Medicine and the Seven Deadly Sins in Late Medieval Literature and Culture
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Medieval
As the term “medieval” is, of course, not native to the period or the texts under study, it is worth reflecting on suppositions about the medieval, especially in regards morality and health. The concept of the Middle Ages or medium aevum, meaning “between ages,” developed after the period denoted as such. Petrarch distinguished the “middle age,” one of darkness and ignorance, from his own age, a time of light and learning. 31 According to the Oxford English Dictionary, the word “medieval” was first used as an expressly pejorative term, meaning “exhibiting the severity or illiberality ascribed to a former age; cruel, barbarous” in 1883. Solidifying the popular use of this term, the film Pulp Fiction established the phrase “to get medieval” meaning “to use violence or extreme measures on, to become aggressive,” in the 1990s. It might seem unnecessary to belabor the point that some popular cinematic references to and depictions of the medieval get it wrong. However, the work of several influential thinkers authorizes these attitudes. For example, the “civilizing process” and similar theories developed by Johan Huizinga and Norbert Elias chart an ascent from barbarism or infancy to civilization and maturity through the development of nuance and restraint in behavior and interactions. 32 Although historians of emotion have recently challenged these theories, they continue to be cited uncritically in both the popular media and scholarly contexts, even by medievalists—further strengthening the reputation of the medieval as uncouth, inflexible, superstitious, and exhibiting a crude or violent sense of justice.
The portrayal of assumed “medieval” attitudes toward medicine and morality is particularly worthy of further interrogation. For example, pointing specifically to medieval leprosy, “one of the most meaning-laden diseases,” Susan Sontag’s Illness as Metaphor advocates a view of disease that is entirely literal, stripped from metaphorical and invariably moral associations. Sontag writes of the segregation of lepers into dedicated houses or leprosaria. Once emptied of medieval lepers, these same structures housed Michel Foucault’s madmen. In Madness and Civilization, Foucault writes that “leprosy disappeared, the leper vanished, or almost, from memory; these structures remained. Often in the same places, the formulas of exclusion would be repeated, strangely similar two or three centuries later.” 33 Sontag and Foucault chart similarities between the “medieval” view of disease and more contemporary conceptions of cancer, AIDS, and mental illness. However, these attempts to locate and dismantle continuities between the present and the past can obscure the distinctive qualities of the Middle Ages.
The historian Carole Rawcliffe revisited claims about medieval attitudes and practices regarding leprosy. In a provocatively entitled chapter “Creating the Medieval Leper,” she shows how nineteenth-century responses to the disease were based largely on misreadings of medieval sources, either taking one exceptional source as representative of a widespread phenomenon, such as the “leper mass,” or failing to put these sources in their social contexts, as in the case of the leprosarium. 34 Nineteenth-century advocates for the institutionalization of the criminal, sick, poor, and insane found a “medieval” that conformed to their ideas of segregation and exclusion. Nineteenth-century readers understood that these leprosaria functioned to contain the “leper race” through enforced isolation and strict prohibition of reproduction. In fact, there is very little evidence of the legal exclusion of lepers in the Middle Ages. In contrast with the Victorian prison model, leper hospitals in the Middle Ages were charitable institutions of which membership was entirely voluntary. 35
Some writers have used historical documents to chart progress away from the Middle Ages and toward science. With reference to the Middle Ages, the decision of People versus Pierson (1903) regulated “faith healing” in the early twentieth century in the USA. Pierson was one of the earliest of these cases and concerned the right of parents not to call a doctor for their child, who was sick with whooping cough, on the grounds of religious conviction. The decision paints a progressive narrative, specifically referencing the Fourth Lateran Council of 1215, which required physicians to call confessors before embarking upon medical treatment. “The curing by miracles, or by interposition of Divine power, continued throughout Christian Europe during the entire period of the Middle Ages, and was the mode of treating sickness recognized by the church” until the eighteenth century, which saw a shift in cultural attitudes precipitated by medical discoveries, until, eventually “it has become a duty devolving upon persons having the care of others to call upon medical assistance in case of serious illness.” 36 In this decision, the New York Court of Appeals juxtaposed the supernatural, moralistic premodern with the “civilized,” secular modern, blaming the allegedly slow progress of medicine after its Hippocratic origins on the Roman Catholic Church. 37
Regardless of the actual practice of calling for confessors before medical treatment, which is contested by many medical historians and rarely mentioned in medical texts except in fatal cases, the idea that the Church only recognized miracles as healing practices is patently untrue. 38 Not only was medicine regulated and therefore recognized by the Church, it was also practiced by medieval priests, who were advised to understand the physical health as part of their effort to understand the spiritual health of the faithful. 39 Likewise, Sontag’s account of “medieval” attitudes toward sickness excludes readings of the relation of body and soul that are less devoid of sympathy and subtlety.
