by Sean Martin
Although the name ‘typhus’ wasn’t coined until the eighteenth century (the name deriving from the Greek typhos, meaning ‘smoky’ or ‘hazy’, a reference to the stupor its victims suffer), historians have long suspected typhus was rife much earlier. It has been proposed as the cause of the Plague of Athens in 430 BC, although this is still debated. Nevertheless, as John C Snyder from the Harvard School of Public Health wrote, ‘classic typhus has been one of the major epidemic diseases of all time. It is probable that typhus fever has been exceeded only by malaria as a cause of widespread human suffering.’140
Hans Zinsser, in his classic book about typhus, Rats, Lice and History (1935), believed that the earliest description of the disease might possibly date from 1083, when an outbreak was recorded by the monks at La Cava Abbey in Salerno, Italy:
In the year 1083, in the monastery of La Cava in the month of August and September, there spread a severe fever with peticuli and parotid swellings, in which one sees clearly the difference from the Pest, a fever of a different kind – and in this case – accompanied by petechial spots.141
The disease is spread by Pediculus humanus corporis – the human body louse. The lice live in the warm clothes of humans (wool and cotton in particular) where they lay their eggs. When they feed on an infected person, the louse becomes infected, and spreads the disease via their faeces. If the louse moves to another person and shits, and if that person then scratches where the flea has bitten, the chances are they will get epidemic typhus. Symptoms include fever, headache, delirium (hence ‘smoky’, ‘hazy’), high temperature and, after a few days, a rash (the ‘petechial spots’ that Zinsser quoted). Fatalities can be around 20 per cent, although they will be higher when other diseases are at work, or the victims are already weak due to malnutrition.
However, there are records of epidemics that do not seem to have been famine-related (although military activity is mentioned in a few cases). Creighton suggests these could have been caused ‘probably from a tainted soil’142, although he doesn’t elaborate on this rather vague comment (more suggestive of Victorian moralising or romanticism than actual epidemiological causes). Creighton adds that these references have been found in ‘the most unlikely corners of monastic chronicles; but it is just the casual nature of the references that makes them credible, and leads one to suppose that the recorded instances are only samples of epidemics not altogether rare in the medieval life of England.’143
In 829, at Christchurch, Canterbury, all but five of the monks died of a pestilence. 897 saw ‘a great mortality of man and beast following the Danish invasion which Alfred at length repelled.’144 In 1010, more invading Danes died of a pestilence in Kent, (according to Ranulph Higden’s chronicle), which was described as a dolor viscerum, probably dysentery. Miasma theory also made an appearance: ‘The stench of their unburied bodies so infected the air as to bring a plague upon those of them who had remained well.’ The outbreak was only brought to an end by St Elphege, the Archbishop of Canterbury, who restored people to health by giving out consecrated bread.
Dead bodies spreading illness reappear in a story told late the following century by William of Newburgh (c.1136–98), although in this case, the dead body in question is of an altogether more supernatural kind: William noted that a plague broke out in the village of Annan on the Solway Firth, which was thought to have been caused by a revenant.145 The sickness was only ended when William’s informant, who claimed to have been present, organised an exhumation of the revenant’s body, which was then summarily cremated.
St Anthony’s Fire
St Elphege and his miraculous loaf notwithstanding, bread, consecrated or otherwise, was no guarantee that one would remain disease free in the Middle Ages. If the bread was made from rye contaminated with ergot fungus (Claviceps purpurea), the chances are you would develop ergotism, the disease that probably lurks behind a number of evocative mediaeval names: St Anthony’s Fire, saint’s fire, hidden fire, evil fire, holy fire, devil’s fire, and Ignis sacer (sacred fire). The St Anthony in question is the desert father and traditional founder of Christian monasticism (c.251–356). His relics were returned to France in 1070 by the Count of Dauphiné, and his tomb became a pilgrimage shrine for sufferers of the ‘fire’ – so-called because one of the visible symptoms was a reddening or blistering of the skin. Indeed, to the shrine was quickly added a hospital for sufferers of the disease, and an order of monks to staff it, the Hospital Brothers of St Anthony.146
The disease can take two forms. One, called convulsive, afflicts the central nervous system, whereas the second, gangrenous, affects the cardiovascular system by constricting the arteries that supply blood to the extremities – hence the reddened and blistered skin, the ‘fire’. Which type the sufferer contracted was dependent on the amount of vitamin A in their diet. A diet with sufficient levels of vitamin A – from dairy produce, most likely – would mean the sufferer would probably contract the gangrenous form. Someone living in a village where dairy produce was scarce would be likely to suffer from the convulsive form.
