My body in the world: medieval concepts of healing and cure

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University
of
Southern
California

Dornsife
College
of
Letters,
Arts
and
Sciences

Dissertation

MY
BODY
IN
THE
WORLD:

MEDIEVAL
CONCEPTS
OF
HEALING
AND
CURE

by

MARY
HARDIMAN
FARLEY

Submitted
in
partial
fulfillment
of
the
requirements
for
the
degree
of

Doctor
of
Philosophy
in
English

August
2015

2

DEDICATION

To
Joseph
Dane,
Advisor
and
Friend

To
Timothy
Dufelmeier,
Patricia
Sims
and
Patricia
Taylor

And
to
the
Memory
of
Dagmar
Barnouw

3

ACKNOWLEDGEMENTS

I
will
soon
complete
my
doctorate,
forty
years
late.
I
owe
special
thanks
to
several

people.

Reentering
academia,
I
was
fortunate
to
have
the
opportunity
to
study
under
the

distinguished
medievalist
Michael
Calabrese,
at
California
State
University
Los

Angeles.
I
could
not
have
done
this
without
him.

More
recently,
when
I
was
making
the
decision
to
reenroll
and
complete
my
work

at
USC,
Thea
Tomaini
showed
me
how
my
experience
could
inform
an
unusual

approach
to
a
certain
area
of
medieval
studies.
She
offered
invaluable
insights
over

coffee
in
her
office,
and
wine
at
Kalamazoo.
I
hope
that
she
will
continue
to
do
so.

Herb
Meiselman
is
a
prominent
physiologist
and
a
great
friend.
I
am
fortunate

that
his
well
known
intellectual
curiosity
has
encompassed
my
idiosyncratic
project,

and
that
he
has
lent
his
humor
and
humanism
to
his
critique
of
my
work.

David
Rollo,
whose
questions
challenged
and
engaged
me
in
my
qualifying
period,

has
helped
me
to
change
my
direction.

I
am
grateful
to
my
daughters,
Megan
Jane
Farley
and
Elizabeth
Anderson,
and
to

my
sister
Jane
Hardiman,
who
are
not
much
interested
in
the
Middle
Ages
but
are

interested
in
me.
In
their
different
ways
they
enabled
me,
in
the
words
of
our
British

father
and
grandfather,
to
“Push
on
regardless.”

I
am
grateful
to
my
high
school
best
friend
Peggy
DeStefano,
intellectual

companion
since
1963,
who
is
just
as
important
as
ever.
For
better
or
worse,
Peggy

helped
make
me
who
I
am.
I
am
grateful
for
a
long
friendship
with
Ruchel
Rita

Resnick
Singer,
direct,
insightful
and
funny,
and
an
Old
Soul.
And
for
Mimsey

Stromeyer,
whose
penetrating
wit,
grace
under
pressure
and
beautiful
paintings

have
lifted
my
spirits
for
forty
years.
Gail
Maltun,
with
whom
I
shared
early

motherhood,
was
still
there
to
spur
me
on
through
writers
block,
and
make
sure
I

finished
my
late
life
project.

I
could
not
have
earned
my
doctorate
without
my
colleagues
and
supervisors
at

Los
Angeles
County-‐University
of
Southern
California
Medical
Center.
Many
thanks

to
the
physicians
who
generously
shared
their
thoughts—along
with
that
special

County
humor,
which
is
somehow
always
cogent,
fearlessly
honest
and
relentlessly

humanistic.

The
accumulated
hours
of
intellectual
exchange
over
four
years,
most
of

it
in
brief,
stolen
breaks
for
fun-‐size
Snickers
bars
in
the
Utilization
Review
office
in

the
Emergency
Room,
have
been
an
unexpected
reward.
But
most
of
all
I
am
grateful

to
the
nurses,
whose
kindness
and
flexibility
enabled
me
to
complete
a
doctorate

while
working
full
time,
and
who
provided
a
particular
kind
of
support:
direct,
loyal

and
honest—and
invariably
witty.
Only
County
Nurses
know
how
to
dish
that
stuff

out.
There
is
no
way
I
could
have
done
this
without
them.

4

Always,
I
thank
Joseph
Dane,
my
committee
chairman
and
brilliant
friend,
who

knew
that
this
was
what
I
needed
to
do,
and
knew
that
I
was
not
always
right
about

how
I
needed
to
do
it.

Special
thanks
to
the
remaining
three
living
friends
to
whom
this
dissertation
is

dedicated—they
know
why,
better
than
I
can
write.

And
to
Robert
Farley,
onetime
partner
and
lifelong
friend,
whose
support
and

scientific
input
have
been
so
valuable,
and
whose
idea
it
was
that
I
should
get
a
PhD.

5

CONTENTS

1.

The
Body
as
Possession:

Healing
and
the
Medieval
Medical
Paradigm

6

2.

“Effects
of
Neurotransmitters
on
the
Spiritus”:

Medical
Spirit
Theory
in
Western
Medicine

17

3.

“The
Glassy
Phlegm
of
Coldness
and
Coagulation”:

Medical
Philology
in
Medieval
Texts

34

4.

Medieval
Neuropsychiatry:
Etiologies
of
Mental
Illness
in

Western
Medicine

72

5.

“The
Insanity
of
the
Fatuously
Happy”:
Nosologies
of

Psychiatric
Disease
in
Medieval
and
Modern
Medicine

96

6.

Heart
of
Darkness:
Madness
in
Medieval
Popular
Psychology

146

7.

Sand
Castles
and
Serious
Medicine:
What
Can
We
Retrieve

From
the
Middle
Ages?

210

Principal
Works
Cited

230

Appendix

What
We
Have
Received:
Conversations
with

Physicians
in
the
Department
of
Emergency
Medicine

235

6

CHAPTER
ONE

The
Body
as
Possession:

Healing
and
the
Medieval
Medical
Paradigm

In
Being
and
Nothingness
Jean
Paul
Sartre
describes
an
encounter
with
his
own
x-‐
ray
film
as
a
primal
experience;
a
microcosm
of
alienation:

So
far
as
the
physicians
have
had
any
experience
with
my
body,
it
was

with
my
body
in
the
midst
of
the
world
and
as
it
is
for
others.
My
body
as

it
is
for
me
does
not
appear
to
me
in
the
midst
of
the
world.
Of
course

during
a
radioscopy
I
was
able
to
see
the
picture
of
my
vertebrae
on
the

screen,
but
I
was
outside
in
the
midst
of
the
world….it
was
much
more

my
property
than
my
being.
1

Having
worked
in
hospitals
for
thirty
years,
I
was
wary
of
Sartre’s
implication
of

medical
officiousness.
He
consented
to
be
x-‐rayed
so
that
physicians
would
have

access
to
this
most
precious
possession,
so
as
to
be
able
to
intervene
in
order
to

restore
it.
Yet
he
elevates
an
imaging
procedure
to
an
existential
threat.

His
reaction,
while
not
pragmatic,
is
not
unreasonable.

Had
Sartre
lived
six
hundred
years
earlier,
the
immediate
results
of
the

interventions
of
his
physician
are
likely
to
have
been,
at
best,
irrelevant
to
his

physical
comfort,
function
and
longevity.
But
that
does
not
mean
that
this
medieval

1

In
Michael
T.
Taussig,
“Reification
and
the
Consciousness
of
the
Patient,”
Social

Science
and
Medicine
143
(1980):
3-‐13,

4.

7

medical
encounter
would
have
been
unsatisfactory,
and
it
probably
would
not
have

elicited
so
damning
a
response.
Sartre
is
not
alluding
to
doubts
about
the
ability
of

his
physicians
to
cure.
He
is
not
addressing
the
question
at
all.
The
angst
inherent
in

this
modern
medical
encounter
originates
in
the
lacuna
left
by
the
paucity
of

healing:
the
therapeutic
movement
of
the
afflicted
person
from
confusion
and
anger

to
signification
and
acceptance,
and
to
hopefulness—whatever
form
that
hope
may

take.
Within
this
empty
space
Sartre
locates
a
critical
negation
of
the
patient’s
self.

My
interest
is
in
exploring
the
clinical
implications
of
concepts
of
healing
in

medieval
medical
science
as
a
way
of
understanding
this
contemporary
problem.

Healing
in
this
paradigm
originated
in
the
use
of
the
metaphysical
as
a
scientific

principle.

I
was
motivated
to
undertake
the
study
of
the
medical
literature
of
the
Middle

Ages
by
curiosity
about
the
nature
of
its
alterity—the
cultural
sources
that
had

produced
the
exoticism
of
an
elaborate
pharmacology
employing
the
curative

powers
of
excrement
and
earthworms.

But
it
became
obvious
that
a
medical
model

that
was
a
cultural
institution
for
fifteen
hundred
years—during
which
time
it
was

also
regarded
as
a
clinical
success—had
succeeded
at
a
fundamental
level.
I
came
to

believe
that
there
is
an
important
medical
function
at
which
their
model

outperforms
our
own.

Medical
historian
Owsei
Temkin
notes
that
healing
is,
anthropologically,
more

ancient
than
cure:

[I]t
should
not
be
overlooked
that
healing,
together
with
hunting,

agriculture,
and
animal
husbandry,
is
much
older
than
our
biological

science.
Concepts
of
health
and
disease
existed
before
Aristotle

established
Western
biology.
Notions
of
healthy
and
diseased
conditions

8

of
the
body
entered
into
the
Aristotelian
teleological
idea
of
living
beings,

so
that
to
some
extent
medicine
has
found
in
biology
what
it
put
into
it….

Medicine
is
healing
(and
prevention)
based
on
such
knowledge
as
is

deemed
requisite.
Such
knowledge
may
be
theological,
magic,
empirical,

rationally
speculative,
or
scientific.
The
fact
that
medicine
in
our
days
is

largely
based
on
science
does
not
make
other
forms
less
medical—
though
it
may
convince
us
that
they
are
less
effective.

2

The
medieval
world,
from
the
earliest
primitive
magic
to
the
academic
disciplines

of
natural
philosophy
in
the
high
Middle
Ages,
believed—correctly,
as
it
turns
out—
that
the
body
is
composed
of
the
same
elements
as
all
created
things
that
are
not

completely
spirit.
Medieval
science
is
the
study
of
a
universe
in
which
all
elements

had
been
set
in
motion
by
the
Unmoved
Mover,
the
God
of
Aristotle
and
of
the

Jewish
and,
later,
the
Christian
universe.
All
elements
interact
constantly
to

influence
each
other,
in
response
to
the
goodness
and
beauty
of
His
creation,
much

as
we
understand
objects
to
follow
the
“law”
of
gravity—except
that
gravity
is
no

longer
regarded
as
a
moral
force.
The
boundaries
between
material
and
spiritual,

and
between
temporal
and
eternal,
are
to
the
medieval
mind
merely
filters.
They
are

transient
products
of
the
post
lapsarian
state
and
not
scientifically
real.

Transcendence
and
imagination
are
embedded
in
this
scientific
understanding
of

how
the
world
works.

In
his
startled
reaction
to
his
radiological
image,
Sartre
is
describing
his

discomfort
at
being
forced
anachronistically
to
experience
his
body
in
a
medieval

way—as
a
possession,
although
a
special
one;
a
sacred
gift
and
a
unique

2

Owsei
Temkin,
The
Double
Face
of
Janus
and
Other
Essays
in
the
History
of
Medicine.

(Baltimore:
Johns
Hopkins
University
Press,
1977)
16.

9

responsibility.
For
the
medieval
person,
the
symbolic
reduction
of
the
body
to
the

status
of
an
object
in
the
world
was
the
antithesis
of
alienation.
This
understanding

of
the
vulnerable
and
deteriorating
corpus
as
a
“thing
among
things”
was
a
function

of
the
human
situation
in
a
coherent
universe
in
which
he
or
she
was
known
and

recognized,
and
in
which
the
personal
soul
would
always
exist.
This
soul,
a
complex

accretion
of
ancient
and
medieval
theology,
philosophy
and
natural
science,
was

probably
that
culture’s
most
significant
product.
If
the
culture
of
the
Western
Middle

Ages
could
be
said
to
have
a
truly
secular
aspect
we
might
say
that
the
soul

encompassed
what
we
now
call
character
and
personality.

This
is
a
situation
that

simply
does
not
communicate
with
existentialism.

My
project
is
offered
in
response
to
calls
within
medieval
studies
for
the

identification
of
humanistically
useful
themes
in
literatures
ecclesiastical,

theological,
philosophical
and
literary.
As
early
as
1953,
E.N.
Johnson,
in
a
joint

address
to
the
American
Historical
Association
and
the
Medieval
Academy,
issued
a

call
for
contemporary
relevance:
“If
we
[medievalists]
cannot
justify
our
interests
by

some
sort
of
contribution
to
the
solution
of
major
contemporary
problems,
then
we

shall
be
deserted
for
some
system
or
some
one
who
promises
to
do
what
we
do
not

do.”
3

I
hope
any
contribution
I
make
to
the
recovery
of
the
medieval
knowledge
of

healing
might
be
sent
“home”
to
my
professional
community.

3

Lee
Patterson,
“On
the
Margin:
Postmodernism,
Ironic
History,
and
Medieval

Studies,”
Speculum
65
(1990):
87-‐108,

108.

10

The
assumption
of
the
seamless
inclusion
of
body
and
soul
in
the
Eternal
Plan

makes
the
professional
treatment
of
mental
illness
a
particularly
fruitful
site
for
the

examination
of
the
medieval
healing
paradigm.
Because
mental
disorders
are

empirically
behavioral,
manifesting
in
non-‐normative
relationships
with
the
“real,”

they
have
always
been
identified
with
the
unseen,
and
thus
with
the
transcendent.

For
this
reason
I
will
focus
what
might
otherwise
seem
to
be
a
disproportionate

amount
of
attention
on
what
I
will
refer
to
as
medieval
psychiatry.

Having
begun
graduate
study
in
my
fifties—and
completing
my
dissertation
in

my
sixties—I
am
able
to
take
advantage
of
some
cultural
sea
changes.
The
study
of

medieval
medical
texts
in
a
department
of
literature
would
until
recently
have
been

considered
inappropriate;
even
frivolous.
I
probably
could
not,
thirty
years
ago,

have
made
an
adequate
case
for
the
literary
qualities
of
these
texts
based
on
the

lyrical
joys
of
the
genre,
despite
the
metaphorical
pleasures
of
the
anthropomorphic

plants
and
kind
and
nurturing
stones
of
Hildegard
of
Bingen.
That
is
certainly
no

longer
the
case.
The
development
that
has
transformed
the
intellectual
climate
of

medieval
studies
into
one
in
which
my
project
might
be
more
welcome—or
could

have
survived
at
all—is
the
emergence
of
interdisciplinary
studies
throughout

academia.
In
medieval
studies
this
has
taken
the
form
of
an
assault
upon
the

traditional
obsession
with
anachronism,
which
Lee
Patterson
defines
as
the

insistence
that
it
is
“better
to
be
dull
than
unsound.”
Patterson
argues
that
this

unwritten
law
once
served
a
now
outdated
political
function:

The
otherness
which
the
Renaissance
bestowed
upon
the
Middle
Ages

conferred
upon
the
medievalist
an
unquestionably
professional
identity,

11

no
small
endowment
in
a
society
in
which
the
utility
of
humanistic
study

was
being
brought
into
question….a
lack
of
contemporary
relevance
too

often
stands
as
one
of
the
prime
indicators
that
an
account
of
a
medieval

text
is
sufficiently
historical—sufficiently
objective—to
be
taken
as

reliable.”

4

My
interest
in
medieval
medical
literature
stems
in
part
from
my
professional

role
in
generating
its
modern
counterpart:
a
creative
enterprise
that
I
do
not

experience
as
artistic.
I
am
an
emergency
room
nurse,
no
longer
charged
with
any

functions
of
patient
treatment.
Instead
I
work
for
the
Department
of
Utilization

Review,
evaluating
patients
for
whom
emergency
department
physicians
are

requesting
admission
to
the
hospital.
“Patients”
is
a
synecdoche
for
“bodies
in
the

midst
of
the
world”:
compromised
bodies
that
exhibit
non-‐normative
chemical
and

mechanical
characteristics
which
indicate
that
their
relocation
to
the
main
hospital

building,
and
subsequent
subjection
to
medical
episodes
of
scrutiny
and
invasion,

will
be
billable
to
insurance
companies
and
to
Medicaid
and
Medicare.
I
use
a

software
system
designed
for
“evidence
based
clinical
decision
support.”
This

possible
descendent
of
the
medieval
exemplum
is
called
Interqual.

5

I
maintain
that

this
screening
function
is
necessary
on
several
levels,
in
addition
to
the
delegation
of

scarce
resources.
Conservative
decision
making
on
hospitalization
protects

individuals
from
exposure
to
infection
and
to
medical
error,
as
well
as
from
the

physical
deterioration
attendant
on
long
term
immobility
and
the
mental
and

emotional
hazards
of
hospital
induced
depression,
anxiety
and
dementia,
and
of

isolation
from
the
community.

And
yet
my
bureaucratic
function
could
certainly
be

4

Ibid.,
102-‐103.

5

©
McKesson
Corporation

12

said
to
lend
itself
to
negative
social
forces
of
personal
alienation
and
of
potential

exploitation,
in
the
political
sense.
Unhappily,
my
professional
role
in
the
medical

system
originates
at
the
point
in
which
that
system
most
blatantly
equates
cure
with

healing.

And
yet
the
parsing
and
quantification
of
disease
and
wellness
is
not
a
post-‐
industrial
creation.
Much
of
the
volume
of
medieval
medical
literature
is
a
mass
of

intricate
classification-‐-‐a
textual
heritage
of
quantification
and
qualification

originating
in
classical
times
and
accruing
throughout
the
early
modern
period.
My

work,
despite
the
embarrassment
of
its
pecuniary
nature,
is
not
radically
different:
it

is
a
serious
(and
weirdly
poignant)
attempt
to
render
the
timeless
problem
of

physicality
manageable
by
circumscribing
it
within
twenty
first
century

biomedicine.
The
hubris
of
this
project
betrays
its
tragic
nature.
Mortality
and

morbidity
are
always
the
rock
of
Sisyphus.

I
generate
documents
that
translate
disease
into
language
that
can
be
socially

processed
and
ordered
and
managed.
I
create
the
modern
equivalent
of
plague

treatises.