Is it relevant to show how the Middle Ages have been maligned, other than to satisfy other pedantic medievalists? The concept of the medieval not only describes the past; it is invoked to explore and shape policy decisions and social attitudes. The Leper Home in Carville, Louisiana was closed as late as 1999. From the time of its founding until the 1950s, residents were kept as prisoners, denied the right to vote, marry, or leave. As misunderstandings about contagion cleared, the proscriptions against the patients relaxed; yet the facility remained open due to the social stigma of leprosy. 40 The recent outbreak of Ebola has several times been compared to the medieval experience of plague, specifically in reference to quarantine zones in Liberia. Critics have evoked “medieval” measures such as quarantine and “cordons sanitaire” to depict the policy as “a reflection really of ignorance and panic.” 41 The isolation of lepers and plague victims does not equate so simply to the brutal military quarantine witnessed in Liberia. 42
How we use the past is significant; and to do so adequately, we must develop a more nuanced view. Generally, a longer appreciation of the relationship of medicine and religion prompts critical analysis of our own perceptions of and attitudes toward the sick and their care. The cases of leprosy and faith healing reveal that our relationship to the past is sometimes less a matter of the “stubborn persistence” or rejection of attitudes that link illness with immorality or sin than of reliance on faulty accounts of what these attitudes were. 43
Medicine
The concept of medicine in the Middle Ages is difficult to grasp due to our expectations and misconceptions of medieval medical texts, which can seem incompatible with modern scientific standards. 44 The medical historian Anne Van Arsdall reminds us that rather than looking for the superstitious and magical in medieval medical recipes, we ought to consider more practical functions. For example, the recitation of charms, phrases or prayers may have been advised simply as a means of making the patient rest and thereby “allowing the herb to do its work in the body, not because the words were believed to have magical effects.” 45 However, this is not to say that the patient might not have believed in the efficacy of these charms or prayers—a belief that induced the relaxed state needed for rest.
The principles of premodern medicine rest on a more holistic sense of healing than most modern medical practices. Following in the Galenic tradition, therapies treated both body and soul. Indeed, Galen believed that body and soul were of the same substance. 46 To this end, medicine considered both “natural” things such as complexions, bodily fluids, organs, physiological processes, an
d “non-natural” things. These non-naturals include six things not essential to the body: food and drink, excretions, air, motion and rest, sleep and waking, and the passions. 47
Another barrier to conceptualizing earlier medicine is that the divisions and categories of knowledge in the Middle Ages are different from our own. Although the supposed rift between religion and science has inspired much intellectual energy, both the dimensions of this rift and how to apply these ideas to premodern religion and science are unclear. A common narrative employed to describe the evolution of secular science traces a rivalry between science and religion after the Middle Ages as a natural extension of Protestant empiricism. 48 Yet medieval theologians were rigorously trained in natural philosophy as the foundation of their education. 49 Some of the most prominent theologians of the period—Albertus Magnus, Robert Grosseteste, Thomas Aquinas, Duns Scotus, William Ockham—were also natural scientists. The historian of science Edward Grant has argued for a “secular” natural science in the Middle Ages, stating that although scientific texts cite biblical authority, the intention is not “to demonstrate scientific truths by appeal to divine authority.” 50
There were certainly moments of tension between science and religion in the universities, as demonstrated in the Condemnation of 1277. The Condemnation responded to concern among some Paris theologians that the dominance of Aristotelian natural philosophy, with its naturalism and determinism, threatened points of Christian dogma. 51 In England, the effect of the Condemnation was to institute a broad emphasis on God’s absolute power over naturalism, which bore a direct relation to medicine and the body’s disposition to certain thoughts and actions, as we shall see. However, a sharp separation was drawn between having that power and exercising it. The distinction between God’s absolute power and ordinate power referred to God’s creation of a set of natural laws and His prerogative not to break these laws, although He theoretically could. 52
