus, 8.13.1–2, p. 168. 21. Ibid., 4.13.9–11, pp. 87– 88; 8.13.1, pp. 167– 68. See also the discussion of pneumatists in Nutton, Ancient Medicine, pp. 202– 6. 22. Aretaios, Aretaeus, 4.13.11–12, p. 88: τοιάδε ὁ ἀήρ, ἤ τι τῶν ἔξωθεν, αἰτίην ἴσχειν δοκέει (literal English translation: “the air or something from those things outside seems to be the cause”). 23. Ibid., 4.13.18–19, pp. 89–90. 24. Ibid., 4.13.17, p. 89. 25. See Fauci et al., eds., Harrison’s Principles of Internal Medicine, pp. 1324–26 (the modern term for this disease is lymphatic filariasis). See also Gascou, “L’ elephantiasis en Égypte gréco-romaine,” p. 274, note 32, for the evidence that the sixteenth-century Italian physician and scholar Niccolo Leoniceno first recognized that Arab physicians used the term elephantiasis for an ailment distinct from Elephant Disease. As a result, physicians began to call leprosy “elephantiasis of the Greeks.” 26. Grmek, Diseases of the Ancient World, pp. 165– 68. 27. Theophrastus, Characters, chap. 19, pp. 116–17. 28. Zacharias, Ioannis Actuarii de diagnosi, in Physici et medici graeci, 2.23, p. 455. 29. Bériac, Histoire, pp. 38–39. See also Grmek, Diseases of the Ancient World, pp. 160– 64, who believes that Hansen’s disease was indeed present among some of the people of Israel who were diagnosed as suffering from tsa’arath. 30. Bériac, Histoire, pp. 38– 41; Grmek, Diseases of the Ancient World, p. 163. 31. Romanos, Kontakia of Romanos, Byzantine Melodist, pp. 75– 83. 32. Gregory of Nazianzos, In laudem Basilii, 63.7, p. 192. 33. Caelius Aurelianus, On Acute Diseases and On Chronic Diseases, 4.1, pp. 814–15. 34. Constantine, Elephancia, 1, pp. 74–75. 35. Avicenna, Liber Canonis, fol. 442–443, liber 4, fen 3, tract 3. 36. Bériac, Histoire, pp. 41– 43. 37. Ignatius of Antioch, Letters of Ignatius, pp. 300–3 (To the Smyrnians, chap. 6). 38. Shepherd of Hermas, visions 8[2.4], pp. 192–93. 39. Justin, Apologia prima, chap. 67, pp. 308–13. 40. Apostolic Constitutions, 4.1–14 (2:168–95). 41. See the introduction to the text by Marcel Metzger, in Apostolic Constitutions, 1:13– 60, esp. pp. 15–16.

Notes to Pages 24–31

19 9

42. Apostolic Constitutions, 4.9 (2:186). 43. Ibid., 4.1–2 (2:170–73). 44. Ibid., 4.2 (2:172). Cf. Matt. 25:35–36. For Christ’s healing the leper, see Apostolic Constitutions, 6.19.3 (2:356–57). 45. Pliny the Elder, Natural History, 26.5, pp. 270–71. 46. Galen, Ad Glauconem, 2.12, p. 142. 47. Galen, Subfiguratio empirica, chap. 10, pp. 75– 80.

Chapter 2 1. Miller, The Orphans of Byzantium, pp. 51– 60. 2. Historia Politica Constantinopoleos, pp. 6–7; Sphrantzes, “Georgios Sphrantzes: Memorii, 1401–1477,” 16.8, p. 26. See the explanation in Barker, Manuel II Palaeologus (1391–1425), p. 372, note 128; pp. 373–74, note 132. 3. Gregory of Nazianzos, Oratio XIV, cols. 855–910; Gregory of Nyssa, Pauperibus, pp. 110–27 (see appendix 2 for English translation). 4. Gregory of Nyssa, Pauperibus, pp. 113, 121. 5. Gregory of Nyssa, Pauperibus, pp. 113–18. 6. For Gregory’s description of loss of feeling, see ibid., p. 118. Cf. Fauci et al., eds., Harrison’s Principles of Internal Medicine, p. 1024. 7. Ibid., pp. 116–17. 8. Gregory of Nazianzos, Oratio XIV, chap. 6, cols. 864– 65, focuses on Elephant Disease; chap. 10, col. 869, describes the symptoms of the disease. 9. Gregory of Nazianzos, In laudem Basilii, chap. 63, pp. 188–92. 10. Regarding this source, see Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ” pp. 33–35 (see appendix 3 for the English translation of the portion of this speech dealing with leprosy). 11. Ibid., pp. 38– 41. 12. See JCod, 1.3.34(35); Miller, Orphans, pp. 51– 60. 13. Vita Zotici II, chap. 9, pp. 354–57. 14. The legend of Zotikos survives in three versions, but all of them date from the eleventh century, 700 years after Zotikos died. Certain stories, such as that of the saint’s martyrdom at the order of the enraged Emperor Constantius II, are not supported by any fourth-century evidence. For a discussion of the three versions of the legend, see the introduction to Vita Zotici II, pp. 339– 45. 15. The description of the leprosy epidemic in Constantinople is preserved in all three versions of the legend. See Sidéris, “Lèpre et lépreux à Constantinople,” pp. 192– 96. In support of Sidéris’s view, Vita Zotici II, chap. 9, pp. 356–57, does not state that in sheltering the lepers Zotikos disobeyed an imperial order but a community decision: ἀθετήσεώς τε τῆς κοινῆς ψήφου καὶ δημοσίου προφανοῦς ἀδικήματος (literal English translation: “of invalidation of a community decision and an open injustice against the demos.” 16. Sidéris, “Lèpre et lépreux à Constantinople,” pp. 187–97. Cf. Brown, Poverty and Leadership in the Later Roman Empire, who argues that the many references to the poor and suffering in the sermons and tracts of Christian leaders of the fourth century do not

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Notes to Pages 32–38

represent a real growth in the number of poor but only the efforts of bishops to develop a support group (clients in the Roman tradition) to win themselves political power in the local poleis. See also Holman, “Healing the Social Leper in Gregory of Nyssa’s and Gregory of Nazianzus’s ‘περὶ φιλοπτωχίας,’ ” who implies that the sudden interest in lepers in the sermons of Gregory of Nyssa and Gregory of Nazianzos is due to new theological perspectives rather than to an increase in the number of lepers in Asia Minor. Stathakopoulos (“Prȇcher les émotions incarnée. Évȇques, mendicants et leurs publics dans l’antiquité tardive, pp. 25–38) argues that Christian bishops underscored the sufferings of lepers to promote charitable giving among wealthy Christians; moreover, the silence of non-Christian sources suggested that these Christian sermons might be exaggerated. Stathakopoulos, however, ignores the non-Christian Libanios who might well refer to groups of lepers in fourth-century Antioch. See Libanios, Oratio XLI (Oratio ad Timocratem). Libanii opera, especially chap. 11, p. 300; chap. 17, p. 303. 17. Galen, Ad Glauconem, 2.12, p. 142. 18. Palladius, Palladio: La Storia Lausiaca, 21, pp. 104–17. 19. Cyril of Alexandria, Letter V, pp. 326–28. Cyril’s letter was not a pious tale but a practical guide for daily living during Lent. 20. Chrysostom, Ad Stagirium, 3.13, PG, 47:490. Cf. Chrysostom’s plans for a leprosarium in Constantinople, in Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ” pp. 38– 41. 21. Vööbus, History of Asceticism in the Syrian Orient, p. 386. 22. For financial support for the Zotikos Leprosarium by Emperor Justin II (565– 78) and the reconstruction under Emperor Maurice (582– 602), see Vita Zotici I, chaps. 11 and 12, p. 82; Vita Zotici II, p. 373. 23. Miller, Orphans, pp. 181, 184– 85. 24. Oikonomides., ed., Kletorologion of Philotheos, p. 123. For the history of the Orphanotropheion and its close ties to the Zotikos Leprosarium, see Miller, Orphans, pp. 51– 60. 25. For Constantine VII, see Theophanes Continuatus, 6.18, p. 449. For John Tzimiskes, see Leo Diaconus, Leonis diaconi Caloënsis historia libri decem et liber de Velitatione Bellica Nicephori Augusti, 6.5, pp. 99–100. 26. Zonaras, Epitome historiarum, 17.12 (3:580– 81). See the explanation by Kislinger, “Zur Lage der Leproserie des Pantokrator-Typikon,” pp. 171–76. 27. Typikon Pantokrator, p. 111, line 1390–p. 113, line 1413; Kislinger, “Zur Lage,” pp. 171–75. 28. Metochites, Theodorou Metochitou Nikaeus, pp. 145– 46. 29. Papadia-Lala, Euage kai nosokomeiaka hidrymata ste Benetokratoymene Krete, pp. 137– 47, follows the history of this Venetian leprosarium at Candia (Heraklion). 30. Philes, Manuelis Philae carmina, poem 11 (2: 25–26). 31. Ibid., poem 30, appendix (2: 390–93). 32. Xanthopoulos, Nikephorou Kallistou tou Xanthopoulou peri systaseōs tou sevasmiou oikou tes en Konstantinoupolei Zōodochou Pegēs kai tōn in autō hyperphyos telesthentōn thaumatōn, Miracle 52, pp. 70–71. 33. Ibid., Miracle 54, pp. 72–73. 34. Historia Politica Constantinopoleos, pp. 6–7; Barker, Manuel II Palaeologus, p. 374.