Gangrenous ergotism began with an itching feeling on the feet, the sensation of ants running around them, before the ‘fire’ became visible. Symptoms of the convulsive form included anxiety, vertigo, noises in the ears, sensations of being bitten or pricked, even stupor. Limbs contracted convulsively, which produced staggering, twitching and other spasmodic movements. Stiffness in the joints would become a lingering symptom. Perhaps most strikingly of all, St Anthony’s Fire could produce psychosis, hallucinations,147 and even serious mental health problems. It’s tempting to speculate on the degree to which ergot poisoning, with its visions and terrors, contributed to the demonpopulated landscape of the Middle Ages.148
Ergotism was a rural disease, flourishing in damp conditions. Areas prone to flooding, such as the Dauphiné, where St Anthony’s relics were housed, found themselves plagued by the fire. August Hirsch, the great nineteenth century German epidemiologist, listed 130 epidemics between 591 and 1879, ‘acknowledging that these occurrences probably represented the tip of the proverbial iceberg.’149 In Hirsch’s list, most of the epidemics between 591 and the fourteenth century took place in France. An outbreak in 922 of the gangrenous type was said to have killed 40,000 people, while another killed 14,000 in Paris in 1128–9.150 Indeed, if England was notorious for famine, the same adage held that France was notorious for ergotism, and Normandy for leprosy.
The Disease of the Sinner
Leprosy was the most feared disease of the High Middle Ages. With their decaying flesh, shambling gait, hoarse rasp of a voice and fetid breath, lepers were figures of revulsion, banished from society and regarded with pity and fear. Although most diseases in the pre-modern world were interpreted as punishments from the divine, leprosy developed a special status in this regard: in Christian Europe, it was the disease of the sinner par excellence. Even today, leprosy is ‘an affliction of almost mythical status’.151
The earliest bone evidence of leprosy dates from late Antiquity, when it appeared in Egypt. As Carole Rawcliffe suggests, ‘Moving gradually westwards, leprosy appears to have reached Italy with Pompey’s victorious legions in 62 BC’.152 Leprosy made its first appearance in England in the late Roman period. A cemetery in Poundbury, Dorset – dating from the fourth century AD – contains skeletons that bear the telltale lesions of the disease. But paleopathology can tell us only so much. Margaret Cox and Charlotte Roberts remind us that the reality was probably much worse: ‘When we look at archaeological bone we may see changes to the normal skeleton but these can never reflect the magnitude of such changes on soft tissue.’153 One can only wonder what such changes were.
It was possible that the lepers buried in Dorset were not native to the county, or even the country, leaving the possibility that they were Roman soldiers who had contracted the disease somewhere in the Mediterranean basin. That would appear to be the most likely source of leprosy’s reaching England. Armies have long been one of the most effective car
riers of disease, along with merchants, missionaries, sailors and pilgrims. (But we must also note that armies could often fall victim to disease, and indeed often lost more men to disease than to enemy action – as we will see.)
While the first pandemic of plague was ebbing, leprosy began to spread slowly across Europe. The Anglo-Saxons called it seo mycle adl, ‘the great disease’.154 It was always perceived as highly contagious, and prohibitions against lepers were issued in England as early as the seventh century, a century that also saw the building of the first lazar house in Britain. These leper communities were effectively ways of segregating and quarantining sufferers of the disease. By 1300, leprosy had reached epidemic proportions.
Despite its notorious later stages, with its all too visible disfigurements, a person could suffer from leprosy for years and not know it. All they would feel would be a numbness on certain parts of their skin, perhaps some joint pain, but this would be nothing exceptional. Then blotches on the skin would develop that would be impervious to pain. The unfortunate leper-to-be could carry on for years like this, with no symptoms apparently out of the ordinary. Skin complaints were normal and many people were stiff from joint pain caused by arthritis or rheumatism.