Compounding the complexities of accessing the medieval worldview is the fractured state of our own learning in the modern university. In the 1950s, a medievalist lamented the division of knowledge into fields in the modern age, and its impact on scholarship on the literature of the Middle Ages, which is “dismembered into specialties which have no contact.” 53 The same might be said of how we view medicine and religion. Current disciplinary divisions often separate historians of medicine and historians of religion. However, recent work begins to rectify this fissure. Joseph Ziegler, for example, has revealed the interpenetration of medical and religious language and ideas in the texts of two major physicians who also wrote learned sermons and religious literature in the early fourteenth century. 54 Literary critics have also read medical texts both as sources for the study of literature and as subjects for literary analysis in themselves. 55 This work has uncovered the wider valence of medicine in medieval culture. Current work on miracle collections has further dismantled the appearance of competition between religion and medicine. Rather than acting as a mere foil for miraculous healing, material medicine was rigorously explored to eliminate natural causes. 56 Furthermore, the Church employed physicians in canonization proceedings. 57 Religious authority recognized medical authority in its own domain.
In the period in question, particularly in England, religion and medicine are not distinct fields as in the modern university; certainly not in the sense of contrasting ontologies. The nature and causality of sickness could be at once supernatural and natural, immaterial and material. The core of authorized religion, as expressed in the canons of the Fourth Lateran Council, recognized the practice of both physical and spiritual medicine.
The twenty-second canon decreed that every physician of the body must call for a physician of the soul before beginning any treatment. Two reasons are given. The first is that bodily medicine will work better after confession “for the cause being removed the effect will pass away.” 58 The logic here is that diseases have spiritual causes, rendering material or bodily medicine superfluous. However, the second reason addresses the question of when the physician should call for the confessor, suggesting a more mutual relationship between spiritual and bodily medicine. The medical practitioner should call for the confessor before he begins treatment rather than during treatment. As the canon further explains, “some, when they are sick and are advised by the physician in the course of the sickness to attend to the salvation of their soul, give up all hope and yield more easily to the danger of death.” 59 These two forms of illness and healing—spiritual and material—are acknowledged to co-exist and interlock in an English confessional produced shortly after the Lateran canons by Thomas of Chobham (d. c. 1230): “no one should take a sick person to the physician [medicus] or give him medicine before he has confessed, because many illnesses do not originate from the nature of the elements or the body, but rather through sin, and thus they can only be cured by confession and repentance.” 60
How secular, then, was the study of medicine? Before its incorporation into university curricula, medicine was taught at specialized and independent institutions. However, with its integration into university teaching, medicine became the first “professional” science, raising its status from technical to theoretical. 61 Physicians were often clerics, as their university education included both theology and medicine. The “secularization” of medicine varied from country to country during the period under study (1215–1500). For example, medicine developed in the English universities in the Middle Ages, although it was considerably less established than on the continent. 62 However, English medicine retained its clerical character for much longer than that on the continent, where secular physicians soon displaced clerics. 63 In the fourteenth century, all but four of the documented physicians operating in late medieval England recorded ecclesiastical income. Although an increasingly secular vocation in the fifteenth century, several clerics still appear as medical men in the period’s records. 64
The integration of medicine into university teaching, however, did enforce a separation of medicine and surgery. Although surgery was practiced in Europe throughout the ancient world and for the whole of the Middle Ages, it did not achieve “institutional stability” until the thirteenth century. The factors enabling the transition included both the translation and circulation of Arabic texts as well as the greater concentration of populations in urban centers, which fostered universities and apprenticeship structures. 65 In contrast with continental universities, neither Oxford nor Cambridge offered teaching in surgery; indeed, medicine itself was a minor subject. 66 Instead, surgery was institutionalized in guilds (the first earliest established in 1368), which provided apprenticeships for practical experience. 67 After a number of years, surgeons took an exam in order to become masters of surgery.