Notes to Pages 38–44

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35. Vita Stephani Dechani, 40, pp. 112–14. 36. Chalkokondyles, Laonici Chalcocandylae historiarum demonstrationes, pp. 136– 37. For the leprosarium in fourth-century Sebasteia, see chapter 4. 37. Brody, The Disease of the Soul, pp. 107– 46. 38. Methodius of Olympus, De lepra, 5, pp. 455–57. 39. Cyril of Alexandria, Glaphyrorum in Leviticum liber, PG, 69:553– 62. 40. Isidore of Pelusium, Letters, Letter 1489 (2:152–55). For the connection to Jewish commentaries on Leviticus 13, see Zias, “Lust and Leprosy: Confusion or Correlation?” pp. 27–31. 41. Sophronios, Los Thaumata de Sofronio, Miracle 13, pp. 269–71. 42. For a discussion of the relationship between the temples of Asklepios and Christian churches dedicated to healing saints, see Miller, The Birth of the Hospital in the Byzantine Empire, pp. 38– 41, 62– 67. See also Cilliers and Retief, “Dream Healing in Asclepieia in the Ancient Mediterranean,” for a discussion of Asklepieia in the ancient world with the latest bibliographical information. 43. Sophronios, Los Thaumata de Sofronio, Miracle 15, pp. 272–74. 44. Chrysostom, In Isaiam: “Vidi dominum.” Homilia IV, PG, 56:123–29. 45. Cyril of Alexandria, Glaphyrorum in Leviticum liber, PG, 69:556. 46. Origen, Contra Celsum, 6.43 (2:113–14). Origen called the disease elephas, the term used by Aretaios of Cappadocia. 47. Gregory of Nazianzos, Oratio XIV, 14, col. 876; 34, col. 904. 48. Ibid., 16, cols. 876–77; 34, col. 904: Gregory of Nyssa, Pauperibus, p. 123. 49. Gregory of Nazianzos, Oratio XIV, 34, col. 904; cf. 6, col. 865. 50. Sophronios, Los Thaumata de Sofronio, Miracle 13, p. 271. Cf. Miracle 15, p. 273. 51. Holman, The Hungry Are Dying, pp. 145– 46. 52. Gregory of Nazianzos, Oratio XIV, 9, col. 868. 53. Ibid., 11–12, cols. 869–73. 54. Ibid., 14, col. 876. See also Holman, Hungry, pp. 148–51. 55. Gregory of Nazianzos, Oratio XIV, 29–31, cols. 896–900. 56. Ibid., 31, col. 900. 57. Ibid., 18, cols. 880– 81. 58. Ibid., 16–17, cols. 876– 80. 59. In twelfth-century Constantinople the canonist Balsamon suggested that some lepers continued to live in their homes and to frequent the churches where they had worshipped before they had fallen ill. See Balsamon, Commentary, PG, 138:552. 60. Miller and Nesbitt, “Saint John Chrysostom,” pp. 35, 36 (text of oration); Philipsborn, “HIERA NOSOS und die Spezial-Anstalt des Pantokrator-Krankenhauses,” pp. 223–30. 61. Gregory of Nazianzos, In laudem Basilii, 63, pp. 190–91; Vita Theodosii (Theodore), p. 35. 62. Vita Martini, 18.3– 4, pp. 292–93. 63. Thomas of Celano, Vita seconda, 9, pp. 14–15. 64. Miller and Nesbitt, “Saint John Chrysostom,” pp. 33– 43. 65. Chugnet, ed., “Vie et recits de l’Abbé Daniel De Scété,” 8, pp. 71–72.

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Notes to Pages 45–50

66. Theodore of Stoudios, Oratio XIII: Laudatio funebris in matrem suam, 4–5, PG, 99:888– 89. 67. Leo Diaconus, Leonis diaconi Caloënsis historia libri decem et liber de Velitatione Bellica Nicephori Augusti, 6.5, pp. 99–100. 68. Vita Zotici I, 14, p. 84. 69. Psellos, Oratio IV, pp. 73–74. 70. Vita Zotici I, 13, pp. 82– 85. 71. The Book of Ceremonies does not include any imperial ceremony at the Zotikos Leprosarium, but this work was compiled during the reign of Constantine VII (sole rule, 945–59), and many of the ceremonies that it describes date from earlier reigns. From the evidence in version one of the Zotikos legend and from the fact that all three versions of the legend date from the eleventh century, it seems that Zotikos became an important saint around 1000. Emperor John I Tzmiskes (969–76) was the first emperor whom extant sources record as having made a ceremonial visit to the Zotikos Leprosarium (Leo Diaconus, Leonis diaconi, 6.5, pp. 99–100). This liturgical visit by the emperor to the Zotikos Leprosarium was apparently added to official ceremonies after the mid-tenth century. See Aubineau’s commentary in Vita Zotici I, pp. 92–95. 72. Vita Athanasii Athonitae B, 73, p. 207. 73. Typikon Pantokrator, pp. 82–109, for the hospital; pp. 108–11 for the gerokomeion. 74. Ibid., pp. 110–13, for the leprosarium. 75. Kislinger, “Zur Lage,” pp. 171–75. 76. Kedar, “A Twelfth-Century Description of the Jerusalem Hospital,” p. 18.

Chapter 3 1. Bennett, “Xenonika: Medical Texts Associated with Xenones in the Late Byzantine Period,” pp. 45– 47. Regarding Byzantine antidotaria, see also Touwaide, “Byzantine Hospital Manuals (Iatrosophia) as a Source for the Study of Therapeutics,” pp. 147– 65. Touwaide uses the term iatrosophia for these medical treatment lists. 2. Bennett, “Xenonika,” p. 52. 3. Hohlweg, “John Actuarius’ De methodo medendi—On the New Edition,” pp. 121–34. 4. For a discussion of the problems of editing Aetius of Amida, see Garzya, “Problèmes relatifs a l’édition des livres IX–XVI du Tétrobiblon d’ Aétios d’Amida,” pp. 245– 57. Zervos (see Bibliography) published the Greek text of fifty-nine chapters of Book Thirteen but not the chapter on leprosy. 5. Gregory of Nazianzos, Oratio XIV, 27, col. 893. 6. See Horden, “How Medicalized Were Byzantine Hospitals?” pp. 45–74, who believes that most Byzantine physicians did not work in hospitals or other philanthropic institutions. For a different perspective, see Miller, The Birth of the Hospital in the Byzantine Empire, pp. 141– 66. 7. Galen, Ad Glauconem, 2.12, pp. 139– 42; cf. Aretaios, Aretaeus, 4.13.9–11, pp. 87– 88; 8.13.1, pp. 167– 68. 8. Aretaios, Aretaeus, 8.13.1, p. 168; cf. Thucydides, History of the Peloponnesian War, regarding loimos (2.47, p. 342).

Notes to Pages 50–56

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9. Only three mss. of Aretaios’s treatise survive from the Byzantine Empire: Neopolitanus gr. III.D.21 (fourteenth century,), Laurentianus gr. LXXV.15 (fifteenth century), and Vaticanus gr. 286 (fifteenth century). See the introduction by Karl Hude, in Aretaios, Aretaeus, pp. vii–x, 2 (conspectus siglorum). 10. For Galen, see Oribasios, Oeuvres d’Oribase, 45.27 (4:59– 62); for Rufus of Ephesus, see ibid., 45.28 (4:63– 64); and for Philoumenos, see ibid., 45.29 (4:65– 82). The section from Philoumenos is the longest, but it contains no statements about the causes of Elephant Disease. It consists completely of treatments. For the biography of Oribasios, see Hunger, “Medizin,” pp. 293–94. 11. See the outline of Aetios’s compendium by Garzya, in Medici bizantini, pp. 255– 58. For Aetios’s biography, see Hunger, “Medizin,” pp. 294–96. 12. Aetius of Amida, Contractae ex veteribus medicinae tetrabiblos, 13.120, pp. 717–19. 13. For Archigenes as a pneumatist, see Nutton, Ancient Medicine, 202–5; for a description of pneumatist doctrine, see Oberhelman, “On the Chronology and Pneumatism of Aretaios of Cappadocia,” pp. 959– 66, where he describes the doctrines of Aretaios as derived from Archigenes. 14. Aetios of Amida, Contractae ex veteribus medicinae tetrabiblos, 13.120, p. 718. 15. For a short biography of Paul of Aegina, see ODB, 3:1607– 8. 16. Regarding Aretaios, see Paul of Aegina, Paulus Aegineta, 4.1.1, p. 317: “I believe that Aretaios the Cappadocian correctly stated that it is necessary that the power of medicines be stronger than that of the disease. Because of this it is not possible to find a cure for Elephant Disease for one cannot find a medicine stronger than it.” In this same section Paul of Aegina repeats Galen’s idea that leprosy and cancer are closely related. 17. See Paul of Aegina, Paulus Aegineta, 4.1.8, p. 321, where he again follows Aretaios by stating that leprosy is extremely contagious, like loimos (cf. Thucycides, History of the Peloponnesian War, 2.47, p. 342). 18. Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ”pp. 38– 41. 19. Gregory of Nazianzos, Oratio XIV, 10–12, cols. 869–74. 20. Ibid., 27, cols. 893. 21. Gregory of Nyssa, Pauperibus, p. 124. 22. Ibid., p. 124. 23. Hippocrates, Airs, Waters, Places, 2–3, pp. 72–77. 24. Gregory of Nyssa, Contra Eunomium, 1.28 (1:31). 25. Leo the Physician, “Leonis philosophi et medici conspectus medicinae,” 5.25, pp. 187– 89. Regarding the term kelephia, see Benveniste, “Un nom grec de la lèpre,” pp. 7– 11. 26. Paul of Aegina, Paulus Aegineta, 4.1.8, p. 321. Cf. Theophanes Chrysobalantes, Theophanis Nonni Epitome de curatione morborum graece ac latine, chap. 233 (2:216–22). 27. Paul of Aegina, Paulus Aegineta, 4.1.5, p. 320. Cf. Theophanes Chrysobalantes, Theophanis Nonni Epitome de curatione morborum graece ac latine, chap. 233 (2:220). 28. Psellos, Carmen, pp. 238–39. 29. See Zipser’s introduction, in John the Physician’s Therapeutics, pp. 3–32. 30. See the ω text, in John the Physician’s Therapeutics, chap. 73, pp. 212–14; cf. Aretaios, Aretaeus, 8.13.2–13, pp. 168–70. 31. Zacharias, Ioannis Actuarii de diagnosi, 2.22, pp. 454–55.