*

*

*

*

*

The
medical
anthropologist
Michael
T.
Taussig
quotes
Sartre’s
description
of
the

x-‐ray
in
support
of
his
argument
that
contemporary
disease
can
be
interpreted
as
a

social
language
emanating
from
the
body,
a
message
of
disjunction
and
resistance

that
Western
biomedicine
translates
into
quantifiable
diagnostic
entities
which

enable
the
commodification
of
sickness
for
purposes
of
profit
and
control:

It
is
with
the
phantom-‐objectivity
of
disease
and
its
treatment
in
our

society
that
I
am
concerned,
because
by
denying
the
human
relations

13

embodied
in
symptoms,
signs
and
therapy,
we
not
only
mystify
them
but

we
also
reproduce
a
political
ideology
in
the
guise
of
a
science
of

(apparently)
“real
things”—biological
and
physical
thinghood.

6

I
find
this
idea
excessively
romantic,
and
inadequate
to
address
the
complicated

failures
of
modern
biomedicine
in
a
fundamental
way.
But
Taussig’s
belief
in
the

universality
of
the
body
as
the
master
metaphor,
and
in
medicine—and
writings

about
medicine—as
uniquely
revelatory
of
a
culture’s
zeitgeist,
are
convictions
I

share-‐-‐so
much
so
that
I
borrow
a
phrase
of
his
to
explain
my
own,
quite
different

argument
that
medieval
medical
writings
should
be
studied
in
a
department
of

literature:

[T]he
body
is…a
cornucopia
of
highly
charged
symbols—fluids,
scents,

tissues,
different
surfaces,
movements,
feelings,
cycles
of
changes

constituting
birth,
growing
old,
sleeping
and
waking.
Above
all,
it
is

with
disease
with
its
terrifying
phantoms
of
despair
and
hope
that
my

body
becomes
ripe
as
little
else
for
encoding
that
which
society
holds

to
be
real….
7

This
is
the
best
short
synopsis
of
the
medieval
medical
paradigm
I
have
seen.

Taussig’s
use
of
the
semiotics
of
disease
as
the
basis
for
a
Marxist
analysis
of
the

Western
medical
system
has
produced
an
effective
critique
of
certain
deficiencies

that
lie
near
its
heart.
These
deficiencies
are
not
completely
responsible
for
the

system’s
failures,
but
they
are
probably
inextricable
from
them.

These
are
not
deficiencies
that
characterize
medieval
medicine,
which
is
holistic.

In
medieval
science
no
aspect
of
sublunar
life
can
be
understood
without
reference

6

Taussig,
“Reification,”
3.

7

Ibid.,
4.

14

to
the
whole.
Physical
and
mental
health
do
not
consist
in
the
absence
of
disease
as

such,
but
in
participation
in
a
state
of
cosmic
balance.

It
can
be
described
in
terms
of

systems
theory:
the
explication
of
how
patterns
are
formed
and
order
arises
in

complex
and
chaotic
systems.
Medieval
medicine
is,
in
a
sense,
a
proto-‐quantum

physics.

The
assumption
of
a
holism
that
contains
the
physical,
mental
and
the

transcendent
unknowable
within
a
model
of
cure
and
healing
are
illustrated
by
the

following
scientific
explanation
of
the
Black
Death,
by
Guy
de
Chauliac.
He
begins
by

dismissing
ignorant
theories
that
the
plague
was
caused
by
human
poisoning-‐-‐the

work
of
the
Jews,
the
“mutilated
poor,”
or
even
the
nobility-‐-‐before
offering
a

sophisticated
explanation
that
incorporates
both
natural
law
and
environmental

epidemiology:

The
truth
is
that
the
cause
of
this
mortality
was
twofold:
one
active
and

universal,
one
passive
and
particular.
The
active,
universal
cause
was
the

disposition
of
a
certain
important
conjunction
of
three
heavenly
bodies,

Saturn,
Jupiter
and
Mars,
which
had
taken
place
in
1345,
the
24
th

day
of

March,
in
the
fourteenth
degree
of
Aquarius….Because
the
[zodiacal]
sign

was
a
human
one
[Aquarius
is
represented
as
a
young
man
pouring
water

from
a
jar]
it
foretold
grief
for
humanity;
and
because
it
was
a
fixed
sign,

it
signified
long
duration….It
so
informed
the
air
and
the
other
elements

that,
as
the
magnet
moves
iron,
it
moved
the
thick,
heated
poisonous

humors;
and
bringing
them
together
within
the
body,
created

apostemes
*

there.
From
this
derived
the
continuous
fevers
and
spitting

of
blood….The
particular,
passive
cause
was
the
disposition
of
each
body,

such
as
cachochymia
[bad
digestion],
debility,
or
obstruction,
whence
it

was
that
the
working
men
or
those
living
poorly
died.

8

*

Boils
or
tumors.

8

Guy
de
Chauliac,
Ars
chirurgicalis
Guidonis
Cauliaci
medici
(1546),
trans
Michael
R.

McVaughn,
in
Sourcebook
in
Medieval
Science,
ed.
Edward
Grant

(Cambridge:
Harvard
University
Press,
1974),
773-‐74
(no.
107)

15

Jacques
Le
Goff,
in
his
great
work
on
the
imagination
as
a
dimension
of
history,

suggests
that
medieval
people
“had
greater
difficulty
than
we
do
in
drawing
a

boundary
between
material
reality
and
imaginary
reality.”

9

Taking
this
statement
in

the
simplest
sense,
I
think
that
we
overestimate
the
degree
to
which
it
is
true.
The

inclusion
of
the
inexpressible
in
early
modern
science—the
embeddedness
of
what

current
proponents
of
Intelligent
Design
Theory
call
the
“irreducibly
complex”—is

certainly
remarkable
by
our
standards.
And
yet,
despite
the
nearly
hegemonic

acceptance
of
biophysics
as
a
pillar
of
our
cultural
life,
a
large
percentage
of
the

population
identifies
the
material
effects
of
spiritual
and
occult
phenomena
in

ordinary
events,
and
many
endorse
both
diseases
and
cures
that
are
empirically

unverifiable
by
the
scientific
community.
Yet
it
remains
undeniable
that
biomedicine

figures
the
‘imagination’
as
its
nemesis.

Because
of
this,
practitioners
and
patients
of
alternative
and
holistic
therapies
in

Western
countries
typically
pursue
a
strategy
of
biophysical
reductionism,
seeking

to
banish
the
“imaginary”
from
their
medical
paradigm.
The
burgeoning
political

strength
of
this
movement
resulted
in
the
creation,
in
1993,
of
the
National
Center

for
Complementary
and
Alternative
Medicine
as
a
branch
of
the
National
Institute
of

Health,
dedicated
to
the
application
of
randomized
scientific
research
studies
to
test

the
effectiveness
of
alternative
therapies,
including
distant
prayer,
in
effecting
cures.

9

Jacques
LeGoff,
The
Medieval
Imagination,
Arthur
Goldhammer,
trans.
(Chicago:

University
of
Chicago
Press,
1985)

6.

16

Robert
Aronowitz,
a
physician
and
researcher
of
the
history
and
sociology
of

disease,
describes
this
fraught
endeavor:

Witness
the
irony
of
contemporary
efforts
to
find
the
active
molecular

building
blocks
of
holistic
therapies
in
order
to
manipulate
them
in

randomized
controlled
trials
under
the
auspices
of
a
newly
created

National
Institute
of
Health
program
devoted
to
studying
holistic

medicine….In
the
career
trajectory
of
a
holistic
critic
of
medicine
seeking

academic
success
or
the
clinical
experience
of
a
late
twentieth-‐century

medical
specialist
taking
care
of
an
individual
whose
pain
does
not

neatly
fit
any
available
disease
category,
there
is
an
ineluctable
fusing
of

perspectives.

10

The
question
is
whether
this
assumption,
which
is
fundamental
to
modern

medicine
as
it
is
currently
arranged,
is
erroneous:
whether
imagination,
conceived

not
as
ephemera—as
dream
or
creative
fantasy-‐-‐but
as
an
expression
of
the
deepest

symbolic
meaning
of
the
inner
world,
functions
as
a
physiological
force.

The

medieval
experience
suggests
that
this
is
so.
It
is
possible
that
healing,
as
opposed
to

cure,
cannot
occur
without
somehow
engaging
it.

Perhaps,
in
insisting
that
their
healing
is
insulted
by
a
failure
of
biomedicine
to

find
“molecular
building
blocks”
for
their
cures
and
biophysical
models
for
their

diseases,
the
alternative
medical
community
sells
itself
short.
Calling
their
science

“imaginary”—which
they
generally
consider
the
worst
possible
epithet—doesn’t

mean
they
aren’t
onto
something.

10

Robert
A.
Aronowitz,
Making
Sense
of
Illness:
Science,
Society,
and
Disease.

(Cambridge:
Cambridge
University
Press,
1998),
p.10.

17

Chapter
Two

“Effects
of
Neurotransmitters
on
the
Spiritus”:

Medical
Spirit
Theory
in
Western
Medicine

A
large
part
of
the
popularity
and
persuasiveness
of
psychology
comes

from
its
being
a
sublimated
spiritualism:
a
secular,
ostensibly
scientific

way
of
affirming
the
primacy
of
“spirit”
over
matter.

Susan
Sontag

11

The
medical
spirit
system
is
a
biophysical
model
with
origins
in
ancient

philosophy.
Examination
of
this
system
is
a
useful
way
to
look
at
the
holistic

character
of
early
modern
medicine.
I
believe
that
this
complex
theory
encapsulates

the
theoretical
foundation
of
medieval
clinical
practice,
and
largely
explains
its

centuries
of
successful
healing.

Although
the
medical
spirits
are
important
in
all
areas
of
this
medicine,
the

application
of
spirit
theory
to
the
treatment
of
diseases
we
now
categorize
as

psychiatric
affords
the
clearest
view
of
the
therapeutics
of
metaphysical

biomedicine
at
the
bedside.
Medieval
psychiatry,
like
our
own,
assumed
that
most

behavioral
illnesses
had
a
physiological
basis.
And
our
culture,
like
theirs,
assumes

that
mental
illness
is
also
a
disorder
of
the
human
spirit.

Positivism
is
usually
unwarranted
in
writing
the
history
of
medicine,
but
it
is
not

invariably
inappropriate.

The
process
by
which
Western
medicine
has
received
and

11

Susan
Sontag,
Illness
as
Metaphor
(New
York:
Vintage
Books,
1978),
54.

18

transformed
ancient
and
early
modern
theories
of
the
causes
of
madness
can
be

examined
for
evidence
of
evolution,
as
well
as
for
examples
of
stability
and

consistency.
The
most
common
and
most
destructive
forms
of
mental
illness
are

stable
across
temporal
and
cultural
lines.
Modern
medicine
is
looking
at
the
same

things
medieval
medicine
saw.
Sometimes
it
has
explained
them
differently,
and

other
times
it
has
created
different
names.

Medieval
psychiatry
is
not
based
on
demonology.
It
is
not
ineluctably
foreign
and

exotic,
and
it
is
structured
similarly
to
our
own.
The
primacy
of
possession
as
the

default
diagnosis
has
been
debunked
over
the
past
twenty
years,
as
closer
readings

of
the
literature
have
revealed
that
medieval
psychopathology
almost
always

assumed
an
immediate
cause
in
corporeal
processes
that
we
now
think
of
as

biochemical.

12

The
sophistication
of
medieval
theories
about
the
etiology
of
mental

disorder
contrasts
with
the
way
medieval
madness
has
traditionally
been
depicted.

But
the
assumption
lingers
that
medieval
ideas
about
mental
illness,
and
the

historical
reception
of
medieval
madmen
and
madwomen,
are
alien
to
modern

understanding.

This
erroneous
assumption
is
kept
alive
by
an
actual
truth,
which
is
that
medieval

psychiatry,
and
medieval
medicine
in
general,
is
predicated
on
a
metaphysical

model
of
biophysics.
This
model
is
inherently
philosophical
and
theological—
elements
that
Western
biomedicine
is
unable
to
incorporate,
and
struggles

12

For
an
overview
of
this
change
see
Simon
Kemp,
“Modern
Myth
and

Medieval
Madness:
Views
of
Mental
Illness
in
the
European
Middle
Ages
and

Renaissance,”
New
Zealand
Journal
of
Psychology
14
(1985):
1-‐8.

19

awkwardly
to
append
to
itself.
Spirituality
is
no
longer
understood
to
be
an
active

force
in
science.
This
has
left
a
lacuna
that
accounts
for
much
of
the
perceived

inadequacy
of
Western
medicine,
despite
its
astounding
ability
to
cure.

The
vehicle
for
transcendence
within
this
medical
model—the
scientific

mechanism
of
its
function—is
the
system
of
the
Galenic
medical
spirits.

Contemporary
medicine
suffers
from
the
lack
of
a
similar
principle,
and
struggles
to

fill
the
void.
I
hope
to
show
two
things:
the
circumscribed
but
genuine
usefulness
of

a
positivistic
approach
to
certain
problems
in
the
history
of
medicine,
and
the

accessibility
of
the
medieval
experience
as
a
response
to
the
need
to
make
sense
of

illness
and
death.

It
has
been
assumed
since
ancient
times
that
madness,
from
a
medical
point
of

view,
is
essentially
cerebral.
The
Hippocratic
idea
that
behavioral
pathology

originates
in
the
head
was
not
universally
accepted
in
the
Middle
Ages,
but
it
was

the
consensus
of
academic
medicine
and
the
basis
of
scientific
theories
of

psychopathology.

Ancient
and
medieval
physicians
also
understood
that
alterations
in
general

bodily
health
act
upon
the
brain
to
impair
its
function.
Mental
disorder
was
seen
as

the
result
of
damage
to
brain
structure,
whether
from
external
trauma-‐-‐a
head

injury;
the
bite
of
a
mad
dog—or
from
hidden
endogenous
events.
These
were

usually
the
outcome
of
the
actions
of
the
humors:
body
fluids
that
changed
in

quantity
and
quality
in
response
to
stressors,
affecting
the
entire
organism.

Hormones,
enzymes
and
neurotransmitters,
transported
by
blood,
lymph
and

nerves,
are
currently
figured
in
this
way.

20

Most
explanations
for
these
phenomena
in
Europe
and
the
Islamic
world
during

the
high
Middle
Ages
stemmed
from
the
theory
that
an
upward
migration
of

unhealthy
humors,
defective
in
quality
or
unbalanced
in
quantity,
distorts
the

ventricles
of
the
brain
and
disrupts
the
healthy
production
and
free
circulation
of

the
psychic
spirits.

The
Natures
of
the
Spiritus

There
are
three
classes
of
spiritus:
the
psychic,
or
animal;
the
vital,
or
cardiac;
and

the
natural.
Galen
had
defined
the
vital
as
the
original,
governing
spirits.
These
were

formed
in
the
heart
from
a
mixture
of
blood
and
inspired
air.
They
innervated
the

heart,
and
they
were
the
proximate
cause
of
physical
life.
The
psychic,
or
animal

spirits
were
concocted
in
the
brain
from
the
pure
substance
of
the
vital
spirits,

circulating
upward
from
the
heart.
The
psychic
spirits
controlled
neurology
and

cognition.
A
third
type
of
spirit,
the
natural,
which
emanated
from
the
liver
and

governed
less
exalted
functions
such
as
digestion,
was
probably
developed
into
a

full
spiritus
from
Galen’s
copious
writings
by
somewhat
later
followers.

The
spirits
were
distinct
from
the
soul—organs,
in
a
sense—and
they
died
when

the
body
died.
Corporeal
and
yet
simultaneously
ethereal,
their
essence
is
usually

described
as
similar
to
that
of
water
vapor
or
to
light.
Alain
de
Lille
described
them

as
subtler
than
air
or
fire,
and
superior
to
these.

13

The
psychic
spirits
figured

13

James
J.
Bono,
“Medical
Spirits
and
the
Medieval
Language
of
Life,”
Traditio
40

(1984):
91-‐130,
103.

21

prominently
in
etiologies
of
mental
illness
because
Galen
had
associated
them
with

the
functions
of
the
brain
and
nerves.

Medieval
spirit
theory
is
essential
to
the
metaphysical
and
profoundly

imaginative
character
of
early
modern
medicine.
Not
only
psychological
health,
but

all
physiological
function
depended
on
the
movements
of
the
various
spirits.
This

was
the
medieval
model
of
physiology.
Medieval
medicine
finds
its
highest

expression,
and
much
of
its
intellectual
basis,
in
the
system
of
the
medical
spirits.

Early
modern
physiology
already
assumed
the
existence
of
neurotransmitters,

and
they
understood
them
as
spiritual
forces.
James
J.
Bono
describes
how
the

medical
spirits,
a
relatively
minor
aspect
of
Galenic
theory,
developed
to
create
a

uniquely
medieval
expression
of
biophysical
science:

What
gave
special
urgency
to
these
explanations
of
Galen’s
modest

medical
spirits
was
the
philosophical
and
theological
constraints
felt
by

those
Christian
Latin
authors
who
wished
to
create
a
language

embracing
both
the
phenomena
of
life
and
the
experience
of
salvation

within
a
unified
conceptual
network.
In
practice,
this
constraint
entailed

that
a
privileged
status
be
granted
to
the
language
of
theology.
Speaking

in
a
currently
fashionable
idiom,
we
might
say
that
behind
the
‘text’
of

Galenic
theoretical
medicine
stood
the
more
privileged
‘text’
of
Biblical

exegesis
and
theological
commentary.
It
is
to
this
‘text’
that
we
must

appeal
if
we
wish
to
see
how
the
problem
of
the
relationship
of
medical

spiritus
to
the
body
was
altered
in
a
way
which
enabled
a
whole

spectrum
of
ideas
regarding
spirits
to
emerge,
be
tested,
and
ultimately,

to
test
early-‐modern
Galenic
systems
of
theoretical
medicine.

The
metaphysical
was
assumed
to
be
a
scientific
principle
empowering
all

subservient
empirical
forces.
Bono
notes
that
during
this
period
the
understanding

of
the
spiritus
was
“transmitted
along
a
range
of
frequencies”
on
the
spectrum
of

materiality:

The
language
of
theology
was
in
the
twelfth
and
thirteenth
centuries
not

a
pure
language,
reflecting
the
immediacy
of
Judaeo-‐Christian

22

experience.
Rather,
it
was
an
abstract
language,
born
of
the
marriage
of

Biblical
revelation
with
classical
philosophy
and
gnosticism….In
the

resulting
fabric,
the
dominant
metaphors
and
values
which
the
language

of
theology
imposed
upon
the
vocabulary
of
classical
philosophy
in
turn

transformed
the
meaning
of
Galenic
medical
vocabulary,
creating
a

distinctive
medieval
language
of
life.
This
new
Galenic
language
of
life

began,
in
turn,
to
weave
a
number
of
various,
sometimes
inharmonious,

versions
of
its
original
pattern.