Eventually, anyone suspected of having contracted leprosy would be examined by a group of village elders, or in some cases, other lepers. Diagnosis involved various techniques of varying degrees of complexity. At the more ‘scientific’ end of the scale, the sufferer was subjected to tests such as seeing how long grains of salt took to dissolve in drops of their blood; examining hair or urine; jabbing their extremities with a needle; and, perhaps strangest of all, ‘observing facial characteristics through a charcoal flame.’155 Simpler tests dispensed with the flame and involved deciding whether the suspected leper looked ‘loathsome’ or ‘satyr-like’. Did people ‘shudder’ at their touch?
Despite the vague air of Monty Python and the Holy Grail about these leper tests, they were surprisingly effective. Danish paleopathologist Vilhelm Møller-Christensen (1903–1988) discovered how accurate they had been when he excavated a leper cemetery near Naestved, some forty miles south of Copenhagen. Møller-Christensen found that the cemetery had been linked to a nearby St Jorgen’s hospital, which treated lepers between 1250 and 1550. Three quarters of the 650 or so bodies buried there showed signs of leprosy.156
As Margaret Cox and Charlotte Roberts noted, skeletal evidence ‘can never reflect the magnitude of such changes on soft tissue.’157 Whatever the bones can tell us, the reality for the person suffering from leprosy would have been much, much worse. Consider the case of this man, whose bones were unearthed in the cemetery of the hospital of St James and St Mary Magdalen, Chichester. He suffered from (according to the skeletal evidence): ‘periods of childhood stress, leprosy, degenerative joint disease, non-specific infection and osseous hypertrophy [an enlargement of the bone] in response to his altered posture as a cripple. He also had a nasal fracture, an oblique fracture of the right radius (probably resulting from a fall), a mid-shaft fracture to the left radius, a crush fracture of the left lunate [a bone in the hand], and a compound, oblique, misaligned fracture of the right femur. All of these fractures have associated secondary osteoarthritis and the right femur has corresponding septic arthritis.’158 It’s almost impossible to imagine the daily purgatory of this man’s life: the constant crippling pain, the social exclusion, the fear and isolation.
There are two main kinds of leprosy: tuberculoid leprosy (also known as white leprosy), which produces mild joint pains and pale skin, and the far more serious lepromatous leprosy. It is this form of the disease which, in one memorable description, ‘erodes noses, swells lips and tongues, erases eyebrows, uproots hair, sculpts facial skin into leonine folds and contorts hands and feet into claws.’159 Lepromatous leprosy also affects the voice, reducing it to a hoarse whisper, gives the sufferer an unblinking stare, and changes the gait into an ongoing stumble. Over time, lepers will lose all sensation in their skin and muscles; fingers, knuckles and toes can fall off; the nose collapses and the front teeth are lost. The hearing can also possibly be affected (the disease producing a chronic middle ear infection).
In addition to leprosy’s horrific litany of afflictions, there was the added isolation and stigma of being a leper. In Europe, lepers were banished from society, being treated as one who had died. (Hence leprosy was dubbed ‘the death before death’, although white lepers lived in relative freedom in southern France.160) This even extended in parts of France, Flanders, and elsewhere, to a mock funeral, the separatio leprosarum, which required the leper to wear a black veil and either stand in a freshly-dug grave or kneel before the altar and have the priest tip three spadefuls of earth from the cemetery on their head – a sort of baptism by grave-earth – while a requiem mass was sung.161 A leper was expected to compose a letter of farewell, known as a congé. The most celebrated of these was written by the troubadour Jean Bodel (1165–1210), ‘the poet laureate of lepers’,162 who was pronounced leprous in 1202. He wrote that his sadness was without equal; he had initially tried to hide his condition, but now feared the isolation and exclusion he must now face as much as death.163
Lepers were forced to dress in a white or grey smock – a forerunner of today’s hospital gowns – and were given a bowl in which to collect alms, a stick to point at things they wished to buy, and a clapper or bell to warn people of their approach. They were forbidden to enter churches, or to go to places such as markets, mills, fairs or taverns where there might be crowds. Such was the fear of contagion, lepers weren’t allowed to touch anyone except other lepers, were forbidden to eat with anyone except other lepers, and could not wash their hands or clothes in a stream. After 1167, they were forbidden to marry in England, and were not allowed to inherit money or land. They could have sex only with their spouse, assuming said spouse had the stomach for it. If the leper still lived at home, they were not allowed to go outdoors without wearing their smock and carrying their bell or rattle. If funds allowed, lepers could go and live in self-contained communities, known as leprosaria, lazarettos or lazar houses. Bodel, who doesn’t seem to have had the financial means to secure a place in the local lazar house, wrote of his attempts to secure a place by appealing to the mayor of Arras. We know Bodel’s appeal was successful as, when he died, another poet, Baude Fastoul, asked to be given Bodel’s place in the leprosarium.164
Lazar houses had originally been part of the Christian concern for charity, which had seen the first western hospitals built in the fourth century AD. By 1300, there were an estimated 19,000 across Europe. The first lazar house in Britain was built in the seventh century, but the majority were founded in the twelfth and thirteenth centuries, just as the epidemic was peaking. They went into decline from the fourteenth century onwards, a possible reflection of leprosy’s decline in Europe from that date. (One theory for this is that leprosy was essentially usurped by tuberculosis, a disease that comes from a bacterium of the same genus as Mycobacterium leprae, the bacterium which causes leprosy. The theory holds that if pulmonary TB strikes people before leprosy, and they survive, then that would confer immunity against the worst ravages of leprosy.165 For more on tuberculosis, see Chapter 5.)