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Notes to Pages 56–64

32. Miller, Birth, pp. 141– 66. 33. Nutton, “Did the Greeks Have a Word for It?” pp. 160– 61. 34. Galen, Subfiguratio empirica, 10, pp. 75–76. 35. Aretaios, Aretaeus, 4.13.19, p. 90. 36. Vita Athanasii Athonitae B, 73, p. 207; Typikon Pantokrator, pp. 110–11. 37. Avicenna, Liber Canonis, liber 4, fen 3, tract 3 (fol. 443). See the evidence that Aetius of Amida’s text was translated into Arabic in Pormann, The Oriental Tradition of Paul of Aegina’s Pragmateia, pp. 304–5). 38. Nutton, “Medicine in Medieval Western Europe,” p. 143. 39. See the passage from Breviarium practicae in Touati, “Contagion,” p. 197, note 67. 40. For Bartholomeus Anglicus, see Touati, “Contagion and Leprosy,” p. 196 and Brody, Disease of the Soul, p. 55; for Arnold of Villanova, see Bériac, Histoire des lépreux au Moyen Âge, p. 23. See also Gilbertus Anglicus, Compendium medicine, fol. 336v. 41. For a complete discussion of the theory of contagion in the Islamic world, see Conrad, “A Ninth-Century Muslim Scholar’s Discussion of Contagion,” pp. 163–77. 42. Vasiliev, History of the Byzantine Empire, 1:240– 44. 43. Miller, Orphans, pp. 82, 98. 44. Ecloga, 2.9.2 and 3, p. 182. Cf. JNov, 22.15. 45. The rule allowing divorce in the case of leprosy was repeated in a later edition of the Ecloga. See Ecloga ad Prochiron mutata, 3.3 (JGR, 6:237). 46. See the account in Vasiliev, History of the Byzantine Empire, 1:339– 42. Cf. the revised dating of the Epanagoge and the Prochiron by Andreas Schmink in ODB, 1:703– 4, 3:1725. 47. Epanagoge, 21 ( JGR, 2:300–307). 48. Prochiron, 11 ( JGR, 2:145–50). 49. Rufus of Ephesus, in Oribasios, Oeuvres d’Oribase, 45.28 (4:63). 50. Galen, Ad Glauconem, 2.12, pp. 139– 44. 51. Aretaios, Aretaeus, 4.13.8, p. 87; 4.13.18, p. 89. 52. Oribasios, Oeuvres d’Oribase, 45.28 (4:63– 64). 53. Aetios of Amida, Contractae ex veteribus medicinae tetrabiblos, 13.120, p. 718. 54. Garzya, “Problèmes relatifs,” pp. 248– 49. 55. Ell, “Blood and Sexuality in Medieval Leprosy,” pp. 153– 61. 56. Ibid., pp. 158– 61. Cf. Aretaios, Aretaeus, 4.13.18, p. 89. 57. Paul of Aegina, Paulus Aegineta, 4.1.1– 8, pp. 317–21. 58. Gregory of Nazianzos, Oratio XIV, 34, cols. 903– 4. 59. Moschos, Pratum Spirituale 14 (PG, 87.3:2861– 62). 60. Philes, Manuelis Philae carmina, poem 30, appendix (2:390–93). 61. Ibid., p. 391, lines 31–34. 62. Newstead, “The Origin and Growth of the Tristan Legend,” p. 124, and note 1. For the relationships among the versions of the Tristan legend, see Whitehead, “The Early Tristan Poems,” pp. 134– 44. 63. Alderotti, I “Consilia,” 143, p. 194, lines 41– 42. 64. Demaitre, “The Description and Diagnosis of Leprosy by Fourteenth-Century Physicians,” p. 336 and note 60.

Notes to Pages 64–68

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65. Fracastoro, De contagione, 2.13, pp. 188– 89. Cf. Demaitre, Leprosy in Premodern Medicine, pp. 93–94, where he discusses other physicians who thought leprosy led to enhanced sexual desire. 66. Roselli, “Les éditions d’Arétée de Cappadoce et le commentaire de Pierre Petit,” pp. 99–100. For evidence that the author of the “Medical Book of Lorsch” had been influenced by Aretaios, see the conclusion. 67. Constantine, Elephancia, 2–3, pp. 76– 81; Avicenna, Liber Canonis, liber 4, fen. 3, tract 3 (fol. 443). 68. Baader, “Early Medieval Latin Adaptations of Byzantine Medicine in Western Europe,” p. 252. 69. Demaitre, “Description,” p. 337. See the text of Theodoric’s description of leprosy in Theodoric, The Surgery of Theodoric, 3.55, pp. 167–79. 70. Galen, Ad Glauconem, 2.12, pp. 139– 40. 71. Paul of Aegina, Paulus Aegineta, 4.1.1, p. 317. 72. Theophanes Chrysobalantes, Theophanis Nonni Epitome, chap. 233 (2:216–22); Zacharias, Ioannis Actuarii de diagnosi, 2.22, pp. 454–55. 73. Paul of Aegina, Paulus Aegineta, 4.1.1, p. 317. 74. Bériac, Histoire, pp. 13–16. See also Harrison’s Principles, pp. 1021–27. 75. Zacharias, Ioannis Actuarii de diagnosi, 2.22, pp. 454–55. 76. Dols, “Leprosy in Medieval Arabic Medicine,” pp. 324–25. For a German translation of al-Majusi’s essay on leprosy, see Richter, “Beiträge zur Geschichte des Aussatzes,” pp. 325–26. Paul of Aegina was translated into Arabic in the ninth century, perhaps by ibn Ishaq Husain; Paul definitely influenced the compendium of al-Majusi. See Pormann, Oriental Tradition, pp. 4, 285, regarding the Arab translation, and pp. 304–5, regarding Paul’s influence on al-Majusi. 77. Bos, “Ibn-al-Jazzār on Medicine for the Poor and Destitute,” p. 365. 78. See Cartelle and Ferreira, “Le De Elephancia de Constantin l’Africain et ses rapports avec Le Pantegni,” pp. 241– 43, concerning the lost essay on leprosy by alJazzār, which is mentioned by Constantine the African and is most likely the Arab source of Constantine’s section on leprosy in the Pantegni (Practica Pantegni, 4.2– 3). This section was copied separately as the De Elephancia of Constantine. The De Elephancia, however, is not an independent work but simply a copy of Practica Pantegni, 4.2– 3. 79. Rawcliffe, Leprosy in Medieval England, pp. 74–75. 80. Ibid., pp. 1–3. 81. Constantine, Elephancia, 2–3, pp. 76– 81. For Theodoric of Cervia’s system of classification, see Theodoric, Surgery, 3.55 (2:167–79), where Theodoric uses the four types of leprosy to order both his description of symptoms and his suggestions for therapies. 82. Bériac, Histoire, pp. 36–37. 83. Gregory of Nazianzos, Oratio XIV, 27, col. 893; Gregory of Nyssa, Pauperibus, p. 124. 84. Vita Zotici I, 13, pp. 84– 85. This section of the Vita presents comments by the author of this version of the Zotikos legend, comments that refer to his own time period and can be taken as accurate for the years prior to the reign of Emperor Michael IV.

20 6

Notes to Pages 68–77

85. Paul of Aegina, Paulus Aegineta, 4.1.5, p. 320. Cf. Theophanes Chrysobalantes, Theophanis Nonni Epitome, chap. 233 (2:220–21). 86. Miller and Nesbitt, “Saint John Chrysostom,” pp. 40– 41. 87. Vita Zotici II, 13–14, pp. 360– 63; 18, pp. 366– 67. See also commentary, p. 376. 88. Ibid., 18, pp. 366– 67. 89. Vita Zotici I, 14, pp. 84– 85. 90. For Byzantine baths with individual tubs, see Berger, Das Bad in der byzantinischen Zeit, p. 97. For the evolution of Byzantine baths from large, open buildings to smaller establishments, run by monasteries or diakoniai, see Magdalino, “Church, Bath and Diakonia in Medieval Constantinople,” pp. 165– 88. See also the article by Caskey, “Steam and Sanitas in the Domestic Realm.” 91. Leo Diaconus, Leonis diaconi, 6.5, p. 100. 92. Vita Stephani Dechani, 40, pp. 112–14. 93. Aretaios, Aretaeus, 8.13.10, p. 170. 94. Paul of Aegina, Paulus Aegineta, 4.1.4, p. 319. 95. Rawcliffe, Leprosy in Medieval England, pp. 265, 329. 96. John Chrysostom, Ad Stagirium, 3.13, PG, 47:490.

Chapter 4 1. Sidéris, “Lèpre et lépreux à Constantinople. Maladie, épidémie et idéologie imperiale à Byzance,” pp. 187–207. 2. We will examine these arguments in chapter 6. 3. For hospitals for curable diseases, see Miller, The Birth of the Hospital in the Byzantine Empire, pp. 89–117. 4. Epiphanios, Panarion, 75.1.3–7 (3:333). 5. The best essay on the urban monastic movement is still Dagron, “Les moines et la ville,” pp. 229–76. 6. Miller, Birth, 85. 7. Basil, Letters, no. 150 (2:366– 67). 8. For Antioch, see Chrysostom’s Ad Stagirium, 3.13 (PG, 47:490). For the general use of xenodocheion, see Epiphanios, Panarion, 75.1.7 (3:333). 9. Gregory of Nazianzosg, In laudem Basilii, 63, pp. 188–92. 10. Gregory of Nazianzos, Oratio XIV, 10–12, cols. 869–74. 11. Epiphanios, Panarion, 75.1.7 (3:333). 12. Gregory of Nazianzos, Oratio XIV, 27, col. 893; Gregory of Nyssa, Pauperibus, p. 124. 13. Procopius, Buildings, 1.9, pp. 78–79. 14. For the three versions of the Zotikos legend, see Vita Zotici II, pp. 339– 45. 15. See the accounts of both Vita Zotici I and Vita Zotici II. See also Sidéris, “Lèpre et lépreux à Constantinople,” p. 190. 16. Vita Zotici I, pp. 99–100. The tenth-century author Leo the Deacon mentioned that the Zotikos Leprosarium was located “opposite Constantinople (see Leo Diaconus, Leonis diaconi Caloënsis historia libri decem et liber de Velitatione Bellica Nicephori Augusti, 6.5, p. 99).

Notes to Pages 77–83

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17. JCod, 1.3.34 (35). 18. Miller, The Orphans of Byzantium, pp. 51–55. For the orphanotrophos’s supervision of several philanthropic institutions in Constantinople, see especially JCod, 1.3. 34 (35). 19. Vita Zotici I, 1, pp. 71–73. 20. Sozomenos, Kirchengeschichte, 4.20.1–2, pp. 169–70; 4.27.2–7, pp. 183– 84; Dagron, “Les moines et la ville,” pp. 246–53. 21. Vita Zotici I, title, p. 71; Sokrates, Kirchengeschichte, 7.26.3, p. 375. Moreover, in the Typikon of the Great Church (the order of feast days observed at the Church of Hagia Sophia), which dates from the tenth century, the Zotikos asylum is called the “ptocheion.” See Typicon de la Grande Église, p. 190 (feast of January 8). 22. Epiphanios, Panarion, 75.1.4.7 (3:333). 23. Sokrates, Kirchengeschichte, 5.7, pp. 278–79; Sozomenos, Kirchengeschichte, 7.5. 5–7, pp. 306–7. 24. See the account by Sidéris, “Lèpre et lépreux à Constantinople,” pp. 196–98. 25. Sokrates, Kirchengeschichte, 6.8, p. 325; Sozomenos, Kirchengeschichte, 8.8.1– 6, pp. 360– 61. 26. Sokrates, Kirchengeschichte, 7.26, p. 375. 27. JNov, 43 (praefatio). 28. For the history of the Sampson Xenon, see Miller, “The Sampson Xenon,” pp. 101–35. 29. Gregory of Nazianzos, Letters, no. 77, pp. 66– 68. If Zotikos had been a zealous Arian, it is unlikely that orthodox Christians would have continued to honor him as a saint. The same holds true for Saint Sampson, the founder of the most famous hospital in Constantinople. 30. Chrysostom, Ad Stagirium, 3.13 (PG, 47:490). 31. Neilos of Ankyra, Epistulae, book 2, letters 110 and 111 (PG, 79:248– 49). These two letters are, in fact, part of one single communication. 32. Palladius, Dialogue sur la vie de Jean Chrysostome, para. 5, lines 128–39, pp. 122–23. 33. Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ” pp. 36–39. 34. Sidéris, “Lèpre et lépreux à Constantinople,” pp. 196–97. 35. Palladius, Palladio: La Storia Lausiaca, 6, pp. 30–37. For leprosariums in the medieval West, see Leistikow, “Bauformen der Leproserie im Abendland,” p. 108. 36. Vie de Pambô, pp. 101–2. These tales about Egyptian ascetics might exaggerate the impact that the activities of these monks actually had on the government and society of Egypt, but details such as the existence of many leprosariums are probably factual since they form the background narrative to the story of the monk’s virtuous activity. 37. Haas, “The Arians of Alexandria,” pp. 236–37. 38. Epiphanios, Panarion, 76.6–8 (3:341). 39. This system is thoroughly treated by Dagron, “Ainsi rien n’échappera à la réglementation,” pp. 155– 82, esp. 155– 61. 40. TheoCod, 16.2.42.1 (a.416); 16.2.43 (a.418). 41. Wipszycka, “Les confréries dans la vie religieuse de l’Egypte Chretienne,” pp. 515–16.