14

The
process
here
delineated
is
distinctly
medieval
in
that
it
is
both
inherently

rhetorical
and
profoundly
metaphorical.
The
manner
in
which
science
evolved
by

way
of
the
vehicle
of
language
could
be
called
a
“semiotic
scientific
method.”

It
is

not
unlike
the
psychotic
symptom
of
“flight
of
ideas,”
a
process
in
which
a

succession
of
intellectual
and
imaginative
notions
that
are
superficially
related,
or

even
unrelated,
progresses
by
means
of
a
series
of
plays
on
words,
creating
a

monolog
connected
by
words
turned
into
synonyms,
or
other
variants
of

themselves,
by
the
mind
in
a
manic
state.
This
phenomenon
partakes
of
the
tradition

of
the
first
century
Etymologies
of
Isidore
of
Seville,
which
was
predicated
on
the

belief
that
words
contained
the
essence
of
physical
things.

The
concept
of
the
spiritus
originated
in
the
Stoic
and
Neoplatonic
traditions
as

the
explanation
of
physical
and
intellectual
animation.
It
was
the
fundamental

explanation
of
the
possibility
of
physical
life,
and
particularly
of
human
life,
because

human
life
is
intrinsically
psychological.

Gilbertus
Anglicus,
in
his
thirteenth
century
work
on
the
medical
spirits,
De
motu

cordis,
uses
the
term
“irradiation”
to
describe
the
circulation
of
the
spirits.
This

14

Ibid.,

99-‐100.

23

seems
to
be
analogous
to
what
we
know
as
the
speed
of
light.

15

Unlike
the
immortal

soul,
they
were
not
figured
as
quasi-‐personalities,
nor
as
sharing
or
representing

what
we
would
think
of
as
character.
They
could
not
be
rewarded
or
punished
as

the
soul
was:
they
were
bodily
organs.

That
a
physical
organ—anatomical,
in
most
senses
of
the
word—could
consist
of

a
nature
so
ethereal
might
seem
to
render
medieval
psychological
science

ineluctably
foreign
to
our
own.
And
yet
the
medieval
model
of
the
medical
spirits

was
developed
to
solve
what
we
think
of
as
a
modern
problem,
which
is
the

recovery
of
physical
and
mental
illnesses
from
incoherence
and
absurdity,
and
the

celebration
of
the
soul.
Medieval
healing
emanated
from
the
reassurance
of
the

triumph
of
the
spirit
over
matter.
This
is
a
problem
we
can
no
longer
solve.

We
still
understand
that
physical
processes
originate
in
forces
we
cannot
see,
and

which
only
the
authorities
among
us
can
explain.
A
“structure”
in
contemporary

physics
generally
refers
to
an
organized
arrangement
of
small
pieces,
such
as
atoms

or
molecules—or
beads
on
a
string.
It
need
not
be
permanent.
Water,
for
example,

has
a
structure
that
is
dynamic,
with
bonds
or
interactions
among
water
molecules

rapidly
forming
and
breaking,
to
be
replaced
by
bonds
or
interactions
between

other
water
molecules.
A
spiritus
might
be
figured
as
similar
to
a
cloud
or
a
column

of
smoke,
in
which
the
same
type
of
dynamic
rearrangement
of
small
components

occurs.
This
idea
could
also
be
easily
developed
to
encompass
something
that
comes

together
in
one
instance
to
create
a
certain
“structure”
with
characteristics
or
a

15

Ibid.,
118.

24

personality
of
that
structure,
but
in
another
instance,
forms
a
new
“structure”
with

different
characteristics
and
a
different
personality.

16

Despite
his
skill
in
vivisection,
Galen
explicitly
refuted
the
concept
of
the

circulation
of
blood.

So
it
is
noteworthy
that
fathers
of
early
modern
medical
spirit

theory,
such
as
Qusta
ibn
Luqa,
described
the
distribution
of
the
vital
spirits
as

movement
through
the
veins,
and
declared
the
primacy
of
the
spirits
in
a
manner

analogous
to
the
way
we
think
of
blood.
Blood
is
not
usually
considered
an
organ,

but
is
regarded
as
the
primary
tissue
physiologically
and,
in
a
larger
cultural
sense,
a

master
metaphor
for
physical
life,
as
in
the
reference
to
a
person’s
close
relatives
as

her
“blood.”
Thus
we
might
usefully
think
of
the
spiritus
as
less
fully
realized
than
an

organ
and
more
similar
to
a
tissue:
a
mass
of
the
specialized
cells
of
which
an
organ

is
formed.
Qusta
called
the
vital
spirits
“the
proximate
cause
of
life
in
the
human

body….It
is
obvious…that
life
is
produced
through
this
spirit,
which
is
in
the

ventricles
of
the
heart.”

17

Analogy
between
the
spirits
and
blood
is
in
some
ways
anachronistic,
although
it

is
useful
in
helping
us
to
comprehend
medieval
biomedical
understanding.
But
at

the
same
time,
deploying
such
an
analogy
exemplifies
the
reason
why
a
positivistic

approach
to
scientific
and
medical
history
can
never
be
ultimately
satisfying,
or

allow
us
to
feel
that
we
understand
what
it
was
to
be
a
medieval
person,
even
as

well
as
we
might
aspire
to
understand
modern
people
of
a
few
generations
ago—

16

Robert
A.
Farley,
Professor
of
Physiology
&
Biophysics
and
Biochemistry,

University
of
Southern
California,
personal
communication.

17

Bono,
95.

25

despite
the
guilty
pleasures
of
figuring
the
anticipation
of
cardiac
circulation
and

hormonal
imbalance
in
medieval
medical
theory.
C.S.
Lewis
endeavored—
successfully,
I
believe—to
explain
the
contained
universe
of
the
medieval

intellectual
as
the
dynamic
amalgamation
of
“the
whole
organization
of
their

theology,
science,
and
history
into
a
single,
complex,
harmonious
mental
Model
of

the
Universe”:

18

[The
man
of
genius]
today
often,
perhaps
usually,
feels
himself

confronted
by
a
reality
whose
significance
he
cannot
know,
or
a
reality

that
has
no
significance;
or
even
a
reality
such
that
the
very
question

whether
it
has
a
meaning
is
itself
a
meaningless
question.
It
is
for
him,
by

his
own
sensibility,
to
discover
a
meaning,
or,
out
of
his
own
subjectivity,

to
give
a
meaning—or
at
least
a
shape—to
what
in
itself
had
neither.
But

the
Model
universe
of
our
ancestors
had
a
built-‐in
significance.
And
that

in
two
senses:
as
having
a
‘significant
form’
(it
is
an
admirable
design)

and
as
a
manifestation
of
the
wisdom
and
goodness
that
created
it.
There

was
no
question
of
waking
it
into
beauty
or
life….The
only
difficulty
was

to
make
and
adequate
response.

19

18

C.S.
Lewis.
The
Discarded
Image:
An
Introduction
to
Medieval
and
Renaissance

Literature
(
Cambridge:
Cambridge
University
Press,
1995)
11.

19

Ibid.,
204.

26

Recovery
of
the
spiritus
in
Modern
Ideas
of
Madness

Contemporary
psychiatry
is
the
specialty
in
which
we
can
most
readily
observe

the
struggle
of
modern
medicine
to
recover
this
longed
for
significance.
I
believe
this

is
what
Susan
Sontag
means
when
she
describes
psychology
as
sublimated

spiritualism.

The
quasi-‐material
nature
of
the
various
Galenic
medical
spirits,
or
pneumata,
is

the
key
to
the
understanding
of
the
theoretical
structure
of
medieval
medicine,
and

of
medieval
psychiatry
in
particular.
This
was
an
organ,
and
yet
not
totally
physical.

The
spiritus
were
conceived
and
developed
in
response
to
the
need
to
account
for

the
swift
progression
of
physiological
events
that
had
their
origins
in
the
heavy
and

sluggish
humors;
in
contrast
to
these,
the
most
frequent
word
used
to
describe
them

is
“subtle”.
The
development
during
the
medieval
period
of
scientific
accounts
of
the

nature
and
the
frequently
unfortunate
sequelae
of
these
movements
became

increasingly
theological.
They
came
to
be
conceived
as
matter
so
attenuated
that

they
exist
at
the
nexus
of
human
mortality
and
morbidity
with
metaphysics.
There
is

no
such
nexus
in
modern
biomedicine:
medicine
is
no
longer
metaphorical.

Bono
cites
the
work
of
Hugh
of
Saint
Victor,
who
used
the
metaphor
of
Jacob’s

Ladder
to
describe
the
function
of
the
spiritus
as
a
medium
between
body
and
soul,

while
at
the
same
time
uniting
vegetative,
sensual
and
intellectual
capacities
of
the

soul,
a
process
negotiated
in
“microcosmic
steps”:

A
medium
for
Hugh
is
not
something
concrete
like
the
oil
used
by
a

painter
to
join
color
to
surface.
Neither
body
nor
soul
is
capable
of
being

dissolved
into
a
medium,
nor
can
the
one
be
affixed
to
the
other
by

means
of
such
an
agent.
The
function
of
Hugh’s
medium
operates
on

entirely
different
principles:
‘Est
ergo
quiddam
quo
ascendit
corpus,
ut

27

approprinquet
corpori’.
The
proper
medium
between
spirit
and
body

leaves
each
intact,
essentially
unchanged…The
Biblical

metaphor…became
a
starting
point
for
reinterpreting
the
vocabulary
of

classical
philosophy
in
the
rationalized,
but
Christian
language
of

theology.

20

The
mixed
metaphors
of
a
simple
workman’s
ladder
and
of
a
chemical

medium
function
with
a
semiotic
flexibility
on
which,
I
believe,
the
medieval

medical
paradigm
ultimately
rests:

In
antiquity
there
already
existed
a
tendency
to
see
spiritus
or
(pneuma)

as
more
noble
than
ordinary
elemental
matter,
as
a
special
kind
of

substance
superior
to
air
or
even
fire.
In
the
Middle
Ages
and
later
in
the

Renaissance
this
tendency
was
capable
of
being
transmitted
along
a

range
of
frequencies.
At
the
lower
end
of
the
spectrum,
spiritus
is
a

material
entity
–-‐
a
sort
of
medium,
and
an
instrument
of
life—located

somewhere
just
above
elemental
matter,
yet
far
short
of
the
dignity
and

immateriality
of
the
soul.
At
the
other
end,
spiritus
approaches
a
quasi-‐
divine
substance.

21

I
believe
medieval
spirit
theory
to
be
one
of
the
most
elegant
creations
of

that
culture,
and
possibly
of
Western
culture
write
large:
an
avatar,
both

symbol
and
substance
at
the
same
time.
Many
of
us
feel
the
necessity
of

bridging
the
physical
and
the
eternal,
but
it
is
no
longer
a
preoccupation
of
the

secular
sciences.
The
development
of
the
doctrine
of
spiritus
is
a
cultural

response
to
a
primal
longing,
which
we
cannot
lose.
We
have
merely
lost
a

consensus
on
how
to
fulfill
it.
Imagine
a
Pub
Med
search
producing
an
article

with
a
title
such
as
“Differential
Effects
of
Dopamine
on
the
Spiritus:
A
Dual

Medical
and
Existential
Approach.”

20

Bono,
p.
105.

21

Ibid.,
pp.
98-‐99.

28

Descartean
dualism
of
mind
and
matter
cleaved
Western
medicine
into
a

radical
disunion
between
“mental”
and
“physical”
that
persisted
even
as

generations
of
discoveries
in
chemistry
and
neurology
increasingly
indicated

that
no
formal
division
exists.
Many
of
the
diseases
traditionally
classified
as

“organic”
have
behavioral
components,
some
mimicking
psychiatric
illness

quite
precisely,
and
neurologists
in
training
are
usually
required
to
complete
a

rotation
in
psychiatry
to
learn
how
to
make
a
differential
diagnosis.

And
yet
it
is
pointless
to
argue
for
the
abandonment
of
the

physical/psychiatric
dichotomy
in
practice,
as
anyone
who
has
dealt
with
the

severely
mentally
ill
knows
well.
In
the
Emergency
Department
where
I
work

the
Psychiatric
Emergency
Room
is
physically
removed
from
the
main
ER,

separated
by
a
hallway
and
of
course
by
locked
doors.
The
psychiatric
nurses

wear
street
clothes,
and
are
never
temporarily
reassigned
elsewhere
in
the

emergency
department:
the
most
seasoned
psych
nurses
probably
don’t

remember
how
to
function
there,
anyway.
Nor
could
this
arrangement
be

fundamentally
altered.
Psychiatric
illness
manifests
in
distinct
ways
that

require
radically
different
management
in
real
time
from
other
medical

diagnoses.
The
pathogenesis
of
mental
disorders
produces
significant
changes

in
personality
and
character,
resulting
in
behavior
that
cannot
be
reasonably

predicted
nor
adequately
addressed
in
ordinary
ways.
It
is
a
disease
that

strikes
at
the
existential
roots
of
the
individual
life.

29

I
asked
Julea
Leshar
McGhee,
an
attending
physician
in
the
Psychiatric

Emergency
Room
at
Los
Angeles
County
/
University
of
Southern
California

Medical
Center,
whether
she
saw
herself
as
treating
the
“soul”:

Most
psychiatrists
really
are
in
this
place
now
where
we
see
madness
as

biological.
It’s
the
other
specialties
who
have
a
hard
time
seeing
madness

as
true
illness,
and
it’s
very
difficult
because
when
things
affect
behavior

you
tend
to
see
it
as
the
person
themselves,
as
the
whole
human
being

instead
of
something
changing
in
their
brain
that’s
making
them
act
a

certain
way…Medication
is
very
important
but
it’s
only
a
piece
of
it,

because
you
are
dealing
with
the
whole
human
being.
We’ve
all
been

socialized
to
think
of
our
personality
as
uniquely
‘us’—uniquely
as
our

soul.
Maybe
you’re
not
religious
and
you
don’t
use
that
terminology,
but

when
you
think
about
the
essence
of
‘you’,
you
think
about
your

personality.
And
that’s
the
challenge
when
you
see
diseases
that
change

your
personality,
like
dementia
or
a
brain
injury—especially
with

damage
to
the
frontal
brain.

22

And
it
challenges
the
very
notion
that
the

personality
is
the
essence
of
you,
because
if
that
changes,
then
who
are

you?
Are
you
the
same
person?

This
dilemma
of
the
contemporary
physician,
both
the
psychiatrist
and
her

colleagues
in
other
specialties,
is
itself
a
survival
of
spirit
theory:
an

understanding
that
madness
is
paradoxically
a
disease
of
the
soul
that
must
be

addressed
in
physical
terms.
In
the
absence
of
a
bridging
concept
like
spiritus,

our
intensely
secular
medicine
is
left
to
do
nothing
but
separate
absolutely.

Spiritual
Systems
Theory

Given
the
inherent
difficulty
of
reconciling
the
roles
of
the
immortal
soul

and
the
spiritus
in
sustaining
physical
life,
the
debate
on
the
nature
and
actions

of
the
spiritus
continued
for
seven
hundred
years.
Twelfth
century

22

Bartholomeus
Anglicus
followed
Plateareus,
12C
School
of
Salerno,
in
believing

that
the
frontal
brain
controlled
imagination,
the
loss
of
which
caused
true

madness.

30

scholasticism
was
particularly
fruitful
for
this
scientific
and
rhetorical
work.

From
the
high
Middle
Ages
into
the
Renaissance
the
ancient
idea
was

developed
into
an
increasingly
complex
scientific
concept.

Bono
notes
that
medical
spirit
theory
was
contentious,
particularly
around

questions
of
ontology
and
especially
in
the
twelfth
and
thirteenth
centuries,

amid
“cosmological
speculations
concerning
the
relationships
of
soul,
body

and
spirits
to
the
world-‐soul,
celestial
bodies,
the
intelligences
and
God

himself.”

23

Indeed,
he
observes,

[0]ne
can
hardly
imagine
the
radical
shifts
in
theoretical
orientation

found
in
the
seventeenth-‐century
physiologies
of
Harvey
and
Descartes

without
the
backdrop
of
dilemmas
posed
by
the
language
of
life
they

inherited
from
the
Middle
Ages.
Such
dilemmas
required
the
adoption
of

various
theoretical
strategies,
which
could
then
transcend
and
ultimately

discard
them.

24

Theoretical
and
increasingly
technical
strategies
inevitably
prevailed,
and

the
spirits
were
forgotten.

Although
biomedicine
no
longer
joins
so
ambitious
a
debate
as
the

relationship
of
the
body
to
God,
it
has
not
outgrown
the
quandary
of

irreconcilable
approaches
to
basic
research.
Physiologists
and
biologists
who

think
of
themselves
as
“reductionists”
now
follow
an
approach
based
on
the

notion
that
identifying
the
structure
and
function
of
the
smallest
parts
of
a

system
will
yield
the
secret
of
how
the
larger
system
(i.e.,
the
human
body

itself)
works
as
a
whole.
“Systems”
physiologists
and
biologists
have
nothing

good
to
say
about
this
approach,
believing
that
the
system
in
its
entirety
can

23

Bono,
97.

24

Ibid.,
102.

31

only
be
understood
by
studying
the
interactions
among
whole
organs,
using

principles
of
engineering
that
have
been
developed
for
this
purpose,
although

not
necessarily
for
living
organisms.

25

There
is
no
wonder
that
the
nature
and
actions
of
the
spirits
generated
a

huge
corpus
of
complex
theological
thinking
over
centuries.
What
seemed
to

be
required
was
a
medieval
“fudge
factor:”
an
attempt
to
bridge
the
temporal

and
physical
with
the
timeless
and
immaterial,
and—because
humans
make

meaning
with
words—to
express
the
ineffable.
The
idea
of
a
“quasi-‐divine

substance,”
which
might
immediately
strike
contemporary
Westerners
as
an

oxymoron,
actually
dovetails
perfectly
with
the
concept
of
transubstantiation.

The
significance
of
the
spiritus
in
mediating
essential
theological
and

physical
problems
is
reflected
in
some
aspects
of
modern
response.
The

Oxford
medievalist
C.S.
Lewis,
who
was
a
strong
Catholic,
took
exception
to
the

spiritus:
“This
tertium
quid,
this
phantom
liaison-‐officer
between
body
and

soul.”