Outside of the universities, boundaries of medicine and religion were blurred. Simple parish priests provided a variety of services. Some related directly to confession, such as the examination of the sinner’s particular physiological make-up (or complexio [complexion]) in the determination of penance. 68 “Complexion” reflected the balance of four bodily substances or humors—sanguis, choler, melancholia, and phlegma—that disposed a person toward a certain outlook, actions, and thoughts.
Other evidence suggests that priests were involved in the care of the sick and the administration of earthly medicine beyond its relation to spiritual outcomes. Nuns and priests staffed medieval hospitals, rather than physicians. 69 Likewise, manuscript studies reveal that priests owned, and appear to have used, medical texts. 70 The translation of such texts into the vernacular also suggests a broader interest in and knowledge of medicine. In England, the number of medical manuscripts in the vernacular increased by about sixfold between the fourteenth and fifteenth centuries. 71
Medicine and religion were neither competitive nor antagonistic. Instead, religious texts often stressed the significance of health and medicine in a wider context, as a social and moral good. Removed from its textual context, “þilke þat lyuen as bi phisike,
bi phisike dieþ” [those who live by medicine, die by medicine] in the late fourteenth-century pastoral The Book of Vices and Virtues seems a stark statement against medicine. 72 However, the passage associates medical regimen for its own sake with lack of charity, specifically eating largely in other men’s houses and meagerly in one’s own. Those who “lyuen as bi phisike” contrast with those who “lyuen gostly,” those who “eten and drynken after þe loue of God, to whom þe Holi Gost techeþ to holde mesure and ordre and resoun.” 73
Furthermore, while sometimes employing medicine as a negative analogy, particularly in the devil-as-physician trope, religious texts do not demonize earthly medicine itself. 74 Rather, the devil offers false advice, suggesting that it is unhealthy to listen to sermons and healthy to stay up late at the tavern drinking and playing dice. Such behavior, however, actually leads to “dropsye [dropsy or edema] or gowte [gout].” 75 The operation of medicine as a positive analogy for confession was far more prevalent. The use of medical metaphors and analogies is covered in more detail in the next chapter, and various terms relating to medicine are addressed as they arise.
The Seven Deadly Sins
For most of the Middle Ages, the sins were a principal organizing tool to explain behavior sanctioned by the Church. Although originating in Greek and Roman philosophy, the Christian concept of the sins dates from the fourth century with the desert monk Evagrius Ponticus (d. 399). 76 But then the deadly sins numbered eight, and they were considered closer to thoughts sent by demons, which became sins if men consented to them. The work of Evagrius was developed and integrated into Western thought by his follower John Cassian (d. 435), who moved out of the desert in the East to the monastery in France. Cassian’s Institutes devotes a chapter to each of the eight sins: gluttony, fornication, avarice, anger, sadness, acedia (indolence or sloth), vainglory, and pride. Later, Gregory the Great (d. 604) made pride the root of all sins rather than a separate sin, and added envy while omitting acedia, thus bringing the total to seven. Scholars have explained Gregory’s emphasis on pride in terms of the contextual change from desert asceticism to monasticism, in which there was greater institutional premium placed on combatting pride. 77 Both the importance and the meaning of the sins varied throughout the medieval period, such as is the case with acedia or sloth. From its earlier meaning as the intellectual anxiety of bookish monks, acedia began to shed its academic pedigree, moving closer to our own meaning of sloth. 78