208

Notes to Pages 83–89

42. TheoCod, 16.2.43 (a.418). Cf. Balsamon, Ecclesiasticarum institutionum collectio (PG, 138:1129–30). 43. For Hermopolis, see Serfass, “Wine for Widows,” p. 101; for additional references to Egyptian leprosariums, see MacCoull, “P. Lond. Copt. I 1077,” pp. 395–96. 44. Vööbus, History of Asceticism in the Syrian Orient, pp. 384– 86. 45. Chronica minora, p. 7 (entry LXVIII). 46. Vita Euthymii, 35, pp. 53–54. 47. Xanthopoulos, Historia Ecclesiastica, 14.50 (PG, 146:1240). For the history of this leprosarium, see chapter 7. 48. Ibid. 49. ODB, 3:2207. 50. Vita Sabae, p. 177, lines 9–14. See the article by Touati, “La Terre sainte,” pp. 169–211, but esp. pp. 171–72, who stresses the large size of philanthropic institutions in Palestine. 51. For the leprosarium, see Vita Theodosii (Theodore), p. 35; for Theodosios’s origins in Cappadocia, see Vita Theodosii (Cyril), p. 105. 52. Vita Euthymii, 48, pp. 68–70. 53. See, for example, Gregory of Nyssa, Pauperibus, p. 123; Gregory of Nazianzos, Oratio XIV, 34, col. 904. 54. Barsanouphios and John, Correspondance, Letter 765, pp. 208–11. In her extensive article counting the number of philanthropic institutions in the Byzantine Empire from circa 300 to 800, Mentzou-Meimare identified only six leprosariums throughout the provinces of the empire, and only one leprosarium in Palestine. Her count, however, was not intended to be a definitive list of leprosariums. For example, she did not include this Letter 765 of Barsanouphios and John, nor did she consider general references to a network of leprosariums, such as that found in Vie de Pambô (pp. 101–2) for Egypt. 55. Vita Theophylacti, 8–9, pp. 74–75. 56. Metochites, Theodorou Metochitou Nikaeus, pp. 145– 46 (description of the leprosarium); p. 152–53 (continued financial support of the emperor). 57. Epiphanios, Panarion, 75.1.7 (3:333). 58. Kedrenos, Historiarum Compendium, 2:504. 59. Ibid., 1:698–99. 60. Novel 19 (Emperor Nikephoros II Phokas), JGR, 1:249–52. 61. Vita Lucae Stylitae, chap. 23, p. 218. 62. Petit, ed., “Monodie de Nicétas Eugénianos,” p. 460. 63. Typikon Kosmosoteira, 70, p. 55. 64. See the examples in Miller, “Death in a Xenon?” pp. 191–96. 65. Kislinger, “Zur Lage der Leproserie des Pantokrator-Typikon,” pp. 171–75. Kislinger (p. 174) maintains that the Kedrenos/Skylitzes text was the only source to refer to a leprosarium as a “gerokomeion” (Kedrenos, Historiarum Compendium, 1:698–99), but Kislinger here indicates that the Pantokrator Typikon text also used the term gerokomeion to refer to a building designed for lepers (see Typikon Pantokrator, p. 111, line 1401). Moreover, the nature of gerokomeia as institutions either for the aged or for people with debilitating chronic illnesses fits their functioning also as asylums for lepers.

Notes to Pages 89–97

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66. Xanthopoulos, Nikephorou Kallistou, Miracle 52, pp. 70–71; Miracle 54, pp. 72– 73; Philes, Manuelis Philae carmina, poem 11 (2:25–26); poem 30, appendix (2:390–93). 67. Vita Stephani Dechani, chap. 40, pp. 112–14. 68. Barker, Manuel II Palaeologus, p. 372, note 128, and pp. 373–74, note 132. 69. Epiphanios, Panarion, 75.1.7 (3:333). 70. Gregory of Nazianzos, In laudem Basilii, chap. 63, pp. 188–92. Cf. Vita Theophylacti, 8–9, pp. 74–75. 71. Miller and Nesbitt, “Saint John Chrysostom,” pp. 38–39. 72. Vööbus, History of Asceticism in the Syrian Orient, pp. 384– 86. 73. Miller, Birth, pp. 100–3. 74. Vita Zotici I, 11, pp. 80– 83. 75. Vita Zotici I, 12, pp. 82– 83. The information concerning this early payment to the Zotikos Leprosarium is confirmed in a novel issued under Emperor Leo VI (see Noailles and Dain, eds., Léon VI, pp. 377–78). 76. Leo Diaconus, Leonis diaconi, 6.5, p. 99–100. 77. For the history of the organization of the orphanage see Miller, Orphans, pp. 182– 88. 78. For the orphanage founded by the wealthy widow in Constantinople, see Proklos, L’homilétique de Proclus de Constantinople, speech 26, pp. 182– 83; for the orphanage in Prousa, see Theodore of Stoudios, Theodori Studitae epistulae, Letter 211, pp. 333–34. For hospitals founded by wealthy laymen, see Miller, Birth, pp. 100–110, but also p. xvii in the introduction to the 1997 edition. 79. Vita Zotici I, 11, pp. 80– 81. 80. Gregory of Nazianzos, Oratio XIV, 6, col. 865; 11, cols. 869–72. 81. Miller and Nesbitt, “Saint John Chrysostom,” pp. 38–39. 82. Barsanouphios and John, Correspondance, Letter 765, pp. 208–11. 83. Vita Theodosii (Theodore), p. 35. 84. Typikon Machairas, chap. 170 (3:1166). 85. Vita Zotici II, 18, pp. 366– 67. 86. All of these stories come from Galen, Subfiguratio empirica, chap. 10, pp. 74– 80. Also see Plato, Republic, 405D– 406C (1:270–75). 87. Barker, Manuel II Palaeologus, p. 372, note 128; pp. 373–74, note 132. 88. Barsanouphios and John, Correspondance, Letter 765, pp. 208–11. 89. Typikon Pantokrator, pp. 110–11, lines 1394–98; cf. Vita Stephani Dechani, chap. 40, pp. 112–14. 90. Cantarella, “Basilio Minimo, II,” pp. 8–9.

Chapter 5 1. Barber, “Lepers, Jews, and Moslems,” pp. 1– 4. 2. Ibid., pp. 4–5; Touati, Maladie et société au Moyen Âge, pp. 726–31. 3. Régistre Jacques Fournier, 2:633–39. For the statement made by the head (commander) of the leprosarium in Toulouse, see p. 635. 4. Touati, Maladie et société, p. 734. 5. Bériac, Histoire des lépreux au Moyen Âge, p. 145.

210

Notes to Pages 97–108

6. Barber, “Lepers, Jews, and Moslems,” pp. 1–17. 7. Touati, Maladie et société, pp. 716–19. 8. Régistre Jacques Fournier, 2:635. 9. Vita Zotici II, 7, pp. 352–55. 10. Chalkokondyles, Laonici Chalcocandylae historiarum demonstrationes, pp. 136–37. 11. Nutton, “Medicine in Medieval Western Europe,” p. 188. 12. Watts, Epidemics and History, pp. 40– 83, but esp. pp. 47– 48. 13. Risse, Mending Bodies, Saving Souls, p. 176. 14. Dictionary of the Middle Ages, 7:549. 15. De Wailly and Guigniaut, eds., “E chronico Aberico monachi trium fontium,” p. 604. 16. Bériac, Histoire, pp. 112–13. 17. Sidéris, “Lèpre et lépreux à Constantinople,” p. 191. 18. Liber Pontificalis, 1:170. 19. Bériac, Histoire, p. 112. 20. Ibid., pp. 112–13. 21. Bede, Bedae Venerabilis homilia XCIII, PL, 94:494–95. 22. Vita Zotici II, 7, pp. 352–55. 23. Kantakouzenos, Ioannis Cantacuzeni eximperatoris historiarum libri IV, 4.2 (3:18). 24. Sidéris, “Lèpre et lépreux à Constantinople,” p. 191. Cf. Bériac, Histoire, pp. 111–12. 25. Bériac, Histoire, p. 111. 26. Gregory of Tours, De virtutibus Sancti Martini, 24, p. 167. 27. Isidore of Pelusium, Letters, Letter 1489 (2:152–55). 28. Sophronios, Los Thaumata de Sofronio, Miracle 15, pp. 272–74. 29. Isidore of Saville. Isidori episcopi Allegoriae quaedam scripturae sacrae, PL, 83:127. Cf. Methodius of Olympus, De lepra, 5, pp. 455–57. 30. Brody, The Disease of the Soul, pp. 147–90. 31. Helinandi Frigidi Montis monachi chronicon, PL, 212:974–75. 32. Sophronios, Los Thaumata de Sofronio, Miracle 13, pp. 269–71. 33. Vita Athanasii episcopi Neapolitani, MGH, chap. 2, p. 441; chap. 6, p. 445. 34. Gregory (pope). Gregorii Magni homilia XXXIX, PL, 76:1300–1. 35. Jacques de Vitry, “Texts on Hospitals,” pp. 120–21. 36. Thomas of Celano, Vita secunda S. Francisci Assisiensis, 9, pp. 14–15. 37. Notkar the Stammerer, Monachi Sangallensis De gestis Karoli imperatoris, 1.21, pp. 740– 41. 38. Le Grand, ed., Statuts d’Hôtels-Dieu et de léproseries, pp. 199–200. 39. Bériac, Histoire, pp. 180– 82. 40. Ecloga, 2.9.2–3, p. 182. See chapter 3 section “Byzantine Divorce Law.”. 41. Stephen II (pope), Epistolae, Responsa, cap. 2, p. 559; cap. 9, p. 560. 42. Pippini capitularia (Compiègne), cap. 19, MGH, Leges, 1:29. 43. Decretum Gratiani, cols. 1146– 47. 44. Decretalium collectiones, cols. 690–91. 45. Rothari’s Edict, cap. 176. 46. “Acta Sancti Athansii episcopi”; see p. 78, which refers to Lazaros, a term implying lepers. Cf. Vita Athanasii episcopi Neapolitani, MGH, p. 441.