(The
spirits)
were,
putting
it
bluntly,
to
be
like
the
aether
of
nineteenth-‐
century
physics,
which,
for
all
I
could
ever
learn
of
it,
was
to
be
and
not

to
be
matter.
This
doctrine
of
the
spirits
seems
to
me
to
be
the
least

reputable
feature
in
the
Medieval
Model.
If
the
tertium
quid
is
matter
at

all
(what
have
density
and
rarity
to
do
with
it?)
both
ends
of
the
bridge

rest
on
one
side
of
the
chasm;
if
not,
both
rest
on
the
other.

26

What
I
see
as
Lewis’
somewhat
overheated
reaction—and
I
see
it
this
way,

because
the
very
concept
that
I
hold
to
be
pivotal
to
the
medieval
medical

25

Robert
A.
Farley,
personal
communication.

26

Lewis,
167.

32

model
is
the
one
he
regards
as
a
weakness,
and
possibly
a
cultural
artifact—
originates
in
our
positions
on
opposite
sides
of
this
bridge.

In
the
modern
religious
conception,
spirituality
is
distinct
from
physicality,

and
those
who
affirm
both
concepts
as
equally
real
do
not
assume
that
either

requires
a
bridge
to
the
other.
The
reconciliation
of
science
to
faith,
a

quintessentially
un-‐medieval
problem,
is
fraught,
and
to
keep
peace
the

modern
Christian
usually
agrees
that
the
distinction
be
respected.
As
a

modern
Catholic,
Lewis
is
affronted
that
a
bridge
to
the
metaphysical
should

be
proposed.

I,
on
the
other
hand,
am
areligious.
I
am
intrigued
by,
and
nostalgic
for,
the

medieval
figuration
of
transcendence
that
incorporates
both
the
desire
for
the

health
of
the
physical
body
and
the
assurance
that
our
Sisyphean
striving
will

end
happily.
The
medieval
intellect
was
not
affronted
by
the
conception
of

such
a
connection
in
the
form
of
a
tangible
structure.
I
think
this
was
because

these
thinkers
did
not
overtly
confront
the
possibility
that
sublunary
existence

might
terminate
in
meaninglessness
or
mystery.

Thus,
the
spiritus
may
be
seen
as
a
working
model
of
how
medieval
science

engaged
in
the
same
type
of
exploration
of
the
material
world
to
which
we

apply
the
name
of
“science”
today,
while
simultaneously
preserving
the

hegemony
of
the
Christian
macrocosm.
The
dichotomy
between
faith
and

science
that
exercises
so
many
contemporary
Westerners
is
here

adumbrated—maintained
at
a
level
so
low
as
to
be
virtually
undetectable

philosophically,
unless
by
a
medieval
“futurist”
who
could
foresee
the
cultural

33

acceptance
of
agnosticism
as
a
rational
personal
belief
and
the
widespread

embrace
of
absurdist
philosophy.
This
philosophical
and
rhetorical

organization
provided
a
large
space
in
which
the
biomedical
scientist
of
the

Middle
Ages
could
develop
theory
and
practice
without
engendering

inadvertent
theological
conflict.

34

CHAPTER
THREE

“The
Glassy
Phlegm
of
Coldness
and
Coagulation”:

Medical
Philology
in
Medieval
Texts

It
is
one
of
the
values
of
lectures
on
the
history
of
medicine
to
keep
alive

the
good
influences
of
great
men
even
after
their
positive
teaching
is

antiquated.
Let
no
man
be
so
foolish
as
to
think
that
he
has
exhausted

any
subject
for
his
generation.

William
Osler

27

Medical
Historian
Owsei
Temkin
argues
that
the
philosophy
of
medicine
should

offer,
in
addition
to
a
medical
logic
and
a
medical
ethics,
a
medical
metaphysics.
He

quotes
Thomas
Aquinas:
“The
purpose
of
philosophy
is
not
to
know
what
men
have

thought,
but
what
is
the
truth
of
things.”

28

I
am
less
optimistic.
I
do
not
believe
that
contemporary
medical
philosophy
is

able
to
contend
with
questions
about
the
nature
of
reality
and
of
existence.

Contemporary
Western
medicine
is
generated
by
an
ontology
that
is
profoundly

materialistic,
and
the
medical
centers
that
are
its
temples
of
healing
are
complex

machines
for
keeping
physical
bodies
oxygenated
and
metabolically
functional

beyond
what
anyone
would
have
considered
“alive,”
even
generations
ago.
Modern

biomedicine
is
a
technical
discipline,
and
it
is
foreign
to
metaphysics.
It
has

“exhausted
the
subject.”

27

Temkin,
102.

28

Ibid.,
104.

35

I
argue
that
the
complex
textual
contribution
of
the
medieval
period
to
the

philosophy
of
medicine,
and
to
philosophy
in
the
larger
sense,
exceeds
that
of

contemporary
medicine.
Looking
at
how
this
philosophy
is
expressed,
I
will
focus
in

this
chapter
on
the
structure
and
content
of
medical
texts.

The
Christianized
medicine
of
medieval
Europe
was
a
thousand
years
in
fruition,

developed
from
sources
out
of
Asia
and
Africa,
as
well
as
from
ancient
Europe.
In
the

texts
of
this
medicine
anatomical
and
pathophysiological
theory,
medical
logic
and

medical
ethics
are
inextricable
from
medical
metaphysics.
We
have
received
and

transformed
the
logical
and
ethical
components
of
this
literature.
We
have
elided

the
spiritual
elements.

The
letter
of
the
ancient
medical
works
contains
clear
similarities
to
that
of

contemporary
literature,
and
some
of
these
are
probably
attributable
to
direct

textual
inheritance.
But
there
are
irreconcilable
differences
of
the
spirit.
While

modern
biomedicine
is
seriously
concerned
with
ethics
and
genuinely
dedicated
to

individual
patient
outcome,
it
cannot
address
the
metaphysical
dimension.
The

reading
of
spirituality
in
science
is
now
a
foreign
language.

The
Texts
Themselves:
Medieval
Medical
Bibliography

Medieval
medical
literature
is
an
eclectic
corpus
that
includes
Latin
treatises
for

teaching
and
debate;
discourse
on
causes,
cures,
and
comfort
measures
for
leprosy,

cancer,
plague,
and
ill-‐fated
childbirth;
instructions
on
the
surgical
correction
of

hernias
and
abdominal
fistulas,
the
setting
of
broken
bones
and
the
relief
of

traumatic
pressure
on
the
brain;
reference
works
composed
largely
of
tables
and

36

almost
devoid
of
complete
grammatical
sentences;
and
collections
of
recipes
for

treating
arcane
and
barely
distinguishable
aliments
with
disgusting
remedies.

This
literature
is
not
as
foreign
to
modern
texts
as
we
have
assumed.
It
is
the

record
of
a
practice
created
to
correct
pathophysiology,
as
this
was
understood.

Early
modern
physiology
is
often
reasonably
accurate.
But
more
important
than
the

fact
that
they
somehow
missed
the
existence
of
cardiopulmonary
circulation
is
their

fundamental
emphasis
on
the
unique
and
personal
nature
of
each
disease.

Our

stance
is
nearly
the
opposite.

The
seminal
texts
taught
in
medieval
medicinal
schools
are
not
simply
derived

from
the
wisdom
of
the
ancients.
They
are
direct
translations,
especially
of
Galen

and
Hippocrates.
Texts
required
at
Oxford
in
the
fourteenth
century
also
included

the
Liber
Continens
of
Rhazes,
the
Liber
Regius
of
Haly
Abbas
and
Avicenna’s
Canon.

These
works
are
listed
among
the
credentials
of
Chaucer’s
Doctor
of
Medicine.

Christianized
early
modern
medicine
was
largely
an
elaboration
on
the
theory
here

contained.

The
canonization
of
medical
texts
as
a
genre
is
largely
the
product
of
the
medical

school
at
Salerno
between
the
late
eleventh
and
the
early
thirteenth
centuries.

Medical
authors
at
Salerno
created
the
articella,
a
series
of
brief
treatments
of

Hippocratic
and
Gallenic
medicine
from
which
medicine
was
taught
in
the
Scholastic

mode
of
debate
and
commentary.
The
Aphorisms
and
the
Prognostics
were
based
on

the
teachings
of
Hippocrates;
the
Gallenic
treatise
was
variously
known
as
the
Ars

Medica,
the
Ars
parva,
the
Tegni,
or
Microtechne.

29

Also
included
in
the
Salernitan

29

Nancy
G.
Siraisi,
Medieval
&
Early
Renaissance
Medicine:
An
Introduction
to

37

curriculum
was
one
of
the
seminal
academic
texts
of
medieval
medicine,
and
the
one

which
probably
had
the
longest
tenure
of
practical
use:
the
Isagoge
of
Johannitius,
a

ninth
century
Assyrian
Christian
whose
birth
name
was
Hunayn
ibn
Ishaq
and
who

wrote
the
treatise
as
an
introduction
to
a
translation
of
Galen’s
Microtegni.

Translated
from
Greek
to
Latin
by
Constantinus
Africanus
in
the
early
eleventh

century,
it
was
entered
into
Western
medical
education
by
the
scholastics
of
Salerno

and
became
a
standard
medical
text
until
well
into
the
Renaissance.
The
Isagoge

contains
the
foundations
of
medieval
medical
theory:
the
humors;
the
elements
and

qualities;
the
naturals
and
non-‐naturals;
the
members,
energies
and
operations,
and

a
rudimentary
treatment
of
the
spirits
that
was
to
become
medieval
spirit
theory.

Original
texts
did
emerge
from
the
important
medical
schools
at
Oxford,
Salerno,

Paris
and
Bologna,
especially
after
the
influential
movement
toward
formal
medical

theory
began
in
Salerno
in
the
eleventh
century.
Despite
the
technical
importance
of

this
professionalization,
the
works
themselves
conflicted
in
details.
Textually,
they

constituted
a
kind
of
glorious
intellectual
pastiche.
Originality
was
not
asserted,
and

not
really
desirable:
there
was
no
concept
of
plagiarism,
and
medieval
authors
are

known
to
have
presented
their
own
work
as
having
originated
in
arcane
works
of

authorities,
in
order
to
enhance
the
reception
of
what
we
would
call
their

“intellectual
property.”

Learned
texts
that
are
specifically
medieval
products
of
continental
and
British

origin
are
generally
compendiums—but
again,
as
Basil
Clarke
notes,
the
individual

Knowledge
and
Practice.
(Chicago:
University
of
Chicago
Press,
1990)

58.

38

virtues
of
such
works
do
not
depend
on
originality
or
even
critical
thinking,
but
on

“the
spirit
of
the
compiler.”
(Clarke
remarks
that
“modern
general
works
are
open
to

the
same
sort
of
appraisal.”)
30

He
lists
the
thirteenth
century
Surgery
of
Roger
of

Salerno,
and
also
the
twelfth
century
Anatomy
of
Ricardus
Anglicus,
which
contains

an
unusually
well
developed
account
of
the
nervous
system.
The
thirteenth
century

Compendium
medicine
of
Gilbertus
Anglicus
is
somewhat
drier
with
its
“academic

method
of
comparative
critique,”

31

whereas
the
encyclopedic
text
of
Bartholomeus

Anglicus
is
both
more
superficial
and
more
influential
historically,
due
to
its

dissemination
among
Batholomeus’s
order
of
the
Friars
Minor,
who
possessed
a

widespread
network
of
itinerant
healers
of
the
body
as
well
as
the
soul.

Bernard
de

Gordon’s
Lilium
Medicine
is
learned
without
being
obtuse,
and
John
of
Gaddesden’s

Rosa
Anglica
is
similarly
readable.

Even
the
new
academic
medical
texts
were
created
from
received
wisdom,
some

of
it
ancient,
along
with
case
studies
from
these
authorities
and
from
respected

contemporaries.
These
texts
are
usually
presented
in
a
discursive,
anecdotal
style,

with
lists
of
symptoms
that
tend
to
be
vague
and
overlapping,
and
often
fanciful
and

imprecise.
The
description
of
phlegm
in
the
title
of
this
chapter
is
an
example.

Textbook
expositions
of
the
middle
to
late
Middle
Ages
are
described
by
Clarke
as

consistent
in
form.
(Although
his
interest
is
in
texts
about
madness,
this
outline
is

30

Basil
Clarke,
Mental
Disorder
in
Earlier
Britain.
(Cardiff:
University
of
Wales
Press,

1975)

87.

31

Ibid.,
88.

39

typical
for
medical
books
of
this
period.)
In
general
they
follow
a
pattern
of
a
“brief

definition
of
the
[organ]
involved;
discussion
of
pathology
(Cause);
description

(Signa);
outlook
(Prognostica);
treatment
(Cura);
final
comment
(Clarificatio).”

This
arrangement
is
structurally
similar
to
that
of
a
modern
medical
text.
The

preface
to
a
popular
text
for
medical
students
describes
its
layout:

Pathophysiology
of
Disease
is
divided
into
20
chapters,
developed
chiefly

by
organ
system.
Each
chapter
is
divided
into
sections
emphasizing

normal
structure
and
function,
pathology
and
disordered
physiology,

common
clinical
presentations,
and
mechanisms
underlying
consequent

symptoms
and
signs.
A
list
of
pertinent
recent
references
is
provided
at

the
end
of
each
chapter
as
suggestions
for
further
reading.

32

Beyond
the
revered
texts
for
the
learned,
the
corpus
of
what
historians
study
as

“medieval
medical
literature”
is
difficult
to
contain
within
a
traditionally
shaped

genre.
There
are
compendia
like
the
Anglo
Saxon
Old
English
Herbarium,
largely
a

list
of
plants
with
prescriptions
for
harvesting
and
preparation
for
a
plethora
of

ailments:
knotgrass
(Polygonum
aviculare
L.)
will
produce
“wonderful
effects”
on
the

vomiting
of
blood
if
it
is
simmered
in
strong
wine
that
is
not
allowed
to
steam;
the

juice
of
the
plant
in
oil
will
soothe
flank
pain
if
rubbed
against
the
sides,
and
when

pounded
with
butter
it
will
ease
the
sore
nipples
of
the
new
mother.

33

Alkanet

(Anchusa
officinalis
L)
will
cure
the
wheezing
and
shortness
of
breath
due
to
asthma

32

Stephen
J.
McPhee,
Vishwanath
R.
Lingappa,
William
F.
Ganong,
and
Jack
D.
Lange,

Pathophysiology
of
Disease:
An
Introduction
to
Clinical
Medicine.
(Norwalk:

Appleton
&
Lange,
1995)

v.

33

Anne
Van
Arsdall,
Medieval
Herbal
Remedies:
The
Old
English
Herbarium
and

Anglo-
Saxon
Medicine.
(New
York:
Routledge,
2002)
157.

40

if
made
into
a
poultice
with
honey
and
bread
that
has
been
baked
using
grease.

34

A

fern
growing
in
the
roots
of
a
beech
tree,
if
pounded
with
lard
and
applied
to
a

binding
cloth,
will
mend
an
incarcerated
hernia
in
the
designated
time
of
five
days.
35

Some
treatises
deal
with
the
calendar,
and
the
implications
of
weather
and

astrology
for
diet
and
hygiene.
There
are
many
treatments
of
the
finer
points
of

phlebotomy.
The
medicinal
use
of
charms
and
prayers
continued
to
be
considered
at

the
highest
levels,
at
least
in
an
ancillary
capacity,
into
the
Renaissance.
Such

treatments
were
offered
by
Bernard
of
Gordon,
Gilbertus
Anglicus,
John
Arderne

and
Thomas
Fayreford.

36

Gorgeously
illustrated
manuscripts
of
the
Tacuinum
Sanitatis,
a
handbook
of

health
maintenance
and
the
use
of
the
“non
naturals”
that
is
derived
from
an

eleventh
century
treatise
by
Ibn
Butlan
of
Baghdad,
survive
in
Vienna,
Paris,
Liege

and
Rome.
The
Tacuinum
lists
natural
entities
and
man
made
products
according
to

their
inherent
qualities,
by
degrees
of
these:
hot
and
cold;
moist
and
dry;
and
their

effect
on
the
relevant
humors.
Thus
dill
(aneti)
is
listed
as
“warm
and
dry
toward

the
end
of
the
second
degree
and
the
beginning
of
the
third”;
it
“brings
relief
to
the

stomach
that
is
cold
and
windy”
but
is
harmful
to
the
kidneys:
“Good
for
cold
and

damp
temperaments,
for
old
people,
in
Winter
and
in
cold
regions.”
Autumn
is
a

health
entity
in
itself,
“moderately
cold
in
the
second
degree,”
and
suitable
to
warm

and
damp
temperaments.
Woolen
clothing,
pasta
and
coitus
have
lists
of

34

Ibid.,
169.

35

Ibid.,
183.

36

Lea
T.
Olsan,
“Charms
and
Prayers
in
Medieval
Medical
Theory
and
Practice,”

Social
History
of
Medicine
16
(2003):
343-‐366.

41

preventative
and
curative
medical
applications.

37

The
unitary
nature
of
medieval

thought
informed
a
medical
holism
in
which
both
physical
substances
and

environmental
forces
were
pregnant
with
toxicology
and
pharmacology.

‘Our
Bodies,
Ourselves’:
Essential
Principles
of
Early
Modern
Practice

Temkin
defines
medical
logic
as
“a
subdivision
of
general
logic;
it
is
a
chapter
in

methodology,
dealing
with
the
concepts
that
constitute
medicine,
their
meaning
as

well
as
correct
use.”

38

The
medical
logic
of
the
Middle
Ages
is
both
elegant
and

complex.

The
Galenic
system.
like
our
own,
approaches
the
problem
of
the
management

and
control
of
disease
entities
with
an
elaborate
nosology.
The
theoretical—or

“theoretic”—is
the
foundation
of
a
paradigm
of
optimal
health
as
the
product
of

balance
among
the
Naturals,
the
Non-‐Naturals,
and
the
Contra-‐Naturals.

The
“Naturals”
usually
include
seven
entities.
These
are
the
“Elements,”
or
basic

components
of
the
physical
body:
earth,
air,
fire,
and
water;
the
“Complexion,”
or

temperament,
which
is
a
personal
balance
of
hot,
cold,
wet,
and
dry;
the
“Humors,”

blood,
phlegm,
black
bile
and
yellow
bile;
the
physical
“Members,”
or
anatomical

parts;
the
“Virtues,”
or
powers
of
action
and
sensation,
similar
to
our
concepts
of
the

sympathetic
and
parasympathetic
branches
of
the
nervous
system;
the
“Operations,”

or
functions,
such
as
the
stomach’s
regulation
of
digestion
by
the
mobilization
of

heat
and
moisture;
the
“Faculties,”
or
abilities.
In
addition
there
are
the
“Spirits,”

37

Luisa
Cogliati
Arano,
ed.
Tacuinum
Sanitatis:
The
Medieval
Health
Handbook.
Oscar

Ratti
and
Adele
Westerbrook,
trans.
(Milan:
Electa
Editrice,
1976).