Most leper communities were secluded groups of cottages that had their own chapel; some even had their own healing wells or springs nearby.166 Although some were self-sufficient, or were supported by private donation, many fell under the supervision of monastic institutions. With church influence prevailing, it is not surprising to learn that the ‘rules inside leprosy houses emphasised poverty and repentance’.167 Being built on the edges of towns and villages, and being full of souls who were seen as dead already, ‘leper houses were liminal in both essence and in location’.168 Orders grew up devoted to the care of lepers, such as that of St Lazarus, founded in Jerusalem in 1098 to look after pilgrims and crusaders. (Leprous knights were compelled to join the order, whose first Grand Master, according to legend, was also a leper; Jerusalem even ha
d a leper king, Baldwin IV, who reigned 1174–85.)
‘Leprosy,’ as Roy Porter noted, ‘provided a prism for Christian thinking about disease.’169 Links were made between lepers and Christ by the likes of Matilda, Henry I of England’s first queen (d. 1118), and Hugh of Lincoln, bishop and later saint (d. 1200), who ‘prompted a fashion for conspicuous acts of abasement before the most physically repugnant individuals’.170 One monk, the memorably named Ralph the Ill-tonsured (d. 1062), asked God to give him leprosy ‘so that his soul might be cleansed of its foul sins,’171 of which there were apparently many. If leprosy was good for the soul, it could also be a disease of the soul in others, developing as a result of blasphemy or sacrilege: ‘Robert Fitzpernel, Earl of Leicester, was, for instance, allegedly afflicted because he unjustly took possession of an estate lately belonging to Hugh of Avalon, the revered Bishop of Lincoln.’172
In tandem with its value as spiritual propaganda, mediaeval physicians argued amongst themselves as to leprosy’s cause. Some favoured a corruption of the humours, while others argued for, variously, ‘divine will, hostile planetary forces, poor diet, corrupt air, dirt, sexual misconduct, prolonged contact with the leprous and heredity’.173 The injunctions against leprosy from the Book of Leviticus were still influential, which, coupled with the fear of contagion, did a great deal to help establish the leper houses. But the predominant cause of leprosy to the mediaeval mind was sin, sex in particular; lepers were seen as inherently lusty and lecherous. The fate of Iseult in Beroul’s twelfth century Tristan – the earliest known version of the story – reflects this. Sentenced to burn for her affair with Tristan, her cuckolded husband, King Mark, is approached by Ivain, a local leper, who has a proposition:
‘I can tell you quickly what I have in mind. Look, here I have a hundred companions. Give Iseult to us and we will possess her in common. No woman ever had a worse end. Sire, there is such lust in us that no woman on earth could tolerate intercourse with us for a single day. The very clothes stick to our bodies. With you she used to be honoured and happily clad in blue and grey furs. She learned of good wines in your marble halls. If you give her to us lepers, when she sees our low hovels and looks at our dishes and has to sleep with us – in place of your fine meals, sire, she will have the pieces of food and crumbs that are left for us at the gates – then, by the Lord who dwells above, when she sees our court and all its discomforts she would rather be dead than alive. The snake Iseult will know then that she has been wicked! She would rather have been burnt.’