Notes to Pages 108–115

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47. Capitulare generale (anno 789), cap. 20, MGH, Leges, 1:69. 48. Bracton: On the Laws and Customs of England, Book 3, vol. 2, pp. 51–52. See the comments by Pollock and Maitland, 1:480. 49. Bérliac, Histoire, p. 222. 50. Sachsenspiegel, 1.4, p. 70. Although the manuscripts of the Sachsenspiegel date from the fourteenth century, the regulations in the code reflect earlier customs. 51. Guillouard, Études sur la condition des lépreux au moyen âge, pp. 34– 47, esp. pp. 46– 47. 52. Decretalium collectiones, cols. 690–91. 53. Bonifatii et Lulli epistolae, no. 26, MGH, Epistulae, 3:277. 54. Hartzheim, ed., Concilia Germaniae, cap. 31 (2:315). 55. Bonifatii et Lulli epistolae, no. 87, MGH, Epistulae, 3:370–71. 56. Bériac, Des lépreux aux Cagots, pp. 56–58. 57. Cartelle and Ferreira, “Le De Elephancia de Constantin l’Africain et ses rapports avec Le Pantegni,” pp. 242– 43. 58. Conrad, “The Arab-Islamic Medical Tradition,” p. 115. 59. Constantine, Elephancia, chaps. 2–3, pp. 76– 81. 60. Salernitan Questions, text B, no. 179, p. 98. 61. Avicenna, Liber Canonis, liber 4., fen 3, tract 3 (fol. 443). 62. Gilbertus Anglicus, Compendium medicine, folios 336v–346, esp. folio 336v: “et interum aut fit ex corruptione regiminis in nutrimento et aere corrupto et anhelitu leprosorum et aspectu.” 63. For Theodoric, see Touati, “Contagion and Leprosy,” p. 190, and note 40. For Alderotti, see Alderotti, I ‘Consilia,’ chaps. 142, 143, pp. 191–94. 64. This passage of Lanfranc of Milan is quoted in Latin and translated by Touati, “Contagion,” p. 190, and note 40. 65. Le Grand, ed., Statuts, no. 11, p. 201. 66. Ibid., no. 16, p. 209. 67. Ibid., no. 17, p. 209. 68. Ibid., no. 28, p. 212. 69. Ibid., p. 206, note 2. 70. Touati, Maladie et société, p. 701. 71. Ibid., p. 713. 72. Vita Zotici II, 17, pp. 364– 67. 73. Ibid. 74. Gregory of Nyssa, Pauperibus, p. 124. 75. Miller and Nesbitt, “Saint John Chrysostom,” pp. 38–39. 76. Alderotti, I ‘Consilia,’ chap. 143, p. 193. 77. See Bériac, Histoire, pp. 46– 47, where the author quotes and comments on Arnold of Villanova’s De signis leprosorum libellus. 78. Gregory of Nyssa, Pauperibus, p. 118. 79. William of Tyre, A History of Deeds Done beyond the Sea, 21.1 (2:397–98). 80. De Wailly and Guigniaut, eds., E chronico Aberico, p. 604. 81. Pollock and Maitland, The History of English Law before the Time of Edward I, 1:480.

212

Notes to Pages 115–122

82. Robertson, ed., Materials for the History of Thomas Becket, 1:458–59. 83. Bériac, Histoire, pp. 58– 65, 197–204. Also see Schmitz-Cliever, “Das mittelalterliche Leprosarium,” pp. 16–18. 84. Barsanouphios and John, Correspondance, Letter 765, pp. 208–11. 85. Liber Augustalis, Liber 3.48, p. 132.

Chapter 6 1. Encyclopédie, ou Dictionnaire raisonné, sub voce “leproserie.” 2. Kurth, La lèpre en occident avant les croisades. 3. Mitchell, “The Myth of the Spread of Leprosy with the Crusades,” pp. 171–76. 4. See Bériac, Histoire des lépreux au Moyen Âge, pp. 164– 65 for statements of contemporaries concerning the increase in cases of leprosy and pp. 162– 63 for the increase in the numbers of French leprosariums. 5. Nassali-Rocca, “Gli Ospedali italiani di S. Lazzaro dei Lebbrosi,” pp. 265– 67. 6. Epstein, Wills and Wealth in Medieval Genoa, p. 181. 7. Schmitz-Cliever, “Das mittelalterliche Leprosarium,” p. 14. 8. Gregory of Nyssa, Pauperibus, p. 113. 9. Epiphanios, Panarion, 75.1.7 (3:333). 10. Peyroux, “The Leper’s Kiss,” p. 178: “In the eleventh through thirteenth centuries, however, osteoarchaeological, institutional, legal, and literary evidence piles up to indicate a substantial increase in the prevalence of infection, only to be followed by leprosy’s swift disappearance from most of Europe in the later Middle Ages.” 11. Bériac, Histoire, p. 165. Cf. Miller, The Birth of the Hospital in the Byzantine Empire, pp. 68–74. 12. Bériac, “Les fraternités des lépreux et lépreuses,” pp. 203–5. 13. See Kealey, Medieval Medicus, pp. 108–9 for the English translation and pp. 200– 201, note 3, for the Latin text. 14. Le Grand, ed., Statuts d’Hôtels-Dieu et de léproseries, pp. 181– 83. 15. Ibid., pp. 181–252. 16. Jerome, Letters, no. 77, pp. 42– 43. 17. Aretaios, Aretaeus 4.13.14, p. 88. 18. In this letter Ad Oceanum de morte Fabulae (Jerome, Letters, no. 77, p. 43), Jerome calls the disease regius morbus (the royal disease). He uses this name again in his short biography of Saint Hilarion (Jerome, Vita S. Hilarionis eremitae, PL, 23:48), where he describes a disease that rots away its victim. In both the Letter to Oceanus and the Vita S. Hilarionis the symptoms fit lepromatous leprosy. By the High Middle Ages, regius morbus usually was used to describe scrofula. Because the kings of France and England supposedly could cure scrofula by touching its victims, the disease was often called regius morbus. Regarding all the uses of the term regius morbus, see Nutton, “Medicine in Medieval Western Europe,” pp. 183– 84, who lists leprosy as one of the meanings of the term. 19. Gregory of Tours, In gloria confessorum, 85, pp. 352–53. See especially the commentary in Sternberg, Orientalium more secutus, pp. 211–12. 20. Sternberg, Orientalium, p. 170.

Notes to Pages 123–129

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21. Adalgisel Grimo, “Das Testament des fränkischen adligen Adalgisel Grimo,” p. 261 (foundation of Saint Agatha); p. 268, line 26 (Verdun); p. 270, line 35 (Metz); p. 270, line 39 (Maastricht). 22. Sternberg, Orientalium, p. 170. 23. Miller and Nesbitt, “Saint John Chrysostom and the ‘Holy Disease,’ ” pp. 38–39. 24. Vita Arnulfi, 21, p. 441. 25. Vita Otmari auctore Walafrido, 2, p. 42. 26. Acta Sancti Athanasii episcopi, p. 78. 27. Vita Roberti de Arbrissello auctore Baldrico, PL, 162:1055. 28. Vita Roberti Arbrissello auctore Andrea, PL, 162:1073. See also Touati, “De Fontevraud à Jerusalem,” pp. 33–34. 29. Gregory of Tours, Liber Vitae patrum, 4, p. 216. 30. For the lepers working together, see the alternate version of this story in Vita Romani, 45, pp. 288–91. 31. Bériac, “Les fraternités,” pp. 203–5. 32. Marchesani and Sperati, Ospedali genovesi nel medioevo, pp. 72–73; Epstein, Wills and Wealth in Medieval Genoa, pp. 181– 82. 33. Epstein, Wills, p. 175. 34. Kealey, Medieval Medicus, p. 108. 35. Bériac, “Les fraternités,” pp. 203–5. 36. Kealey, Medieval Medicus, chap. 5, pp. 108–9, and commentary, pp. 113–16. For wine at Beaulieu, see Bériac, Histoire, pp. 258–59. 37. Kealey, pp. 108–9. 38. Brody, The Disease of the Soul, pp. 147–57; Gibbs and Johnson, Medieval German Literature, pp. 149–54. 39. Kealey, Medieval Medicus, pp. 108–9. 40. Le Grand, ed., Statuts, p. 215. 41. Ibid., Rules of Montpellier, no. 7, p. 183. 42. Kealey, Medieval Medicus, no. 8, p. 108; Le Grand, ed., Statuts, Rules of Lille, no. 11, p. 201. 43. Robert of Flamborough, Liber poenitentialis, pp. 150–51; Rawcliffe, Leprosy in Medieval England, p. 29. 44. Touati, Maladie et société, p. 688. 45. Ibid., pp. 685–702. 46. Bériac, Histoire, pp. 258–59. 47. Bériac, Histoire, pp. 122–23. Cf. Gregory of Nazianzos, Oratio XIV, 34, col. 904. 48. Le Grand, ed., Statuts, pp. 199–200. 49. Bériac, Des lépreux aux Cagots, p. 48. 50. Rules of Saint Mary’s of Dudston, Kealey, Medieval Medicus, pp. 108–9 (see esp. no. 23); Le Grand, ed., Statuts, Rules of Lille, no. 4, p. 200. 51. Gregory of Tours, Liber vitae patrum, 4, p. 216; Vita Romani, 45, pp. 288–91. 52. Bériac, Des lépreux aux Cagots, p. 46. 53. Epiphanios, Panarion, 75.1.7, (3:333). 54. Bériac, “Les fraternités,” p. 204; Kealey, Medieval Medicus, pp. 113–16.