38

Temkin,
104.

42

which,
as
we
have
seen,
are
understood
as
the
life
forces
that
organize
and
control

the
virtues
and
functions
and
literally
“keep
body
and
soul
together.”

The
“Contra-‐Naturals”
are
the
general
term
for
the
pathological
processes,

accidents
or
assaults
that
destroy
the
body
or
impair
function.

The
“Non-‐Naturals”
are
extrinsic
to
the
body
but
crucial
to
its
health,
as
they

transiently
inhabit
it:
exercise
and
repose;
sleep
and
wakefulness;
food
and
drink;

surfeit
and
excretion;
and
the
passions.
(That
digestion
should
be
considered

extrinsic
to
the
body
might
seem
counterintuitive,
but
modern
physiology
continues

to
hold
that
the
contents
of
the
alimentary
canal
exist
in
the
environment,
rather

than
being
ensconced
within
the
body
per
se,
such
as
a
fetus
or
a
bullet
would
be.)

The
Isagoge
was
used
as
an
introductory
text
for
medical
students.
Many
such

introductions
to
clinical
medicine
are
published
now.

Physiological
analysis
is
fairly

detailed,
although
medieval
students
were
spared
the
mastery
of
biochemistry:

Of
black
bile.
Black
bile
exists
in
two
different
fashions.
In
one
way
it
may

be
said
to
be
natural
to
the
dregs
of
the
blood
and
any
disturbance
of
the

same,
and
it
can
be
known
from
its
black
colour
whether
it
flows
out
of

the
body
from
below
or
above,
and
its
property
is
cold
and
dry.
The
other

kind
is
altogether
outside
the
course
of
nature,
and
its
origin
is
from
the

adustio
of
the
choleric
quality,
and
so
it
is
rightly
called
black,
and
it
is

hotter
and
lighter,
and
having
in
itself
a
most
deadly
quality
and
a

pernicious
character.

39

What
we
now
know
as
melena,
the
tarry
black
stool
that
contains
digested
blood

from
a
lesion
high
in
the
colon
and
is
distinct
from
hematochezia,
or
fresh
red
blood

from
a
lower
lesion
or
a
hemorrhoid,
is
probably
black
bile.

39

Henry
Patrick
Cholmeley,
John
of
Gaddesden
and
the
Rosa
Medicinae
(Oxford:

Clarendon
Press,
1923)
138.

43

Elaborations
on
this
system
over
the
centuries
included
explorations
of
the

qualities
of
the
humors
and
explications
of
their
migration
throughout
the
body;

theories
of
pathophysiology,
often
based
on
the
ill
effects
of
such
humoral
shiftings;

tables
of
differential
symptomatology;
explanations
of
specific
maladies
attributed

to
individual
humoral
composition,
or
“complexion,”
which
was
genetic
and
dictated

treatment;
and
pathways
of
environmental
disease
causation
through
poor
personal

choice,
ignorance,
or
indiscipline
in
‘hygiene,’
which
denoted
the
improper
usage
of

the
“non-‐naturals.”

There
were,
for
example,
four
types
of
phlegm:
salty;
sweet;
acrid;
and
glassy.
The

last,
as
Johannitus
notes,
was
predominant
in
the
bodies
of
the
elderly.
The
phlegm

that
accompanied
cerebral
pathology
was
generally
characterized
as
“sweet”—as

indeed
it
is;
cerebrospinal
fluid,
unlike
mucus,
contains
a
high
percentage
of
glucose,

and
testing
the
nasal
discharge
of
a
brain
injured
patient
with
a
glucose
strip
to

detect
leakage
from
occult
damage
to
the
cranium
is
currently
part
of
routine

bedside
assessment.
The
medieval
physician
analyzed
his
patient’s
fluid
by
tasting

it.

While
the
examination
of
urine
was
the
skill
most
commonly
associated
with

medical
practitioners,
as
exemplified
by
the
thousands
of
surviving
illustrations
of

both
male
and
female
healers
brandishing
flasks
and
urinals,
blood
was
also
a
major

source
of
diagnostics.
Nancy
Siraisi
describes
hematological
analysis:

A
work
on
phlebotomy,
attributed
to
the
twelfth
century
Salernitan

author
Maurus,
gives
careful
instructions
for
observation
before,
during,

and
after
coagulation;
characteristics
to
be
noted…included
viscosity,

hotness
or
coldness,
“greasiness”
(unctuositas),
taste,
foaminess,
rapidity

of
coagulation,
and
the
characteristics
of
layers
into
which
drawn
blood

separated.
As
a
final
step,
the
practitioner
was
supposed
to
wash
the

44

coagulated
blood
and
once
more
feel
its
texture.
Blood
that
was
greasy
or

showed
certain
characteristics
after
washing
was
a
particularly
ominous

sign
that
suggested
a
diagnosis
of
lepra.

40

Astral
movements
could
cause
disease
in
unlucky
people,
depending
on
their

physical
susceptibility.
The
convocation
of
physicians
who
gathered
at
the

University
of
Paris
to
respond
to
the
first
appearance
of
the
plague
declared
that
the

unprecedented
calamity
was
the
result
of
an
unfortunate
Age
of
Aquarius,
in
which

the
conjunction
of
Saturn,
Jupiter
and
Mars
had
unleashed
great
earthquakes
(which

probably
did
occur
in
the
East).
These
seismic
events
had
released
noxious
vapors

from
the
cracked
bowels
of
the
earth.

The
inhalation
of
these
would
cause
plague
in

susceptible
individuals,
particularly
young
women
of
rosy
countenance,
who
were

complexionately
hot
and
moist.
Long
term
experience
of
a
series
of
epidemics

resulted
in
nuances
in
this
theory,
some
of
which
are
speculated
as
having
been

anticipations
of
modern
epidemiology.

Clinical
Creativity:
Medical
Arts
and
Artisans

The
recovery
of
the
ancient
texts
was
serendipitous,
and
their
dissemination

erratic,
sometimes
over
generations.
Most
significant
from
a
modern
perspective,

this
medical
science
was
achieved
in
the
absence
of
organized
data
collection.

Created
without
the
statistical
mathematics
essential
to
the
protocols
of

reproducible
science,
it
is
a
vast
body
of
learning
about
cause
and
cure
that
is

qualitative
in
approach
and
anecdotal
in
content,
reliant
on
received
wisdom
and

verbal
descriptions
and
on
the
logical
analysis
of
case
histories.
Although
it
contains

40

Siraisi,
124-‐25.

45

anticipations
of
contemporary
medical
understanding,
some
of
them
quite

remarkable,
virtually
the
entire
corpus
was
written
in
response
to
Galenic
humoral

theory,
the
unassailable
tenure
of
which
is
difficult
for
us
to
conceive.
It
is,
from
a

technical
point
of
view,
irreconcilable
with
modern
medical
research.
The
books
are

also
remarkable,
by
modern
standards,
for
the
absence
of
clear
boundaries
among

presenting
patients.

Basil
Clarke
describes
this
embryonic
professional
database:

[T]hese
accounts
often
offer
more
than
one
variety
of
complexio,
or

mixture
of
humors
in
different
proportions,
as
alternative
explanations

for
a
given
condition
or
for
varieties
of
it.
The
syndromes
are
not

unequivocally
sketched
and
the
humoral
mixtures
posited
lacked,
of

course,
precise
definition,
measurement
and
adequate
empirical

correlation
with
the
disorders.
The
clinical
experience
of
writers
varied

greatly,
too.
But
in
a
given
case
these
descriptions
provided
the
physician

with
a
network
of
ideas
for
achieving
an
approximate
match,
though
not

with
one
directive
solution,
as
is
often
assumed.

41

The
concept
of
“approximation”
is
of
course
anathema
to
the
modern

practitioner.
The
“art
of
medicine”
is
no
longer
understood
to
emerge
from
personal

creativity,
but
from
fidelity
to,
and
anticipation
of,
empirical
principles.

Original
texts
of
medieval
medicine,
even
academic
ones,
included
data
that
was

sometimes
so
creative
as
to
be
what
we
would
consider
scientifically
idiosyncratic.

Faith
Wallis,
discussing
an
anonymous
treatise
on
pulses
and
urine
popular
in
the

early
Middle
Ages,
sometimes
ascribed
to
Galen
and
sometimes
to
Alexander
of

Trales,
considers
the
author
a
“connoisseur”
of
urines.
He
describes
this
waste
as

either
‘delicate
in
color’
or
‘cloudy
in
an
evil
way.’

42

This
would
now
be

41

Clarke,
90.

42

Faith
Wallis
Wallis,
ed.,
Medieval
Medicine:
A
Reader
(Toronto:
University
of

46

an
absurd
anomaly:
a
medical
exposition
of
clinical
data
in
which
defining

characteristics
are
not
delineated
technically
but
communicated
aesthetically.
These

are
styles
of
representation
now
common
in
the
arts,
such
as
the
description
of

operatic
singing
as
“sparkling,”
“plush”
or
“transgressive,”
or
of
wine
as
“austere,”

“subtle,”
or
“fruit-‐forward.”

Indeed,
celebrated
medical
careers
evolved
amidst
an
ethos
of
personal

creativity
similar
to
that
surrounding
the
rise
of
a
gifted
modern
chef,
as
opposed
to

the
positivistic
theme
of
technological
conquest
that
defines
medical
careers
now.

Thus
Wallis
notes
that
professional
preparation
involved
“face-‐to-‐face
training
with

a
master,”
and
that
the
textual
reference
itself
was
relegated
to
“mnemonic
support.”

Pocket
sized
texts
for
the
itinerant
practitioner
appeared
in
the
pre-‐Scholastic
era,

derived
from
recognized
texts
or
compiled
from
private
practices.

Much
of
the
material
was
useful
for
diagnostic
purposes
only.
Prognostication,

even
of
a
negative
outcome,
was
an
important
factor
in
a
healer’s
reputation.
The

lengthy
treatment
of
pulses
in
the
above
text
contains
a
section
on
variation
during

the
course
of
pneumonia,
beginning
with
the
“strong
and
rapid”
tachycardia
of

incipient
sepsis:

In
cases
of
pleurisy,
the
pulse
is
rapid.
When
the
disease
worsens,
it

becomes
more
rapid,
and
it
is
swift,
strong,
and
(so
to
speak)
fluctuating,

and
it
feels
like
it
is
thrusting
against
the
fingers
of
the
person
inspecting

it.
When
this
disease
changes
into
pneumonia,
the
pulse
becomes
more

rapid….A
“rapid”
pulse
is
one
that
completes
its
leaps
and
falls
in
a
short

period
of
time.
A
“swift”
pulse
executes
the
movements
of
its
course

speedily.
A
“strong”
pulse
pulsates
against
the
length
of
the
inspector’s

Toronto
Press,
2010,
38.

47

[fingers]
with
a
strong
motion.
A
“fluctuating”
pulse
is
one
that
flows

more
in
its
leap,
like
liquid
enclosed.

43

When
the
disease
reaches
the
“danger
point”—presumably,
generalized
sepsis—
the
pulse
“becomes
indistinct
and
seems
to
disappear
and
(so
to
speak)
formicates.”

The
rage
of
the
body
against
“the
dying
of
the
light”
dissipates
into
the
short
and

cringing
life
of
ants.

Fortunately
technology
is
our
least
significant
inheritance
from
this
medical

culture.
It
was
highly
successful
at
providing
meaning
to
people
enduring
critical

encounters
with
morbidity
and
mortality,
and
consequently
it
functioned
as
a

powerful
force
for
social
cohesion.
Contemporary
medicine
excels
at
explaining
the

“how”
of
disease
progress,
and
often,
at
least
in
a
generic
sense,
the
“how”
of

origination
(you
drank
too
much
alcohol;
you
carry
an
unfortunate
gene).
Medieval

medicine
was
able
to
explain
the
personal
“why,”
in
a
much
more
ambitious
sense

that
today
we
would
call
existential.

Because
these
texts
are
intended
to
be
practically
useful,
etiologies
and
diagnoses

in
the
style
of
modern
professional
standards
are
abundant,
and
some
of
these
raise

intriguing
questions
about
the
origins
of
their
anticipations
of
our
science
and
the

qualities
of
our
inheritance
of
theirs.
The
following
is
an
explication
of
what
I
take
to

be
hepatitis
or
cirrhosis—a
poorly
differentiated
diagnostic
category
that
was

already
ascribed
to
the
liver,
and
correlated
with
a
hardening
of
the
organ,
abnormal

clotting
of
the
blood
and
the
accumulation
of
ascitic
fluid
in
the
abdomen.
Ascites

was
drained,
as
it
still
is,
through
a
tube
inserted
through
the
peritoneum
and
the

43

Ibid.,
41.

48

abdominal
fascia.
This
technique
is
now
known
as
paracentesis,
a
word
noted
by
the

OED
to
have
appeared
in
sixteenth
century
French
as
‘paracentese’:
“to
drawe
away

the
water
out
of
the
bellyes.”
This
passage
is
taken
from
The
Wisdom
of
the
Art
of

Medicine,
a
composite
work
of
unknown
derivation
that
appears
in
several
medieval

manuscripts:

From
what
humor
does
the
liver
become
irritated?
From
melancholy

humor
and
too
much
morbid
drainage
because
of
cold.
It
descends
from

the
head
into
the
stomach
and
thence
into
the
capillaries
of
the
liver,
and

from
this
comes
coagulation
and
irritation
of
the
liver.
And
the
right
part

of
the
stomach
will
swell
up
and
will
suffer
from
indigestion,
and
pain

will
throb
in
the
right
side.

44

In
pulmonary
medicine,
John
of
Gaddesden
accurately
describes
the
pathological

process
then
called
phthisis,
which
appears
to
be
a
diagnosis
applicable
either
to

fulminating
pneumonia
or
to
late
tuberculosis.
Phthisis
was
understood,
as
such

diseases
are
now,
to
originate
in
the
inability
of
the
ulcerated
lungs
to
“sufficiently

ventilate
the
heart.”
The
resulting
increase
in
respiratory
effort
is
hampered
by
the

presence
of
fluid
in
the
lungs,
which
occurs
because
of
pooling
due
to
compromised

respiratory
effort
and
the
inadequate
pumping
of
the
underoxygenated
heart,
so

that
the
vascular
system
cannot
carry
the
accumulating
fluid
away.
Gaddesden

refers
to
the
diseased
pulmonary
fluid
as
sanies,
a
Latinate
term
for
serosanguinous

fluid
that
contains
pus.
Although
he
does
not
say
so,
it
is
likely
that
he
regarded
this

substance
as
a
putrefaction
of
phlegm.

The
labor
of
respiratory
distress
worsens
the
lesions
in
the
lungs.

From
these

logical
observations
Gaddesden
deduces
a
mechanical
explanation
for
the

44

Ibid.,
17.

49

progression
of
the
body
to
generalized
sepsis:
“sanies
is
drawn
back
and
‘fumi
aucti,

et
non
sufficienter
eventati’
go
all
over
the
body,
inflame
it,
and
so
cause
hectic”

[hectic
is
a
generalized
fever
originating
in
a
solid
organ].

45

This
is
a
strange
passage
of
pathophysiology,
morbid,
bizarre
and
compelling,

and
it
affords
a
glimpse
of
the
knowledge
at
the
core
of
medieval
healing.
The

analysis
of
the
physical
phenomenon
known
as
fumi
or
“fumes”
within
the
body

cavity
in
the
absence
of
free
air,
like
the
nature
of
the
noxious
“burning”
that
turns

humors
into
ashes
and
causes
disease,
is
absent
from
the
text.

It
is
a
literary
and

metaphorical
concept
embedded
in
scientific
literature,
a
technical
device
available

to
a
science
that
is
designed
to
negotiate
a
profoundly
metaphorical
world.

One
of
the
standard
inclusions
in
any
basic
bibliography
of
medieval
medicine

was
the
encyclopedia
written
by
Batholomaeus
Anglicus,
who
was
not
a
physician

or
scientist
but
a
Franciscan
theologian
and
scholastic
scholar.
His
highly
influential

De
proprietatibus
rerum,
completed
around
1245,
is
a
practical
manual,
more

readable
than
scholarly
scientific
texts
and
widely
disseminated
by
the
Friars
Minor,

whose
ministry
included
itinerant
healing.
The
book,
as
described
by
Faith
Wallis:

…Enjoyed
very
wide
circulation
in
the
Middle
Ages,
including
twelve

printed
editions
before
1500.
Its
nineteen
books
cover
the
Creator,

angels,
and
souls;
human
life
(humors
and
qualities
in
book
4;
anatomy

in
book
5;
life-‐cycle
and
estates
of
life
in
book
6;
medicine
in
book
7);
the

heavens
and
time;
the
created
world
(organized
around
the
four

elements);
and
some
miscellaneous
themes
such
as
the
senses,
number,

etc.

46

45

Cholmeley,
42.

46

Wallis,
248.

50

Readings
in
the
syllabus
of
medieval
medical
schools
are
often
pedantic,
as
such

literature
is
today.
Consider
this
passage
from
Avicenna’s
Canon
on
the
etiology
of

cancer
and
the
clinical
differentiation
of
malignant
tumors:

Cancer
is
an
atrabilious
[black
bile]
swelling
[tumor];
its
development
is

from
combustible
[metabolized]
atrabile
through
a
biliary
substance
or

through
a
substance
in
which
there
is
a
biliary
element
combusted
from

it,
and
not
through
turbid
drainage.
It
differs
from
scirrhus
[benign
solid

tumor
which
may
turn
malignant]
by
being
accompanied
by
pain,

acuteness
and
some
degree
of
beating
[throbbing]
and
rapid
growth

because
of
increase
of
substance
and
swelling
as
a
manifestation
of
this

substance
boiling
at
its
junction
with
the
organ.
It
differs
also
by
the

vessels
which
formed
around
it
to
the
organ
in
which
it
exists
simulating

the
legs
of
cancer
crab
and
it
is
not
red
as
cellulitis
but
“with
a
trend”
to

blackness,
heat
and
greenness….
47

The
economy
and
precision
of
this
rhetoric
and
the
formality
of
its
rhythm
are
like

those
of
sections
on
pathophysiology
and
clinical
presentation
in
modern
texts
for

medical
students—and
about
as
stylistically
enjoyable.