214

Notes to Pages 129–134

55. Jankrift, Leprose als Streiter Gottes, p. 88, and especially p. 92; Marchesani and Sperati, Ospedali genovesi nel medioevo, pp. 72–73. 56. For Brives, see Le Grand, ed., Statuts, no. 31, p. 212. See also the donations by the feudal aristocracy around Paris to the Lazarus Leprosarium of Paris, in Archives (SaintLazare), p. xviii. 57. Le Grand, ed., Statuts, no. 1, p. 181; no. 3, p. 182. 58. Klövekorn, Der Aussatz im Köln, p. 42. Regarding the size of the Cologne leprosarium, see Schmitz-Cliever, “Das mittelalterliche Leprosarium,” p. 26. 59. Klövekorn, Der Aussatz im Köln, p. 22. 60. Touati, Maladie et société, p. 688. 61. Le Grand, ed., Statuts, no. 2, p. 182. 62. Ibid., no. 10, p. 208. 63. Bériac, Histoire, pp. 224–25. For the original document, see Archives (Saint-Lazare), doc. 160, pp. 153–55. 64. Bériac, Histoire, p. 224. 65. Ibid., p. 227. 66. Le Grand, ed., Statuts, pp. 198–99, “l’ordonnance des ladres bourgeois rendus.” 67. Klövekorn, Der Aussatz im Köln, p. 49. 68. Le Grand, ed., Statuts, no. 32, p. 213. 69. King Louis VI (1108–37), early in his reign, established a fair at Paris, the proceeds of which were to benefit the Lazarus Leprosarium of the city. See Heulhard, La Foire Saint-Laurent, pp. 3– 6. 70. Barsanouphios and John, Correspondance, Letter 765, pp. 208–11. 71. Miller and Nesbitt, “Saint John Chrysostom,” pp. 38–39. 72. Le Grand, ed., Statuts, no. 10, p. 208. 73. Bériac, Histoire, pp. 155– 60, 236. 74. Kealey, no. 10, p. 109; p. 201: “dum negotia tractabunt.” 75. Le Grand, ed., Statuts, no. 3, p. 182; chap. 8, p. 183. 76. Ibid., no. 24, p. 202. 77. Ibid., nos. 1–3, pp. 206–7. 78. Ibid., no. 5, pp. 207– 8; no. 20, p. 210. 79. Ibid., no. 6, p. 208. 80. Ibid., no. 24, p. 211. 81. See ibid., no. 21, p. 218, on the obligation of the prior to assemble a chapter meeting once a week. Cf. ibid., p. 218, note 1, where Le Grand has included the entry from the cartulary for April 23, 1257, describing who attended the chapter meetings. The full document is published in Archives (Chartres), no. 345, pp. 146– 47. 82. Marchesani and Sperati, Ospedali genovesi nel medioevo, p. 77. The decisions regarding the leprosarium and its property were taken “voluntate et consensu infirmorum.” See p. 78 for the lepers’ right to elect the prior. 83. Ibid., pp. 78, 89. 84. Vita Zotici II, 17, p. 366. 85. Typikon Pantokrator, p. 113, lines 1405– 6. 86. Oikonomides, ed., Kletorologion of Philotheos, p. 123.

Notes to Pages 134–139

215

87. See the discussion of this seal in Nesbitt, “St. Zotikos and the Early History of the Office of Orphanotrophos,” p. 420, and note 6. The Greek word adelphoi on this seal clearly refers to the leper residents of the Zotikos Leprosarium, not to monks of a monastery associated with the leper hospital. First, two documents, nearly contemporary with the seal, refer to the leper residents as adelphoi. See Typikon Pantokrator, p. 113, lines 1405– 6, and Vita Zotici II, 17, p. 366. Second, the Orphanotropheion and the Zotikos Leprosarium were administered directly by a government bureau, not by an imperial monastery, as was the case at the Pantokrator Hospital, which received funding from the emperor but was administered by a monastic community. In fact, in the entire history of the Zotikos Leprosarium, there is no evidence of a formal association with any monastic community. See figure 4, p. 87. 88. See Georgopoulou, “Late Medieval Crete and Venice”; Maltezou, “Byzantine ‘Consuetudines’ in Venetian Crete.” 89. Papadia-Lala, Euage kai nosokomeiaka hidrymata ste Benetokratoymene Krete, pp. 137– 47. 90. The Cretan leprosarium hired physicians, which probably represents a Byzantine tradition. For the physicians, see Papadia-Lala, Euage kai nosokomeiaka, p. 144. Bériac, in Histoire, pp. 259– 64, stresses how little evidence there is for physicians’ involvement in Western leprosariums before the fourteenth century. 91. Papadia-Lala, Euage kai nosokomeiaka, p. 142. Cf. Vita Zotici II, 17, p. 366. 92. Papadia-Lala, Euage kai nosokomeiaka, p. 142. 93. Ibid., pp. 141– 42. 94. Archives (Carte di Verona), doc. 6, pp. 11–12. 95. Manousakes and Gemert, “Anekdota engrapha,” doc. 50, pp. 156–57. 96. Adalgisel Grimo, “Das Testament,” p. 270, line 35 (Metz); p. 270, line 39 (Maastricht). 97. Manousakes and Gemert, “Anekdota engrapha,” doc. 50, pp. 156–57. 98. Kealey, Medieval Medicus, pp. 108–9. See also Bériac’s claim that all of the leprosariums of Aquitaine were composed of both male and female residents (Bériac, Des lépreux aux Cagots, p. 48). 99. Le Grand, ed., Statuts, 218, note 1; Archives (Chartres), no. 345, pp. 146– 47. 100. See Archives (Carte di Verona), pp. 145– 64, for the entire story. For Briana’s testimony, see pp. 146–50. 101. Marchesani and Sperati, Ospedali genovesi nel medioevo, p. 78, note 15. 102. Papadia-Lala, Euage kai nosokomeiaka, p. 142. 103. Régistre Jacques Fournier, 2:633. 104. For the Knights of Saint Lazarus, see Jankrift, Leprose als Streiter Gottes. For the structure of the order, see especially pp. 86–101. 105. Régistre Jacques Fournier, 2:633. 106. Bériac, Des lépreux aux Cagots, p. 43.

Chapter 7 1. Hyacinthe, “De Domo Sancti Lazari milites leprosi, pp. 210–24, provides a short history in English of the Lazarites’ evolution into a military organization. See also the more detailed monograph in German by Jankrift, Leprose als Streiter Gottes.

216

Notes to Pages 139–144

2. For a comparison of Byzantine and Western Christian views on warfare, see Miller, “Introduction,” pp. 1–13. 3. See Jankrift, Leprose als Streiter Gottes; Marcombe, Leper Knights; Hyacinthe, L’ordre de Saint-Lazare de Jerusalem au Moyen Âge. 4. See, especially, Barber, “Lepers, Jews, and Moslems,” pp. 1–17. 5. Jankrift, Leprose als Streiter Gottes, p. 58. 6. Ibid., pp. 22–23. 7. Ibid., pp. 31–36. 8. Ibid., pp. 74–78; Shahar, “Des lépreux pas comme les autres,” pp. 20–23. 9. Jankrift, Leprose als Streiter Gottes, pp. 78– 80; Shahar, “Des lépreux pas comme les autres,” pp. 24–25. 10. Bériac, Histoire des lépreux au Moyen Âge, p. 224. 11. Shahar, “Des lépreux pas comme les autres,” pp. 34– 41. 12. Ibid., pp. 37–38. 13. Jankrift, Leprose als Streiter Gottes, p. 82 (letter of Patriarch Robert); p. 44 (decree of Pope Innocent IV). See also Shahar, “Des lépreux pas comme les autres,” pp. 29–32. With regard to Pope Innocent IV’s exemption, see also Merzbacher, “Die Leprosen im alten kanonischen Recht,” pp. 43– 44. 14. That Lazarites always elected a leprous brother as master is evident from Pope Innocent IV’s exemption of 1253. See Jankrift, Leprose als Streiter Gottes, p. 58. Jankrift (pp. 52–55) presents an argument that the Crusader Kingdom’s more liberal approach to leprosy came from a supposedly more accepting attitude toward victims of the disease in Islamic society. Shahar, in “Des lépreux pas comme les autres,” p. 34, rejects the idea that Islam had any influence on the Frankish crusaders’ views toward lepers. Rather, Shahar believes that the Franks let leprous warriors continue to fight because of the precarious military situation for Christians in the Holy Land and the severity of the leper epidemic among Franks in Palestine. 15. Le Grand, ed., Statuts d’Hôtels-Dieu et de léproseries, nos. 1, 3, pp. 206–7. 16. Régistre Jacques Fournier, 2:633–35. 17. Merlo, “Esperienze religiose e opere,” pp. 31–35. 18. Jankrift, Leprose als Streiter Gottes, p. 58. Cf. Kealey, Medieval Medicus, pp. 108– 9, 111–12. 19. Archives (Carte di Verona), pp. 146–50. 20. Shahar, “Des lépreux pas comme les autres,” pp. 34–35. 21. Medieval documents show that lepers could work in fields, construct buildings, and even riot effectively. See Rawcliffe, Leprosy in Medieval England, pp. 317–18, for a description of how leper residents from the leprosarium of West Somerton destroyed their institution in the late thirteenth century during a riot against their unjust prior. 22. See Savona-Ventura, in “The Order of Saint Lazarus in the Kingdom of Jerusalem,” pp. 58–59, who has identified two men of the twelfth-century Kingdom of Jerusalem who served the Lazarites as “confratres.” 23. Jankrift, Leprose als Streiter Gottes, pp. 36, 51. 24. See the rule of the leprosarium of Montpellier, in Le Grand, ed., Statuts, nos. 2 and 3, p. 182. 25. Jankrift, Leprose als Streiter Gottes, pp. 30–31.

Notes to Pages 145–150

217

26. Jankrift, Leprose als Streiter Gottes, pp. 31–33; Marcombe, Leper Knights, p. 7. 27. For Greek, Latin, and Syriac sources that describe Empress Eudocia’s Church of Saint Stephen, see Vincent and Abel, Jérusalem, pp. 761– 65. Regarding her philanthropic foundations, see Vita Euthymii, 35, pp. 53–54. 28. Xanthopoulos, Historia Ecclesiastica, 14.50 (PG, 146:1240). 29. Vincent and Abel, Jérusalem, p. 753. See also Leyerle, “Children and Disease in a Sixth-Century Monastery,” pp. 349–56, concerning recent archaeological investigations at the Church of Saint Stephen that have identified a burial site of monks from a monastery associated with the church. Moreover, a careful study of the skeletal remains has shown that one-third of the 167 individuals buried at this site were children (pp. 352– 53). Leyerle supposes that these children died in a hospital, but it seems more likely to us that they were orphans from an orphanage associated with the monastery and leprosarium. See Crislip, “Monastic Health Care and the Late Antique Hospital,” p. 104, for orphans at Egyptian monasteries. The pairing of a leprosarium with an orphanage also occurred at Constantinople, where the Zotikos Leprosarium was associated with the Oprhanotropheion (see chapter 4 section, “Asia Minor and Constantinople”). 30. Vincent and Abel, Jérusalem, p. 753. 31. Klövekorn, Der Aussatz im Köln, p. 26. Regarding the Zotikos Leprosarium, see Vita Zotici I, 11 and 12, p. 82; Vita Zotici II, p. 373. 32. Vincent and Abel, Jérusalem, pp. 754–55. 33. Tobler and Molinier, eds., Commemoriatorium de casis dei vel monasteriis, p. 302. In describing the Church of the Holy Sepulcher (p. 301), the anonymous Latin author mentions priests, deacons, and other ranks of clergy without specifying their ethnic identity. We know that the clergy of the Church of the Holy Sepulcher were Greeks. It seems certain that when this author mentioned two priests at the Saint Stephen Church, he was also referring to Byzantine Greek clergy. 34. Kedar, “Gerard of Nazareth,” p. 55. 35. Ibid., 11–12, p. 72. 36. Ibid., pp. 66– 69. 37. Nasalli-Rocca, “Gli Ospedali italiani di S. Lazzaro dei Lebbrosi,” pp. 262–70. 38. Marcombe, Leper Knights, pp. 135–54. 39. Jankrift, Leprose als Streiter Gottes, pp. 88, 92. 40. Marcombe, Leper Knights, pp. 142– 61. 41. Ibid., pp. 161– 64. 42. Marcombe, Leper Knights, pp. 17, 135. Cf. Hyacinthe, L’ordre de Saint-Lazare de Jérusalem au Moyen Âge, pp. 77–78. 43. See Hyacinthe, L’ordre, pp. 77–78, who interprets Pope Clement’s bull as evidence that the Order of Saint Lazarus still maintained leprosariums in some of its Western commanderies. 44. Bullarum, no. VII, pp. 742– 43. 45. Nicholson, The Knights Hospitaller, pp. 34– 42, provides a summary of both Templar and Hospitaller defeats from 1260 to 1291. For the papal measures to assist the Knights of Saint Lazarus, see Jankrift, Leprose als Streiter Gottes, pp. 99–101. 46. Le Grand, ed., Statuts, pp. 206–14. 47. Heidemann, Papst Clemens IV, pp. 80– 81.

218

Notes to Pages 150–159

48. Registri dell Cancelleria angioina, 2:65– 66 (no. 234). 49. Ibid., 7:274–75 (no. 29). 50. Ibid., 2:65– 66 (no. 234). 51. Ibid., 8:110 (no. 105). 52. Ibid., 7:274–75 (no. 29). 53. Bottari, “I lebbrosi di Messina,” pp. 23–24. 54. Hyacinthe, L’ordre, p. 79. 55. Barber, “Lepers, Jews, and Moslems,” pp. 1–17, but especially pp. 6–10. 56. Régistre Jacques Fournier, 2:633– 43, but see especially p. 633 for Agasse’s office of commander. 57. Ibid., 2:635, 639. 58. Ibid., 2:635. 59. Ibid., 2:639. 60. Barber, “Lepers, Jews, and Moslems,” pp. 1–17; Jankrift, Leprose als Streiter Gottes, p. 118. 61. Barber, “Lepers, Jews, and Moslems,” pp. 16–17. 62. Régistre Jacques Fournier, 2:641. 63. Heidemann, Papst Clemens IV, pp. 21–33, 59– 83. 64. Molinier, ed., Correspondance (Alfonse), no. 868, pp. 556–57. 65. Bériac, Des lépreux aux Cagots, p. 58.

Conclusion 1. Bullarum, no. VII, pp. 742– 43. 2. Porter, The Greatest Benefit to Mankind, p. 121; Foucault, Madness and Civilization, p. 3. 3. For Basil, see Gregory of Nazianzos, In laudem Basilii, 63.5, pp. 190–91; for Martin of Tours, see Vita Martini, 18.3– 4, pp. 292–93. 4. For Pope Gregory’s story, see Gregory (pope), Gregorii Magni homilia XXXIX, PL, 76:1300–1301; for Bishop Athanasios, see Vita Athanasii episcope Neapolitani, MGH, pp. 441, 445. 5. See chapter 3 section, “Byzantine Divorce Law.” 6. Alderotti , I “Consilia,” 143, p. 194, lines 41 and 42. 7. Aretaios, Aretaeus, 4.13.18, p. 89. 8. Gouguenheim, Aristote au Mont-Saint-Michel, pp. 45– 49. For Latin medical treatment lists from southern Italy with entries taken from Greek physicians, see Miller, The Birth of the Hospital in the Byzantine Empire, p. xxvi. For Byzantine influence in Salerno, see Browning, “Greek Influence on the Salerno School of Medicine,” pp. 189– 94. For Pietro d’Abano’s career, see Hohlweg, “Diadosē,” pp. 54–55. 9. Lorscher Arzneibuch, pp. 11–13. 10. Ibid., no. 46, pp. 128–29, “Ad elephantiosos.” 11. Aretaios, Aretaeus, 4.13.1–9, pp. 85– 87. 12. Miller, Birth, pp. 100–5. 13. See chapter 6 section, “Finances.”

Notes to Pages 159–162

219

14. Nesbitt, “St. Zotikos and the Early History of the Office of Orphanotrophos,” p. 420, and note 6. 15. See chapter 3 section, “Categorizing Leprosy.” 16. See chapter 5 section, “The Laws.” 17. For Byzantine romances, see ODB, 3:1804–5; Romanzo Bizantino del XII secolo, pp. 9–39. See also the comments by Kaldellis, Hellenism in Byzantium, pp. 256– 83. 18. See Le Grand, ed., Statuts d’Hôtels-Dieu et de léproseries; Archives (Carte di Verona); Archives (Chartres); Archives (Saint-Lazare). 19. Tabuteau, “Historical Research Developments,” pp. 45– 46. 20. Archives (Carte di Verona), doc. 78, pp. 146–55, 154–57. 21. Ibid., pp. xxxiii–xxxviii.

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Index

All dates are AD, unless otherwise specified. Adalgisel Grimo, 122–23 Aetios of Amida (mid-sixth century), 49, 51, 61 Agasse, Guillaume (commander of leprosarium), 96–97, 137, 142, 151–53 Agricola (Bishop), 122 Alderotti, Taddeo, 64, 111, 114, 157 Alexander III (Pope), 107, 109 Alexander IV (Pope), 149 Alexandria: elephantiasis at, 10, 13, 32; leprosarium at, 82, 83 Alphonse II of Toulouse (Count), 153–54 Ambelakianes, Irene, 137 Andronikos (son of Emperor Manuel II), 38, 89 antidotaria (medical recipes), 48– 49, 51, 55, 157–58 Antioch: leper asylum at, 33, 70, 79– 80 Antony (Saint), 32–33 Apostolic Constitutions, 24, 31 Aquitaine, 128

Arab physicians and commentators, 57–59, 64, 66, 111 Archigenes (first-second century): pneumatist opinions of, 14, 51, 57–58 Aretaios of Cappadocia: date of activity of, 14; description of elephantiasis by, 14, 16; treatise On Acute and Chronic Diseases by, 14, 157; pneumatist theories on; contagion of, 15–16. See also appendix 1 in this book Arians, 31, 78–79, 81, 82 Arnold of Villanova, 114 Arnulf of Metz (Bishop), 123 Asia Minor, 28–30, 86, 98 assistance to lepers: church initiatives in support of, 30, 33–34, 82, 83, 90, 122, 123–24; local programs for, 121–22, 125; personal involvement in, 32, 43, 44– 45, 69, 86, 122–23, 124, 143, 146 Athanasios the Athonite (Saint), 57

24 0

Index

Athanasius of Naples (Bishop), 124, 156 Auterive, 138 Avicenna (tenth century), 58, 111 Baldwin IV (King), 115, 141– 42, 144 Barsanouphius and John (monks), 85, 91, 94 Basil I (Emperor), 60, 106, 107, 156 Basil of Caesarea (Bishop): legend of, 144; leper asylum built by, 30, 43 bathing and washing, 44– 45, 68– 69, 86, 123, 146– 47 Beaulieu (Chartres): leper assemblies at, 133; regulations of, 126 Bede, 101 Belgium: leprosariums in, 120 Briana: deposition of, 136–37 Brives: rules and regulations of, 112, 132–33; support of residents of, 130; vineyards of, 131 Brussels, 120 burning of lepers, 96, 97, 138 Burton Lazars, 129, 147 Byzantine culture in the West, 156–58 Caelius Aurelianus (fifth century), 22 Caesarea (Cappadocia): leper asylum at, 30, 74 cancer, 65, 70, 71, 80 Candia (Crete), 37, 134–35 care of widows and orphans, 23–25, 33, 91 Chalon-sur-Saône: leprosarium at, 122 Charlemagne, 108 Charles of Anjou, 150–51 Christ’s appearance as leper, 103, 156 Christ’s attitude toward lepers, 20–21, 22 Clement IV (Pope), 148– 49, 155 Cologne: alehouse of leprosarium at, 131; entrance fees to leprosarium at, 130 colors of leprosy, 13, 14, 39, 102 Constantine (Emperor): contraction of leprosy by, 98, 100; drowning of lepers by, 31, 98; legend of, 100–101 Constantine VII (Emperor), 36 Constantine IX (Emperor), 45 Constantine the African (eleventh century), 22, 66– 67, 110, 111 Constantinople, 31, 75. See also John Chrysostom (Bishop): construction of leper asylum by; Zotikos (Saint): leprosarium of Constantius II (Emperor), 34, 77, 90, 91 Council of Compiègne, 107

Coursières, 138 Crusades, 73, 119. See also Knights of Saint Lazarus Cyril of Alexandria (Patriarch): comments on Leviticus of, 39, 41; Lenten Letter on poor and lepers by, 33 Dakhleh Oasis cemetery, 11 Damasus (Pope), 144 Daniel (Egyptian ascetic), 44 diet’s effects, 13, 15, 50 Dudston: leper house at, 121; regulations of, 126, 127, 132, 135–36 Ecloga, 59– 60, 106, 107 Edessa, 33–34 Edward I (King), 148 Egypt: arrival of leprosy into, 10–11; leprosariums in, 81– 83 elephant disease. See elephantiasis elephantiasis: increase in incidences of, 29–30, 72, 120–21; stages and symptoms of, 11–12, 16, 60– 61, 65, 157; as term, 12, 14, 158. See also leprosy (Mycobacterium leprae) emir of Granada, 97, 152 Epanagoge, 60 Epiphanios of Cyprus, 73–74 epitropos (procurator), 133, 134 Eudes de Châteauroux (Cardinal), 112 Eudocia (Empress), 84, 91, 144– 45, 146 Eudoxia (Empress), 44 Eulogios (teacher at Alexandria), 32–33 Eustathios of Sebasteia (Bishop), 74, 77 examinations and tests for leprosy, 114–16 Fabiola, 121–22 Fontevrault, 124 Fracastoro, Giambattista, 64 France, 120, 121, 122, 124, 126 Francis of Assisi (Saint), 44, 105 funeral regulations, 82– 83 Galen of Pergamon (second century): 6–7, 13, 25, 32, 50, 56, 65, 92–93 Genoa (Cape Faro): leprosarium at, 120, 125, 133, 137 Gent, 120 George of Cappadocia, 82– 83 Gerald of Cremona (twelfth century), 22, 58, 110