Similarly,
in
the
Acta
Sanctorum
of
Julii
Tomus
Primus,
the
physician
Jean
of

Tournemire
is
interviewed
on
a
case
of
breast
cancer
(the
patient
happened
to
be

his
daughter).
He
is
asked
how
he
made
the
diagnosis
of
“the
cancerous
disease
or

aposteme
called
“cancer”:

He
said
that
he
judged
from
the
way
in
which
it
became
manifest
that

this
aposteme
was
a
hidden
cancer,
on
two
points:
first,
it
started
from
a

small
induration
like
a
hazelnut;
secondly,
it
was
not
painful
unless
the

spot
was
touched.
These
are
two
conditions
that
are
proper
to
[this

disease],
they
are
not
found
in
other
apostemes
which
are
phlegmatic,

sanguine,
or
choleric,
but
are
specific
to
melancholic
apostemes,

generated
from
melancholic
matter.
Such
an
aposteme
is
called
a
“hidden

cancer”
by
doctors….a
cancer,
after
it
is
ulcerated,
is
a
completely

incurable
ailment,
especially
in
the
breast
and
in
any
place
where
it

47

John
M.
Riddle,
“Ancient
and
Medieval
Chemotherapy
for
Cancer.”
Isis
76
(1985):

319-‐330.

321.

51

cannot
be
completely
rooted
out
with
a
razor
(for
a
place
where
it
can
be

completely
rooted
out
with
a
razor,
it
is
curable.)

48

All
of
this
is
observation
from
clinical
experience,
and
congruent
with
current

knowledge.

At
the
same
time,
because
medieval
ontology
produced
a
science
that
was

fundamentally
metaphorical,
their
medical
texts
are
more
likely
than
ours
to
afford

occasional
pleasures
of
literary
creativity.

Consider
this
explanation,
from
the
Physica
of
Hildegard
of
Bingen,
of
the

formation
of
the
carbunculus,
a
potent
healing
stone
effective
against
“any
illness”

when
placed
briefly
within
the
umbilicus
or,
in
the
case
of
headache,
on
top
of
the

head:

Carbunculus
develops
during
an
eclipse
of
the
moon.
Then
the
moon
is

weary
and
wishes
to
fade,
as
sometimes
it
shows
itself
failing
when,
by

divine
order,
it
shows
that
there
will
be
famine,
plague,
or
changes
of

kingdoms.
At
that
time,
the
sun
sinks
all
its
powers
into
the
firmament.
It

places
its
tongue
into
the
other’s
mouth,
so
that
it
may
resuscitate
that

which
has
died.
It
warms
the
moon
with
its
heat,
arousing
and
sustaining

it
with
its
fire,
making
the
moon
shine
again.
Carbuncle
is
born
at
this

time.
It
has
splendor
from
the
sun’s
heat,
while
it
enlarges
the

moon….Since
an
eclipse
of
the
moon
is
rare,
this
stone
is
rare.
Its

strength
is
unusual,
and
it
should
be
feared
and
used
with
much

reverence
and
concern.

49

48

Wallis,
347.

49

Priscilla
Throop,
Hildegard
von
Bingen’s
Physica:
The
Complete
English
Translation

Of
Her
Classic
Work
on
Health
and
Healing.
(Rochester,
VT:
Healing
Arts
Press,

1998)
149.

52

Hildegard
was
not
a
physician
but
a
philosopher,
theologian
and
ecclesiastical

administrator,
who
was
scientifically
educated
and
a
respected
healer.
Her
medical

career
can
best
be
understood
as
the
product
of
a
culture
in
which
all
knowledge

was
continuous
within
a
rational
cosmos.
Divisions
between
schools
of
knowledge,

such
as
philosophy
and
physics,
were
not
firm
barriers
but
porous
membranes.
Her

erudition
in
theology
and
philosophy
and
her
gift
of
mysticism
were
not
regarded
as

interesting
addenda
to
a
technical
education,
but
as
constituent
elements
of
an

advanced
education
in
medicine
and
healing.

Her
reputation
as
a
counselor
of

princes
and
popes,
and
as
a
mystic
whose
visions
were
consulted
by
Thomas
Becket,

enhanced
her
celebrity,
as
such
associations
would
today.

Hildegard
died
almost
a
century
before
the
strongest
surge
toward
academic

professionalism
arose
from
the
burgeoning
of
bureaucracy,
bringing
the

introduction
of
formal
licensing,
exclusions
in
practice
and
the
legal
regulation
of

malpractice.
Physica,
a
work
of
pharmacology
employing
minerals,
animals
and

plants,
was
the
result
of
her
experience
in
the
abbey
infirmary
and
herb
garden.

Cause
et
Curae
was
a
study
of
human
physiology
and
pathophysiology,
including

diagnostic
techniques
such
as
the
measurement
and
examination
of
pulse
and
body

temperature,
urine,
stool,
blood,
and
the
“strength”
of
semen.

Lynn
Thorndike
describes
the
scientific
integrity
of
her
idiosyncratic
practice:

So
much
attention
to
the
Biblical
story
of
creation
and
of
Adam
and
Eve

as
is
shown
in
the
first
two
books
of
the
Cause
et
curae
might
give
one

the
impression
that
Hildegard’s
natural
science
is
highly
colored
by
and

entirely
subordinated
to
a
religious
point
of
view.
But
this
is
not
quite
the

impression
that
one
should
take
away.
A
notable
thing
about
even
her

religious
visions
is
the
essential
conformity
of
their
cosmology
and

physiology
to
the
then
prevalent
theories
of
natural
science…Science

53

serves
religion,
it
is
true,
but
religion
for
its
part
does
not
hesitate
to

accept
science.

50

Hildegard
also
held
the
view,
common
among
medieval
Christian
writers,

that
one
purpose
of
the
natural
world
about
us
is
to
illustrate
the

spiritual
world
and
life
to
come,
and
that
invisible
and
eternal
truths
may

be
manifested
in
visible
and
temporal
objects….But
neither
Hildegard

nor
medieval
Christians
in
general
thought
that
the
only
purpose
of

natural
phenomena
and
science
was
to
illustrate
a
spiritual
truth
and

point
a
moral.
But
this
always
constituted
a
good
excuse
which
sounded

well
when
one
of
the
clergy
wished
to
investigate
or
write
about
things

of
nature.

51

Hildegard’s
pharmacological
theory
derives
from
the
physical
and
spiritual

qualities
of
animals,
plants
and
minerals,
and
also
from
a
principle
of
occult

anthropomorphism
stemming
from
a
belief
in
the
animation
of
the
entire

macrocosm
with
the
spirit
of
Divine
grace.
Unlike
the
Vitalism
that
holds
living

things
distinct
from
the
inanimate
because
they
are
governed
by
a
non-‐physical

element,
this
science
recognized
the
active
participation
of
nonsentient
matter.

Unlike
many
of
her
contemporary
authorities
in
medicine—who
were
of
course

almost
uniformly
male—Hildegard
was
possessed
of
a
gentle
and
forgiving

disposition
that
informs
most
of
her
work,
and
since
the
science
of
her
day
was

more
deeply
inflected
than
ours
with
the
imaginative
and
spiritual,
this
quality
is

seminal.

The
result
is
that
her
medicinal
recipes
exhibit
an
enhancement
of
the
usual

medieval
tendency
to
ascribe
a
form
of
emotional
consciousness
to
non-‐human

50

Lynn
Thorndike,
A
History
of
Magic
and
Experimental
Science.

(New
York:
Columbia
University
Press,
1923)
vol
II
131-‐32.

51

Ibid.,
137

54

animal
or
inanimate
components.
Her
rhetorical
arts
transform
the
medieval
law
of

“kindely
inclining”—the
chemical
and
physical
attraction
of
matter
to
similar

substances—into
volitional
metaphor.
This
employment
of
“magical
realism”
in
a

work
of
hard
science
is
not
unique-‐-‐the
law
of
gravity,
for
example,
was
understood

as
the
result
of
the
kindely
inclining
of
all
things
toward
the
earth,
the
center
of
the

created
universe—although
“kindely”
here
is
still
restricted
to
the
natural
tropism

toward
substances
of
similar
nature,
and
contains
no
nuance
of
emotional
response.

But
Hildegard’s
poetic
physics
rewards
literary
analysis.
There
is
a
cheerfulness

here,
a
naïve
and
hopeful
busyness,
that
is
absent
from
similar
works
of
the
period,

and
conveys
the
comforting
wholeness
that
characterized
abstract
scientific,

theological
and
philosophical
explanations
for
the
common
medieval
person.

Here
she
prescribes
an
ocular
cure
using
the
jacinth
stone,
a
form
of
the
zircon:

Jacinth
is
born
from
fire
at
the
first
hour
of
the
day,
when
the
air
holds
a

gentle
heat.
More
airy
than
fiery,
it
senses
the
air
and
its
heat,
in

proportion
to
the
air
it
holds….A
person
who
suffers
fogginess
in
his

eyes,
or
whose
eyes
are
agitated
or
suppurative,
should
hold
a
jacinth
in

the
sun.
It
immediately
remembers
that
it
was
born
from
fire
and
quickly

heats
up.
He
should
then
dampen
it
with
his
saliva
and
quickly
place
it
on

his
eyes,
so
that
it
warms
them.
He
should
do
this
often,
and
his
eyes
will

become
clear
and
healthy.

52

Note
the
gentleness
of
the
phrasing
and
the
choice
of
words—the
troublesome

eyes
that
are
“foggy,”
like
those
of
a
sleepy
child;
the
stone
“remembering”
its
origin

in
warmth
and
bringing
comfort
to
the
afflicted
eyes,
which
become
“clear
and

healthy.”
The
entire
text
is
suffused
with
wholesomeness
and
comfort.

52

Throop,
139

55

Physica
opens
with
this
passage:
“With
Earth
was
the
human
being
created.
All

the
elements
served
mankind
and,
sensing
that
man
was
alive,
they
busied

themselves
in
aiding
his
life
in
every
way.
And
man
in
turn
occupied
himself
with

them.”

53

Consider
the
contrast
with
the
relationship
to
minerals
of
the

contemporary
person,
as
described
by
Albert
Camus:

perceiving
that
the
world
is
“dense,”
sensing
to
what
a
degree
a
stone
is

foreign
and
irreducible
to
us,
with
what
intensity
nature
or
a
landscape

can
negate
us.
At
the
heart
of
all
beauty
is
something
inhuman….The

primitive
hostility
of
the
world
rises
up
to
face
us
across
millennia.

54

Nor
is
this
merely
a
stylistic
matter.
Metaphysical
physics
was
a
major
asset
in

Hildegard’s
famous
ability
to
heal.
Medieval
medicine
usually
did
not
cure.
But
that

does
not
mean
that
it
did
not
heal.

It
is
not
audacious
to
argue
for
coherence
between
Hildegard’s
scientific
writings

and
contemporary
methodological
discourse.
The
poetry—and
the
poetic
license—
that
inform
the
structure
of
Hildegard’s
medical
texts
is
Foucaultian.

Even
truly
technical
works
of
the
medieval
medical
genre
often
seem
quaint
to

modern
scientific
readers,
because
they
sound
poetic.
Consider
this
discourse
on

one
of
the
five
varieties
of
the
humor
phlegm,
from
the
Isagoge:

There
is
glassy
phlegm,
which
arises
from
great
coldness
and
coagulation

such
as
occurs
in
old
people
who
are
destitute
of
natural
warmth.
And

there
is
another
which
is
cold
and
moist;
it
has
no
odour,
but
retains
its

own
coldness
and
moistness.

55

53

Ibid,
9

54

Albert
Camus,
The
Myth
of
Sisyphus
and
Other
Essays.
Justin
O’Brien,
trans.

(NewYork:
Vintage
Books,
1955)

55

Cholmeley,
138

56

Perhaps
the
slender
and
brittle
bodies
of
the
elderly
invited
the
comparison
with

glass.

Philosophical
Structure

Galenic
medicine
is
divided
between
the
“theoretical,”
which
corresponds
to
our

concepts
of
anatomy
and
physiology,
and
the
“practical,”
which
we
now
call
the

“clinical.”

I
will
define
“practice”
in
both
medical
models
as
congruent
with
the

contemporary
definition
of
goal-‐based
treatment
situated
in
the
individual

encounter
with
the
patient
and
focused
on
his
or
her
manifestation
of
illness
and
on

the
expectations
for
outcome.

Medieval
practice
may
have
differed
more
from
its
counterpart
in
modern

medicine
than
medieval
physiological
theory
does.
This
difference
can
be
explained

using
a
model
created
by
medical
historian
Owsei
Temkin,
who
identifies
two
views

of
disease:
the
“ontological”
and
the
“physiological.”

As
I
understand
Temkin’s
use
of
the
word,
“ontological”
is
an
assertion
of
the

integrity
of
disease
as
a
virtual
life
form:
a
dynamic
product
of
independent
organic

forces.
The
ontological
position
regards
a
disease
as
a
natural
process
with
a

predictable
course,
independent
of
its
manifestation
in
any
particular
patient,
and

possessing
a
name
and
an
identity
of
its
own.
This
idea
of
disease
specificity

originated
with
the
seventeenth
century
English
physician
Thomas
Sydenham,

considered
the
father
of
nosology,
the
science
of
disease
classification,
who

57

proposed
that
diseases
be
studied
as
botanists
study
plants.

56

The
oncologist
who

defines
your
disease
as
a
Stage
Three
prostate
cancer,
which
has
a
high
Gleason

score
and
is
expected
to
evolve
into
Stage
Four
over
six
months,
is
employing
the

ontological
view.

The
physiological
view
encounters
each
illness
as
a
unique
event,
comprised
of

the
many
variables
of
the
physiology,
passions,
and
physical
and
social

environments
of
the
patient.
The
physiological
stance
is
the
basis
of
various
folk
or

practical
medical
systems
that
have
remained
entrenched
in
many
contemporary

cultures,
because
they
are
perceived
as
effective
in
managing
the
personal
and
social

ramifications
of
disease.
These
are
successful
models,
although
they
are
not

scientific
models.

The
ontological
position
dovetails
with
modern
Western
medicine,
whereas

medieval
medicine
is
based
on
the
physiological
view.
However,
for
a
medical

science
that
is
conceived
as
the
exploration
of
a
logical
Eternal
Plan,
the
ontological

and
physiological
views
are
inextricable,
as
are
body
and
soul.
Individual
disease
is
a

living
metaphor
for
the
condition
of
the
individual
within
the
macrocosm:
an
idea

not
unlike
the
Marxist
interpretation
of
anthropologist
Michael
Taussig,
presented

in
the
first
chapter
of
this
dissertation.
Modern
medicine
is
metaphorical
only
in
a

limited
sense,
in
that
it
is
a
metaphor
for
a
secular
truth.
That
truth
can
be
stated

this
way:

“As
long
as
death
can
be
delayed,
it
can
be
denied.”

56

Temkin,
427

58

Because
it
is
unstructured,
the
physiological
view
offers
a
larger
space
for
the

nurturing
of
personal
hopefulness.
It
is
simultaneously
irreconcilable
with
modern

biomedicine,
and
congruent
with
existential
experience.
Biomedicine
has
been

irrevocably
informed
by
the
germ
theory
of
disease:
the
concept
of
a
pathological

process
caused
by
a
life
form
with
an
inherent
agenda
of
its
own.
Perhaps
Hildegard

of
Bingen
anticipated
this
sort
of
“kindely
inclining.”

Neither
model
is
pure.
Recognition
of
the
ontological
has
always
been
a
factor
in

Western
medicine.
Sydenham
practiced
during
the
great
plague
of
London
and,
as

Temkin
remarks:
“the
plague,
I
understand,
has
little
concern
with
individual

variations.”

57

But
Temkin
also
points
out
that
Plato
had
used
the
animal
metaphor

for
disease,
and
that,
in
the
second
century
BC,
Varro
“had
actually
spoken
of

animals,
too
small
to
be
seen
by
the
eye,
‘which
by
mouth
and
nose
through
the
air

enter
the
body
and
cause
severe
diseases.’
”

58

Ancient
microbiology
gives
new

meaning
to
the
concept
of
historical
anticipation.

Scientific
Discipline

For
a
sense
of
the
technical
rigors
of
early
modern
academic
medical
texts,

consider
another
passage
from
the
Isagoge.
It
is
part
of
a
discourse
on
the
function

of
the
“fundamentals,”
the
most
essential
of
the
“members”
of
the
body:
the
brain,

heart,
liver,
and
testicles.
These
particular
members,
which
are
considered
the

“master
organs,”
have
their
“proper
energy
whence
the
members
are
ruled
and
in

57

Charles
E.
Rosenberg,
“What
is
Disease?:
In
Memory
of
Owsei
Temkin.”
Bulletin
of

The
History
of
Medicine
77(2003):
491-‐505.
493

58

Temkin
426-‐27

59

which
their
particular
properties
consist”:

59

a
concept
that
might
be
essentially
the

same
as
modern
cytology,
or
basic
structure
and
function
of
cell
specialization.

The
energies
are
conceived
as
influencing
the
functions
of
the
lesser
organs:

Other
[organs]
there
are
which
work
by
the
energy
proper
to
them,
but

yet
they
obtain
their
origin
and
vigour
from
the
principals
and

fundamentals.
Such
are
the
stomach,
the
kidneys,
the
intestines,
and
the

muscles
(lacerti).
For
these
by
their
own
proper
energy
pick
up
the
food

and
commute
it,
and
they
do
their
actions
according
to
their
nature,
and

they
have
other
energies
of
their
own
arising
from
the
principals
and

fundamentals,
in
which
principals
consist
sense
and
life
with
voluntary

motion….But
the
energy
which
does
service
and
is
not
done
service
to,
in

the
same
way
desires,
retains,
and
digests,
and
it
expels
those
matters

which
are
subject
to
the
feeding
energy,
just
as
the
feeding
energy
is

subject
to
the
nourishing
energy.

60

A
modern
reader
of
scientific
literature
might
acknowledge
this
to
be
a
plausible

explication,
given
the
biophysical
knowledge
of
the
time.
Obviously
the
necessity
of

the
functions
of
the
brain,
heart
and
liver,
and
the
dependent
status
of
the
“lesser

organs,”
is
still
recognized.

It
is
a
general
exposition,
slightly
anthropomorphic
in

style,
in
that
the
organs
are
in
a
sense
personified.
In
narrative
form
and
level
of

complexity,
it
is
an
explanation
that
might
be
composed
for
a
student.