Index Gerard of Laodicea (Bishop), 146 German leprosariums, 130 gerokomeion, 46, 88, 89 Gilbertus Anglicus, 111 Gnostics, 23 Gregory I (Pope), 103, 156 Gregory II (Pope), 109 Gregory IX (Pope), 149 Gregory of Nazianzos: sermon on lepers by, 30, 41– 43, 52–53 Gregory of Nyssa: medical opinions of, 53–54; sermon on leprosy and Christian duty of, 28–29, 54. See also appendix 2 in this book Gregory of Tours, 101, 102, 124 Guido of Le Puy (Bishop). See Clement IV (Pope) Hansen, Gerhard Armauer, 7 Hansen’s Disease, 7–9, 29, 114 Henry of Bracton: classification of lepers by, 108 Hermopolis, 83 “Holy Disease” (leprosy): as term, 5, 21, 28, 41, 43, 63, 94, 106 humors: as black bile (melancholia), 7, 13, 52, 53, 54, 65– 66; as yellow bile, 7, 65– 66 Hyrcanus of Judah (King), 144 Ibn al-Jazzār (tenth century), 66 Ibn Qutayba (ninth century), 58–59 Ignatius of Antioch (bishop), 23 India, 10–11 Innocent IV (Pope), 142, 149 Isaak Komnenos, 88 Isidore of Pelusium, 39, 102 Isidore of Seville, 102 Italy: entrance of elephantiasis into, 12, 25; leprosariums in, 120, 121, 125, 135, 136 Ivo of Chartes (Bishop), 126 Jacques de Vitry (Cardinal), 105 Jerome (Saint), 121–22 Jerusalem: leprosariums at, 84, 91, 141, 144– 45 Jews, 18, 97, 113 Job, 41, 45, 128 John I Tzimiskes (Emperor), 36, 45, 69, 90 John II Komnenos (Emperor), 36, 46, 57, 94, 133 John VI Kantakouzenos (Emperor), 101 John Chrysostom (Bishop): agitation against, 44; construction of leper asylum by, 30, 81;

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finances of leprosarium of, 90, 131–32, 158–59; oration in honor of, 6, 30, 44, 113–14; rejection of contagion theory by, 113–14. See also appendix 3 in this book John Moschos, 62 John Zacharias (fourteenth century), 17–18, 49, 56, 62, 65 Jourdain (preceptor), 152 judham, 22, 66 Justin II (Emperor), 34, 90 Justinian (Emperor), 59, 75, 79, 84, 90, 158 kakochymia (“bad mixture”), 8, 11 kelephia, 54 kissing of lepers, 43– 44, 105, 156 Knights of Saint John, Jerusalem hospital, 47 Knights of Saint Lazarus: bull of Clement IV in favor of, 148– 49; decline of, 142; leprosarium of, 141; organization and regulations of, 141, 142– 43; origins of, 140– 41, 144– 45; property and finances of, 141, 148– 49, 151; transfer of leprosariums to, 148– 49, 150–51 Lanfranc of Milan, 111 Lazariotai, 84– 85 Lazarus: as leper, 85; as symbol, 41 Lazarus Leprosarium (Jerusalem), 141 lektarioi, 82– 83 Leo (physician and compiler), 64 Leo I (Emperor), 77 Leo III and Constantine V, 59 Leo VI (Emperor), 60, 106, 157 leontiasis: as first stage of leprosy, 11; as term for leprosy, 8 Leper Massacre (1321), 96–97, 151–53, 156 lepers: assemblies of, 132–33, 135, 136–37, 150; beverages and clothing of, 70, 126, 127; isolation of, 29, 33, 42, 58, 80, 94, 97, 98–99, 107, 108–9, 112, 119, 123, 150, 155; property of, 107, 108, 109, 130, 132; testaments of, 109, 130 lepra: as term, 17–18, 21–22 lepromatous leprosy: spread into Egypt, 10–11; symptoms of, 1–2 leprosariums: financial underpinnings of, 129–32, 158–59; rules of, 5– 6, 126–27, 132–33, 134–35; separation of men and women in, 82, 128, 141

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Index

leprosy (Mycobacterium leprae): modern explanations of cause and types of, 7– 8; pre-modern medical views on cause and transmission of, 11, 13, 15–16, 50, 51, 52, 53, 54, 55, 57, 58–59, 111 Leviticus 13 and 14: Christian interpretation of, 39– 41, 155 Liber Pastoralis, 198 Life-giving Spring (Monastery of), 37, 63, 89 Lille: leprosarium regulations at, 112, 132 Livre au Roi, 141 lobotropheion (“leprosarium”), 86 Lodi, 100, 101, 115 Lombard Law, 107, 115, 160 Lorsch (Monastery). See “Medical Book of Lorsch” Lucretius (first century BC), 12 Lüttich, 120 Maastricht, 123, 135 magical incantation, 13 Manetho, 12 Manuel Philes (poet), 37, 63, 89 marriage bond: laws and rulings on the loosening of, 59– 60, 106–7, 156 Martin of Tours (Saint), 43 Martyrios (“Christ-bearer”), 103 Maurice (Emperor), 34, 88 “Medical Book of Lorsch,” 157–58 Messina, 151 Methodius of Olympus, 39, 102 Metochites, Theodore, 86 Metz, 122, 135 Michael IV (Emperor), 45, 68 Michael Psellos (eleventh century), 55 Miriam, 19 Monastery of Machairas (Cyprus), 92 monks: classification of lepers as, 127–28 Montpellier: leprosarium regulations at, 121, 127, 130, 132 morphea, 22 Muhammed, 58 Mycobacterium leprae, 7, 11 Naaman, 19 Naples, 107, 124 Narbonne (diocese of), 153, 154 Neilos of Ankyra, 80 Nicaea: leprosarium at, 37, 86

Nicholas I (Pope), 107, 156 Nicholas V (Pope), 133 Nikephoros (Patriarch), 36 Nikephoros I (Emperor), 91 Nikephoros II (Emperor), 88 Nikomedeia: leprosarium at, 86 Nonnos (Bishop), 84 nosokomeion, 84, 88, 122 Noyon: regulations at leprosarium of, 131 Oribasios, (fourth century), 50, 64 Origen, 41 Orphanotropheion, 91 orphanotrophos, 77, 133–34 Othmar (Abbot), 123–24 paleopathology, 8, 11, 120 Palestine: leprosariums in, 84– 85 Pâmbo (monk), 82 Pamiers: inquisition at, 96–97, 151–52 Pantokrator Monastery, 46, 89 parabalani, 82– 83 Paris. See Saint Lazarus (Paris) Paul of Aegina (first half of the seventh century), 51–52, 55, 65 Philip V (King), 96–97, 152–53 Pliny the Elder (first century), 12 Plutarch (ca. 46–120), 12, 15 poisoning of wells, 96, 97, 152 Prochiron, 60 Procopios, 75 ptochotropheion (“refuge for the poor”), 74, 77, 86 Qur’an, 58 Rabbula of Edessa (Bishop), 33–34, 83, 90, 94 Robert of Arbrissel, 124 Robert of Flamborough (canonist), 127 Roger of Mowbray (Earl), 129 Romanos III (Emperor), 36, 86, 89 Romanos the Melode, 21 Romanus (Saint), 124 Rome: leprosarium at, 121–22 Rothari (King), 107 Rufus of Ephesus (first century), 11–12, 61 Saint Gall: hospitolium of, 123 Saint Giles Holborn: leprosarium at, 148

Index Saint Lazarus (Candia): leprosarium of, 134–35 Saint Lazarus (Paris): leprosarium of, 130–31 Saint Stephen’s Church (Jerusalem), 145 salves, 13, 55, 68, 70 satyriasis, 8, 11–12, 61– 62, 63– 64, 157 Sebasteia: leper asylum at, 38, 73–74, 98 Sens: leprosarium at, 131 Serbia (Dečani): leprosarium in, 38, 70, 92 Shepherd of Hermas, 23 sin: leprosy as punishment sin, 38– 40, 57, 99–100, 101–2 Sophronios of Jerusalem (Patriarch), 39– 40, 102 Stephen II (Pope), 106 Stephen Uroš III (King of Serbia), 38, 69–70, 89, 92, 95 Strasbourg: leprosarium at, 130 Straton, 11 Summa Pastoralis, 128 Sylvester (Pope), 100–101 Teachings of the Apostles, 24 Templars, 141 terms for leprosy, 8, 17–18, 21–22 Tetrabiblos. See Aetios of Amida (mid-sixth century) Thémines, 138 Theoderic of Cervia, 67, 111 Theodosios the Cenobiarch (Saint), 43, 84, 92 Theophanes Chrysobalantes, 49, 55, 65 Theophylakt of Nikomedeia (Bishop), 86

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Timur, 38, 98 Toulouse: leprosariums at, 97, 120, 152, 154 Trier: leprosarium at, 130 Tristan and Isolde, 2, 63, 160 tsa’arath: as term, 18, 20 tuberculoid leprosy, 7, 10, 67, 159 Uzzah of Judah (King), 19–20 Verdun, 122–23 Verona: leprosarium at, 135, 136–37 Voghera (Lombardy): leprosarium at, 142 “walking corpses”: as term, 2 Walter of Lille (Bishop), 106 Whitby: leper hospital in, 70 William of Tyr (Bishop), 115, 142 women: as administrators of leprosariums, 137, 138; as participants in leprosarium meetings, 136, 137, 159 Xanthopoulos, Nikephoros Kallistos, 37, 84, 89, 145, 146 xenodochium, 122 xenon(es), 46, 56, 74, 79, 80, 88, 89 Zacharias (Pope), 109 Zotikos (Saint): legend of, 30–31, 68– 69, 75–77, 98, 101, 113; leprosarium of, 30–31, 34, 36, 45, 46, 69, 86, 88, 90, 91, 113, 133–34; location of leprosarium of, 68– 69, 77; orphanage of, 30–31, 36, 77, 89, 91