The
most
significant
difference
from
contemporary
medical
discourse
is
not
in

structure,
but
in
a
certain
type
of
content
that
is
elided:
there
is
no
attempt
to

explain
the
physiological
process
by
which
the
essential
energies
of
the

fundamentals
arise.
Also
unexplained
are
the
mechanisms,
whether
mechanical,

chemical
or
biological,
by
which
the
fundamentals
act
upon
the
lesser
organs
to

achieve
the
results
that
are
essential
to
life—nor
is
the
necessity
of
an
explanation

59

Cholmeley
139

60

Ibid.,
139-‐140

60

acknowledged.
In
medical
literature
today,
such
an
omission
would
form
a

significant
lacuna:
the
existence
of
this
mechanism,
even
if
unknown,
would
be

implicit.
The
deferral
of
discussion
would
require
explanation,
at
least
by
noting
that

the
phenomenon
remained
“poorly
understood.”
It
would
be
a
missing
connection,

much
the
way
certain
blocks
in
the
periodic
table
remained
empty
into
the
nineteen

sixties,
when
the
unknown
elements
were
eventually
uncovered.

To
Johannitus
and
his
successors
over
a
millennium
the
question
was
not
one
of

how
this
problem
should
be
approached-‐-‐or
even
whether
it
was
appropriate
to
ask.

In
fact
it
was
not
even
a
problem.
It
was
not
a
matter
of
physics
but
of
“special

metaphysics”:
learned
men
could
not
fully
explicate
it,
and
were
not
required
to
try.

I
see
the
rhetorical
stance
of
medieval
authors
as
similar
to
that
of
contemporary

proponents
of
Intelligent
Design
theory,
who
dispute
evolution
on
the
grounds
that

aspects
of
creation
are
“irreducibly
complex.”
From
classical
times
until
the
belief
in

occult
physiological
energies
waned
in
Western
medicine
in
the
seventeenth

century,
few
authors
seem
to
have
interrogated
the
nature
of
these
powers
in
an

ultimate
way.

During
the
Enlightenment
the
term
“science”
was
bestowed
upon
the
branch
of

knowledge
that
had
previously
been
known
as
“natural
philosophy.”

The
word
had

first
appeared
in
twelfth
century
French
to
denote
“knowledge
as
granted
by
God”

and
was
used
in
English
to
denote
“the
state
or
fact
of
knowing;
knowledge
or

cognizance
of
something”;
and
“knowledge
as
a
personal
attribute.”
(OED)
The

narrower
modern
meaning
was
deployed
with
the
intent
to
carve
the
discipline
out

of
the
corpus
of
philosophy.

61

Technical
Case
Studies
and
Meta-Factuality

A
medical
science
in
which
standard
texts
include
case
histories
of
cures
that

could
not
have
taken
place,
or
could
not
have
resulted
from
the
medical
regimen

described,
is
absurd.
If
we
read
this
phenomenon
in
the
only
way
we
can
now

approach
medicine,
which
is
by
means
of
the
scientific
method,
we
must
suspect

that
such
documentation
might
be
fraudulent.
But
conscious
obfuscation—which

did
exist—is
a
peripheral
explanation
for
the
predominance
of
bizarre
reportage
in

medieval
medical
literature.
Most
of
these
assertions
were
not
concocted
for
the

consumption
of
the
credulous
consumer,
but
incorporated
into
scholarly
texts
and

portable
handbooks
for
the
healers
themselves.

The
restoration
of
health
and
function
in
the
wake
of
an
uncertain
prognosis

would
naturally
be
attributed
to
the
interventions
of
the
physician,
although
the

treatment
might
seem
bizarre
to
us
now.
Thus
John
of
Gaddesden,
an
early

fourteenth
century
Oxford
trained
physician
and
theologian
and
the
author
of
a

standard
text
called
the
Rosa
medicina,
who
is
cited
as
a
medical
authority
in
the

Canterbury
Tales,
offered
this
treatment
of
smallpox:

[T]ake
red
scarlet
or
another
type
of
red
fabric,
and
wrap
the
patient
up

in
it,
as
I
did
with
the
son
of
the
most
noble
King
of
England
when
he
was

sick
with
the
disease,
and
I
made
everything
that
was
around
his
bed
to

be
red;
and
this
is
a
good
cure.
In
consequence,
I
cured
him
without
any

vestiges
of
the
smallpox.
However,
one
should
take
care
not
to
anoint
the

region
of
the
smallpox
after
[the
pustules]
emerge,
because
this
will

block
the
pores.

61

61

Wallis,
274

62

The
potency
of
the
color
red
is
understood
to
originate
in
the
classical
Greek

concept
of
“special
properties,”
which
inhere
in
certain
natural
substances
but
are

hidden
and
inaccessible
to
human
reason,
and
can
be
known
only
from
empirical

evidence.
The
attraction
of
a
magnet
for
iron
is
the
classic
example.
Such

phenomena
represent
a
discrete
class
of
knowledge.
These
are
also
functions
of

special
metaphysics,
and
may
be
understood
in
terms
of
their
effects
but
can
be

investigated
no
further.
This
is
why
dual
professional
“certification”
in
medicine
and

theology
enhanced
Gaddeson’s
status
as
a
physician,
much
as
the
MD-‐PhD
in

medicine
and
biophysics
or
neuroscience
does
today.

That
much
of
this
knowledge
is
thoroughly
anecdotal
results
in
a
narrative

process
that
ultimately
bears
what
looks
to
us
like
strange
clinical
fruit.
An
early

fifteenth
century
German
medical
student
produced
a
casebook
from
his

apprenticeship
at
the
bedside
rounds
of
two
renowned
Paris
physicians,
Gillaume

Boucher
and
Pierre
d’Ausson.
He
recounts
the
protracted
treatment
of
a
paralytic

stroke
with
a
regimen
of
enemas
and
pills
designed
to
draw
down
morbid
matter

from
the
cerebral
region,
and
pharmaceuticals
made
of
gold
and
opium
applied

topically
to
the
tongue
to
treat
aphasia
and
dysarthria,
The
patient
was
deprived
of

sleep,
to
prevent
the
accumulation
of
phlegm
in
the
cerebral
ventricles,
and
herbal

unguents
were
applied
to
his
shaven
head.
After
eighteen
days
of
near
hopelessness,

during
which
Boucher
evidently
abandoned
the
case,
d’Ausson
achieved
a
cure.
The

patient
spoke
perfectly
and
regained
some
use
of
his
paralyzed
side,
ambulating

about
his
room.

63

The
herbal
ingredients
employed
in
this
lengthy
treatment
were
exhaustive,
and

included
yellow
iris,
Spanish
pellitory,
white
hellebore,
colocynth,
agaric,
marsh

mallow,
clamint,
marjoram,
betony,
and
Arabian
lavender.
Eventually
the
physician

became
nervous,
fearing
“lay
folk
defaming
the
doctor
after
a
patient
dies,
saying,

‘Look
at
those
doctors!
They
administered
so
many
remedies
that
they
killed

him!’
”
62

However,
while
d’Ausson
clearly
realized
that
his
ministrations
might
fail,
there
is

no
evidence
that
he
did
not
really
believe
that
they
were
the
state
of
the
art,
and

constituted
the
patient’s
best
hope
of
recovery.

We
must
also
consider
the
nature
of
the
medieval
system
of
professional

communication,
which
was
episodic
and
attenuated
over
geographical
and
temporal

space,
especially
before
the
high
Middle
Ages.
This
meant
that
medical
idiosyncrasy,

as
well
as
simple
unfounded
rumor,
could
be
transmuted
by
luck
or
chance
into

centuries
of
received
wisdom.

Without
the
governance
of
the
scientific
method
and
subjection
to
peer
review,

there
was
no
understanding
of
circumscribed
scientific
facts
existing
independently

of
the
marvelous
and
impenetrable
imaginative,
which
facts
could
therefore
be

reproduced
by
any
competent
practitioner,
regardless
of
his
or
her
personal
virtue.

The
fragility
of
this
system
was
particularly
receptive
to
the
medieval
predilection

for
the
“scientific
marvelous,”
a
supernatural
interpretation
of
physical
science
in

which
I
include
medical
spirit
theory.
The
marvelous
was
defined
in
the
twelfth

62

Wallis,
397-‐99

64

century
by
Gervase
of
Tilbury
as
“that
which
surpasses
our
understanding
even

though
it
be
natural.”

63

Jacques
Le
Goff
describes
the
“marvelous”
as
“a
natural
form
of
the
supernatural

(that
is,
the
miraculous,
which
depends
solely
on
God’s
saving
grace)
and
the

diabolical
supernatural
(or
magic,
governed
by
Satan’s
destructive
activity.)”

64

He

defines
it
as
the
element
in
the
medieval
imagination
that
“stands
at
the
crossroads

where
religion,
literature
and
art,
philosophy,
and
sensibility
meet.”

65

It
was
enormously
successful
in
satisfying
the
human
predilection
for
wishful

thinking.

“Use
the
Word
‘Obstruction’
”:
Ethics
and
Professional
Demeanor

Inextricable
from
the
matter
of
credibility
in
clinical
documentation
is
an

understanding
that
the
early
modern
practitioner
kept
in
the
forefront
of
his
or
her

consciousness.
This
is
the
knowledge
that
individual
outcomes
that
were
not

hopelessly
dire
were
almost
always
completely
unpredictable.
Some
medical

thinkers,
such
as
Henri
de
Mondeville,
did
venture
to
suggest
that
all
disease

phenomena
were
potentially
understandable
empirically.
This
was
a
highly
unusual

assertion,
and
possibly
rogue.

The
problem
was
a
function
of
the
peculiar
medieval
juxtaposition
of
ideological

certainty
married
to
an
awareness
of
practical
powerlessness.
The
intellectual

rebound
resulted
in
organized
efforts
by
the
medical
profession
to
protect
itself
by

63

Jacques
Le
Goff,
12

64

Ibid

65

Ibid,
11

65

presenting
the
best
image
possible,
and
to
finesse
its
degree
of
mastery
over
the

clinical
course
of
disease.
This
was
not
so
much
a
matter
of
disingenuousness
as
an

honest
effort
to
make
sense
of
the
practitioner’s
personal
and
professional
situation.

It
was
obviously
an
ethically
slippery
slope.
Perhaps
this
is
the
historical
origin
of

the
infamous
reluctance
of
the
medical
profession
to
police
itself.

The
late
thirteenth
century
physician
Arnald
of
Villanova
advised
his
peers
on
the

general
management
of
the
clinical
encounter.
This
was
usually
initiated
with
the

examination
of
the
patient’s
urine,
sometimes
days
or
weeks
before
the

presentation
of
the
patient
himself.
Because
the
consumer
was
also
conscious
of
the

empirical
shortcomings
of
medieval
biomedicine
(even
though
he
or
she
did
not
see

the
situation
in
relative
terms,
because,
Henri
de
Mondeville
notwithstanding,
there

existed
no
viable
idea
that
it
might
be
otherwise)
there
was
invariably
a
possibility

that
the
urine
might
belong
to
an
animal,
or
might
not
be
urine
at
all—white
wine,

perhaps,
or
stewed
thistles—and
that
the
doctor
might
be
tricked
into
a
revelation

of
incompetence.

Arnald
suggests
that
the
doctor
should
stare
hard
at
the
messenger.
If
this
person

blushes
or
appears
uncomfortable,
the
doctor
should
accuse
him
or
her
of
trickery.

He
should
then
pour
some
of
the
liquid
on
his
finger
and
pretend
to
blow
his
nose,
in

order
to
smell
it.

If
the
substance
is
deemed
to
be
human
urine
and
nothing
else
is
known
about

the
patient,
the
doctor
is
advised
to
declare
that
there
is
an
obstruction
in
the
liver.

66

If
the
messenger
objects
that
the
pains
are
in
other
extremities,
the
doctor
must

insist
that
these
radiate
from
the
liver:
“and
particularly
use
the
word
obstruction,

because
they
do
not
understand
what
it
means,
and
it
helps
greatly
that
a
term
is
not

understood
by
the
people.”

66

But
even
this
should
not
be
interpreted
to
mean
that
crass
fakery
was
an
open

secret
among
the
professional
class.
The
prognostic
ability
of
a
competent

investigator
at
a
urine
flask
was
firmly
believed
for
centuries.

The
literature
on
the
diagnostics
of
uroscopy
was
vast
and
complex.
Here
is
one

example,
from
the
popular
twelfth
century
scholastic
text
of
Gilles
of
Corbeil:

A
very
limited
quantity
of
urine,
passed
with
difficulty,
livid
and
oily,

foreshadows
death;
livid,
passed
frequently
but
in
scanty
quantity,
points

to
strangury;
*

lividity
coupled
with
minute,
distinct
particles
consistently

indicates
respiratory
trouble;
a
grainy
lividity
foretells
affliction
of
the

joints
and
rheumatism.
If
the
womb
presses
upon
the
spine
or

diaphragm,
it
gives
the
surface
of
the
urine
a
livid
tinge.

Thin
urine,
white
in
color,
is
a
sign
of
spleen,
dropsy,
intoxication,

nephritis,
delirium,
diabetes,
rheumatism,
black
bile,
epilepsy,
dizziness,

chill
of
the
liver,
or
(with
a
bilious
fever)
death;
in
the
old
it
is
a
sign
of

debility
or
childishness.

67

Some
of
this
prognostication
is
reasonably
accurate.
Scanty,
thick
and
dark

colored
urine
does
in
fact
predict
death
by
renal
failure,
and
tiny
crystals
in
urine

indicate
gout,
or
“rheumatism.”
Dilute
urine,
which
appears
“thin”
and
light
in
color,

may
be
a
sign
of
dehydration,
heart
failure,
or
the
overproduction
of
urine
due
to

diabetes
insipidus,
a
condition
caused
by
excessive
endocrine
production
of

anitdiuretic
hormone.
It
may
indicate
dangerously
low
sodium
levels,
which
can

66

Michael
R.
McVaugh,
“Bedside
Manner
in
the
Middle
Ages,”
Bulletin
of
the
History

of
Medicine
71.2
(1997)
201-‐223.

201

*

Difficult
urination

67

Wallis,
257

67

cause
nausea,
confusion,
restlessness
and
irritability,
muscle
spasms,
seizures
and

coma.

A
monastic
chronicler
of
the
early
tenth
century
records
an
attempt
to
trick
a

famous
physician,
a
monk
named
Notker
at
the
monastery
of
Saint
Gall.
A
messenger

was
dispatched
with
a
request
that
Notker
examine
the
urine
of
the
ailing
Duke
of

Bavaria.
The
specimen
was
in
reality
the
urine
of
a
pregnant
servant
girl.
Notker

praised
God:
“The
Lord
is
going
to
perform
an
unheard
of
miracle.
A
man
is
going
to

have
a
baby!
In
about
thirty
days
the
Duke
will
give
birth
to
a
child
and
will
nurse

him.”
When
the
servant
girl
was
delivered,
the
messengers
returned
to
Saint
Gall

with
the
duke’s
own
urine.

68

So
a
uniform
public
stance
that
was
cautiously
defensive
does
not
seem
to
have

been
indicative
of
a
widespread
conspiracy
but
a
cumulative
response
to
the
deeply

private
misgivings
of
each
practitioner,
however
learned,
who
wondered
whether

he
had
sufficiently
mastered
the
necessary
analytical
and
prognostic
acumen.
Since

these
skills,
for
the
most
part,
did
not
exist,
no
doctor,
however
revered,
could
be

consistently
confident
of
possessing
them.

Further
along
in
the
clinical
relationship,
a
twelfth
century
physician
gives
his

colleagues
this
advice
on
snatching
professional
success
from
the
jaws
of
failure:

Find
out
as
much
as
possible
in
advance
about
the
patient’s
symptoms,

so
that
even
if
you
can’t
tell
from
pulse
and
urine
exactly
what
is
wrong

with
him,
he
will
still
believe
in
your
powers
when,
without
any

prompting,
you
tell
him
how
he
is
feeling.
You
should
promise
him

68

Ekkehard,
Casus
Sancti
Galli,
ch
10
(MGS
II).
In
Plinio
Prioreschi,
A
History
of

Medicine
Vol
V:
Medieval
Medicine
(Omaha
NB:
Horatius
Press)
2003,
583

68

health,
with
the
Lord’s
help,
but
whatever
his
condition,
tell
his
friends

privately
that
he
is
very
grave,
so
that
if
he
recovers
your
reputation
will

be
the
greater
and
if
he
dies
they
will
be
able
to
bear
witness
that
you

had
despaired
of
him
from
the
first.

69

While
there
is
no
point
apologizing
for
the
duplicity
involved
here,
this
is
not
as

transparent
as
such
a
ruse
would
be
today.
The
translations
that
comprised
the

textual
corpus
of
the
New
Galenism
of
the
early
thirteenth
century,
which
fueled
an

explosive
professionalism
as
medicine
aspired
to
the
formal
academic
status
of
law

and
theology,
emphasized
that
patient
confidence
in
the
medical
provider
was

important,
and
sometimes
essential,
to
good
outcome.
Galen’s
commentary
on
the

Prognostics
of
Hippocrates
states:
“The
trust
of
patients
in
committing
themselves

[to
a
physician]
is
essential,
and
he
to
whom
patients
trust
themselves
cures
the

most
illnesses.”

70

Belief
cures.
The
power
of
the
placebo
is
an
ancient
knowledge,
and
was
not

always
regarded
with
the
cynicism
it
carries
now.
The
tenth
century
Syrian
Melkite

Christian
Qusta
Ibn
Luqa,
whose
dozens
of
translations
of
Greek
medicine
into

Arabic
became
part
of
the
corpus
of
the
New
Galenist
academics
in
thirteenth

century
Europe,
based
his
medical
text
Physical
Ligatures
on
the
therapeutic

manipulation
of
the
powerful
connection
between
body
and
mind.
The
mind
is

capable
of
correcting
the
physical
imbalances
that
cause
bodily
illness,
and
the

wearing
of
physical
ligatures—such
as
a
wild
goat’s
eye
bound
with
sweet
marjoram

moistened
by
the
urine
of
a
red
bull
voided
in
the
evening—will
cure
certain

physical
ailments
provided
that
the
wearer
sincerely
believes
in
them.

69

McVaugh,
204

70

Ibid.,
210

69

Jacme
d’Agramont,
in
his
vernacular
plague
treatise,
noted
that
“the
imagination

alone
causes
some
diseases.”
He
gave
the
example
of
the
man
who
easily
balances

while
walking
across
a
wooden
beam
on
the
floor,
but
cannot
negotiate
this
feat

when
the
same
beam
is
suspended
above
the
ground.
Other
physicians
argued
that

some
people
die
as
a
result
of
believing
that
death
is
imminent.
Fourteenth
century

Spanish
physician
Alfonso
Chirino
in
his
Replicacion
Espejo
de
medicina
fol.
42v

argues
that
the
patient’s
“good
imagination”
is
essential
to
cure
and
solely

responsible
for
many
of
them.
Confidence
in
the
physician
was
his
best
therapeutic

tool,
and
deontologists
taught
that
lying
to
preserve
this
trust
was
a
useful
clinical

technique.

71

This
venerable
ancient
“clapping
for
Tinkerbell”
was
a
medical
principle,
and
not

in
the
sense
of
amelioration
and
cheering
up
that
we
believe
in
such
things
today—it

was
derived
from
the
scientific
model
of
continuity
between
soul
and
physical
body,

and
the
continuity
of
this
personal,
temporal
union
with
the
timeless
cosmos.
The

model
was
made
concrete
and
scientific
by
the
medical
spirits.

Magic,
Ritual
and
Textuality

We
now
know
how
to
cure
the
Black
Death.
To
do
this
we
must
perform
a
special

ceremony.

Physicians
write
orders
on
special
papers
or
on
computer
software,
using
ritual

language
and
symbols.
Nurses
wearing
paper
clothing
of
certain
colors,
usually
baby

71

Michael
Solomon,
Fictions
of
Well
Being:
Sickly
Readers
and
Vernacular
Medical

Writing
in
Late
Medieval
and
Early
Modern
Spain
(Philadelphia:
University
of

Pennsylvania
Press,
2010)
6-‐7.

70

blue
or
light
yellow,
open
the
patient’s
vein,
much
as
medieval
practitioners
did.

Instead
of
draining
quantities
of
blood
they
insert
small
plastic
tubes
into
the
cut,

and
connect
plastic
sacks
of
gentamicin,
ciprofloxin
and
chloramphenicol
to
the

tubes,
sequentially.
Thus
begins
an
elaborate
ritual,
in
which
the
clear
or
yellowish

fluid
drips
slowly
into
the
blood,
dictated
by
the
calculation
of
drop
factors

calibrated
to
avoid
toxic
reactions.

The
textual
product
of
this
extended
curative
process
is
a
corpus
of
explicitly

prescribed
documentation.
Although
it
must
be
prepared
by
designated
individuals,

and
by
them
only,
it
is
important
that
they
adhere
to
a
strict
avoidance
of
personal

creativity.
Fidelity
to
stipulated
standards,
including
exhaustive
thoroughness
in
the

documentation
of
everything
that
happened,
and
of
particular
events
that
did
not

happen,
equals
excellence
for
this
text.
Regardless
of
outcome,
this
narrative
is

preserved
in
the
patient’s
record
for
many
years,
and
may
be
retrieved
and

evaluated
for
its
technical
and
rhetorical
qualities
by
medical
and
legal
experts

much
later.
This
patient
record
is
called
a
“history.”

If
the
patient
has
bubonic
plague,
he
or
she
will
almost
certainly
be
cured.
If
the

diagnosis
is
pneumonic
plague,
an
extremely
aggressive
disease,
the
chances
of

recovery
are
greater
than
fifty
percent.

So
more
than
half
the
time
this
ritual,
repeated
in
a
ceremonial
series
over
a

period
of
days
or
weeks,
yields
what
contemporary
medicine
unabashedly

champions
as
the
ultimate
victory:
the
patient
does
not
die.
This
is
the
only

medicine
that
our
culture
could
have
produced,
and
this
narrative
style
is
the
only

way
this
ritual
could
have
been
communicated.

71

We
no
longer
listen
for
the
music
of
the
spheres—and
we
distrust
poetry
in
basic

science.
The
patient’s
individual
recovery
is
also
our
communal
redemption.
Our

medical
literature
is
a
product
of
this.

72

CHAPTER
FOUR

Medieval
Neuropsychiatry:

Etiologies
of
Mental
Illness
in
Western
Medicine

Melancholy
is
either
natural,
or
secretious
and
unnatural….Of
secretious

melancholy,
one
sort
originates
from
the
bile
when
burnt
to

ashes…another
originates
from
the
phlegm
when
burnt
to

ashes…another
is
generated
from
the
blood
when
burnt
to
ashes…a

fourth
finally
comes
from
natural
melancholy
when
this
has
become

ashes.

Avicenna,
Canon
of
medicine

72

The
word
“frenzy”
is
derived
from
frenes,
the
membranes
that
surround

the
brain.
It
comes
about
in
two
ways.
[First],
from
red
bile
which
is

made
light
by
its
innate
heat
and
by
the
heat
of
a
fever,
and
then
stirred

into
a
rage
and
carried
upward
by
the
veins,
nerves,
and
arteries;
this
is

collected
into
an
aposteme
*
,
and
causes
true
frenzy.
Alternately,
it
is

caused
by
fumes
ascending
from
the
body
to
the
brain,
and
perturbing
it,

and
this
is
“parafrenzy,”
that
is,
not
true
frenzy.

Bartholomaei
Anglici
De
genuinis
rerun
coelestium,

terrestrium
et
infernarum
proprietatiubus

c1272

73

________________________________

72

Raymond
Klibansky,
Erwin
Panofsky,
and
Fritz
Saxl.
Saturn
and
Melancholy:

Studies
in
the
History
of
Natural
Philosophy,
Religion
and
Art
(New
York:
Basic

Books,
1964)
88

*

Aposteme
is
a
purulent
swelling,
including
those
we
now
understand
to
be

localized
infections
or
neoplastic
growths.

73

Wallis
24

73

Generally
speaking,
we
now
know
that
decreased
neurotransmission
and

connectivity
is
the
neurobiological
basis
of
schizophrenia….In
the
brain,

normal
synaptic
organization
implies
the
provision
for
normal

communication
among
brain
cells….Hyperdopaminergic
states
have

primarily
been
associated
with
positive
symptoms
of
schizophrenia,
such

as
hallucinations,
delusions,
and
psychosis.
Hypodopaminergic
states

have
primarily
been
associated
with
negative
symptoms
of

schizophrenia,
such
as
cognitive
difficulties,
lack
of
energy
and

motivation,
and
depression.

Ann
Futterman
Collier

74

If
we
read
the
ancient
neuroscience
as
metaphorical—perhaps
as
poetry—it

becomes
apparent
that
these
three
passages
are
describing
the
same
phenomena.

Medical
spirit
theory
has
no
equivalent
in
modern
psychiatry,
but
many
pivotal

concepts
of
early
theory
survive,
or
have
recognizable
descendants
in
modern

theory.
There
is
much
in
the
ancient
texts
that
shows
what
has
been
gained,
and

what
sacrificed.
That
which
follows
is
a
comparative
analysis
of
explanatory
models,

and
an
argument
that
the
dissimilarities
are
less
significant
than
they
appear.
We

probably
know
more
about
the
biochemical
determinants
of
mental
illnesses,

especially
the
more
severe
ones.
They
knew
as
much
as
we,
and
possibly
more,

about
how
to
address
these
successfully
in
the
lives
of
patients.

Modern
scientific
literature
understands
hormones,
enzymes
and

neurotransmitters,
transported
by
blood,
lymph
and
nerves,
as
performing
the

ancient
humoral
functions
and
producing
the
necessary
results.
The
specific
actions

of
each
of
these,
and
the
roles
played
by
ineffable
forces,
whether
conceived
as

74

Ann
Futterman
Collier,
“Neurobiology
of
Psychotic
Illness.”
In
Lee-‐Ellen
C.

Copstead
and
Jacquelyn
L.
Banasik,
eds.
Pathophysiology.
(St
Louis:
Esevier

Saunders,
2013)
974-‐995.
975-‐76

74

spiritual/psychological,
environmental,
or
even
Divine/metaphysical,
are
debated

now
as
they
were
then.
The
experts
of
both
cultures
exhibit
more
hubris
than
is

warranted
by
the
depth
of
their
understanding.

I
examine
the
question
of
the
history
of
psychopathology
at
a
moment
in
which

Western
psychiatry
is
drawn
back
toward
the
assumption
of
mind-‐body
continuity,

a
foundation
of
early
modern
thought
that
was
yet
to
be
derailed
by
Descartes.
In
a

move
that
signaled
a
significant
paradigm
shift,
the
Fourth
Edition
of
the
Diagnostic

and
Statistical
Manual
of
Mental
Disorders
of
the
American
Psychiatric
Association,

published
in
1995
and
recently
replaced
by
a
Fifth
Edition,
officially
retired
the
term

“organic.”
The
guidebook
to
the
DSM-‐IV
explains
that
this
decision
is
the
result
of

rapidly
accumulating
evidence
of
biological
determinants
of
diagnoses
previously

thought
of
as
“nonorganic,”
and
actually
concludes
that
all
of
the
DSM-‐IV
disorders

are
organic,
although
“all
are
also
related
to
psychological
factors
and
to
the

environmental
context.”

75

Psychiatry—or
at
least
an
influential
segment
of
it,
including
the
elite
group
that

produces
this
international
diagnostic
bible—appears
to
be
returning
to
a
medical

model
of
insanity
that
is
contained
within
biology.
Five
hundred
years
after

Decartes,
we
find
ourselves
wondering
whether
the
spiritual
might
be
all
biological,

after
all.
In
doing
so
we
are
re-‐approaching
the
medieval
model:
but
only
in
a

75

Allen
Frances,
Michael
B.
First
and
Harold
Alan
Pincus,
The
Essential
Companion

to
the
Diagnostic
and
Statistical
Manual
of
Mental
Disorders,
Fourth
Edition.

(Washington,
DC:
American
Psychiatric
Press,
2005)
87

75

general
way.
More
accurately,
we
are
turning
their
model
inside
out.
They

understood
that
the
biological
was
all
spiritual.

It
is
a
conceptual
gulf
we
cannot
bridge,
employing
our
science
on
its
own
terms,

which
is
the
only
way
we
can
employ
it.
This
is
inevitably
tragic.
Anger
at

biomedicine
for
failing
to
deliver
a
satisfactory
model
of
healing
lies
at
the
center
of

countless
political
battles
throughout
the
Western
world.
The
frustrated
urge
to

circumvent
conventional
medicine
fuels
an
increasingly
influential
alternative

health
movement.

The
question
is
not
what
practical
measures
we
can
employ
to
solve
this
problem.

It
is
whether
we
can
aspire
to
address
the
issue
at
all.

Philosopher
William
Barrett
writes:

Religion
to
medieval
man
was
not
so
much
a
theological
system
as
a
solid

psychological
matrix
surrounding
the
individual’s
life
from
birth
to

death,
sanctifying
and
enclosing
all
its
ordinary
and
extraordinary

occasions
in
sacrament
and
ritual.
The
loss
of
the
Church
was
the
loss
of

a
whole
system
of
symbols,
images,
dogmas,
and
rites
which
had
the

psychological
validity
of
immediate
experience,
and
within
which

hitherto
the
whole
psychic
life
of
Western
man
had
been
safely

contained.
In
losing
religion,
man
had
lost
the
concrete
connection
with
a

transcendent
realm
of
being;
he
was
set
free
to
deal
with
the
world
in
its

brute
objectivity.
But
he
was
bound
to
feel
homeless
in
such
a
world,

which
no
longer
answered
the
needs
of
his
spirit.

76

It
is
not
an
easy
situation
to
ameliorate.

76

William
Barrett,
Irrational
Man:
A
Study
in
Existential
Philosophy.
(Garden
City,

NY:
Doubleday,
1962)
25

76

Humoral
Theory
and
Behavioral
Illness

Celebrated
studies
often
conflict;
provocative
research
results
are
retracted
or

tacitly
abandoned.
Some
of
the
modern
data
is
undoubtedly
significantly
more

accurate
than
similar
theories
of
fifteen
hundred
years
ago.

What
is
certain
is
that

much
of
the
modern
knowledge,
with
the
exception
of
medication
for
severe

psychosis,
has
not
proven
significantly
more
useful.

The
Hippocratic
idea
of
the
origin
of
behavioral
pathology
in
the
head,
while
not

universally
accepted
during
the
Middle
Ages,
persisted
and
figured
in
various

theories
during
the
many
centuries
in
which
the
humoral
system
was
in
clinical
use.

The
sensory
and
motor
effects
of
direct
brain
damage
were
reported
in
fourth

century
Byzantium
by
Poseidonus.
In
recent
decades
we
have
classified
such
direct

causes
of
mental
pathology
as
“organic.”

That
trauma
to
the
head
resulted
in
behavioral
change
can
only
have
been

obvious,
and
the
implication
that
mental
disorders
that
seemed
to
appear

spontaneously
were
also
the
result
of
physical
processes
has
always
been
present.

Endogenous
causes
were
believed
to
be
mediated
by
changes
in
the
four
humors:

black
bile,
yellow
bile,
blood,
and
phlegm.

The
Galenic
humors
are
relatively
tenacious
body
fluids
that
changed
in
quantity

and
quality
and
migrated
through
the
body,
either
sluggishly
or
in
the
form
of

vapors,
in
response
to
stress
or
to
the
uses
of
the
non-‐naturals.
Liquid
humors
are

rendered
visible
by
disease
events,
such
as
the
dry
retching
of
green
or
yellow
bile;

the
production
of
thick,
colored
phlegm
in
pneumonia;
or
the
escape
of
clear,

77

crystalloid
phlegm
in
the
leakage
of
cerebrospinal
fluid
from
the
nose
after
a

fractured
skull.

The
ability
of
these
dense
and
sluggish
substances
to
rapidly
effect
both
dramatic

and
subtle
changes
was
sometimes
explained
by
theories
in
which
the
humors
were

pathologically
transformed
by
being
burnt
or
dried;
infected,
which
was
not

imagined
as
invasion
but
rather
as
spoiling,
poisoning
or
tainting,
possibly
by

morbid
air
and
foul
water;
or
corrupted,
a
concept
similar
to
putrefaction.
The
last
is

a
paradoxical
change
in
nature
that
might
be
analogous
to
our
understanding
of

cancer.
A
corrupt
humor
was
called
“pecant.”
It
is
possible
to
conceive
of
leukemia

and
lymphoma
as
pecant
states
of
blood
and
phlegm.

Theories
of
the
specifics
of
humoral
action,
which
were
extremely
various
and

frequently
contested,
are
analogous
to
the
scientific
debates
currently
swirling

around
what
is
understood
to
be
the
centrality
of
hormones
and
neurotransmitters

in
mental
pathology.

Bartholomeus
Anglicus,
in
his
thirteenth
century
De
proprietatibus,
describes
a

high
medieval
“textbook”
understanding
that
psychopathology
is
generated
by
the

formation
of
corrupt,
or
“adust,”
humors,
which
are
scorched
and
dried;
or
else
by

an
unhealthy
excess
of
normal
humors.
Blood,
once
rendered
corrupt,
or
putrefied,

as
might
happen
if
it
were
burnt
by
the
overconsumption
of
wine,
clogs
the

ventricles
of
the
brain.
Among
the
possible
sequelae
is
frenzy,
a
variegated
term
we

will
explore
further,
but
one
generally
correlated
with
psychosis.

The
endothermic
process
by
which
humors
“burn”
is
an
enigma.
It
is
never

explicitly
identified
with
ordinary
flame,
the
way
the
fire
of
Hell
is
depicted
in
the

78

theological
and
imaginative
literature
as
an
enhancement
or
elaboration
of
earthly

fire—which
for
example,
sometimes
burns
deathly
cold,
or
without
light.
(Lightless

conflagration
was
to
become
a
pivotal
concept
in
Paradise
Lost
and
has
entered

modern
literature
as
a
metaphor
for
severe
depression,
as
in
William
Styron’s

memoir,
Darkness
Visible.)

In
contrast
with
the
concept
of
spiritus,
the
phenomenon

of
internal
combustion
is
strangely
undeveloped.
Yet
it
is
similar
to
spiritus
in
that
it

is
one
of
the
points
at
which
medieval
medical
theory
is
situated
most
completely

within
the
quasi-‐metaphysical
realm
from
which
their
natural
philosophy
emanated.

Always
in
medieval
science,
there
is
a
point
at
which
the
investigator
demurs

from
deconstructing
the
sacred.
At
such
points
scholastic
interrogation
peters
out.
It

is
also
a
point
in
medical
history
at
which
an
intellectual
continuity
with
imaginative

literature
can
best
be
seen,
and
the
effect
on
the
modern
reader
is
not
unlike
that
of

the
genre
of
magical
realism.

Consider
this
treatise
on
black
bile,
formerly

attributed
to
Hugh
of
St.
Victor
but
probably
written
by
Hugo
de
Folieto
in
the
late

twelfth
century:

It
reigns
on
the
left
side
of
the
body;
its
seat
is
in
the
spleen;
it
is
cold
and

dry.
It
makes
men
irascible,
timid,
sleepy
or
sometimes
wakeful.
It
issues

from
the
eyes….The
black
bile
reigns
in
the
left
side
because
it
is
subject

to
the
vices
which
are
on
the
left.
It
has
its
seat
in
the
spleen
because,
in

its
sadness
over
the
delay
in
returning
to
its
heavenly
home,
it
rejoices
in

the
spleen
as
in
hope
[“spleen”—“spes”]

77

Also
notable
here
is
the
employment
of
etymology
in
a
scheme
of
scientific

deduction.
The
similarity
of
the
word
for
the
largest
lymph
node
to
the
name
of

Spes,
the
ancient
Roman
goddess
of
hope,
is
considered
significant
on
the

77

Klibansky
107

79

assumption
that
words
contain
the
essence
of
things,
which
is
predicated
on
the

larger
faith
in
a
rationally
ordered
universe.

Shortly
after
the
turn
of
the
first
millennium
the
medical
school
of
Salerno

adopted
the
theory
of
Avicenna
that
melancholy
was
the
result
not
simply
of
the

quality
and
quantity
of
black
bile,
but
of
morbid
changes
in
all
four
of
the
humors,

such
that
even
burnt
phlegm
would
result
in
a
particular
form
of
mental
illness.

But
black
bile
was
still
regarded
as
the
most
important
humor
in
psychoneurology.

Here
Avicenna
describes
a
spectrum
of
depressive
mood
disorder
that
appears
to

encompass
all
of
the
bipolar
syndrome,
to
the
edge
of
florid
psychosis:

If
the
black
bile
which
causes
melancholy
be
mixed
with
blood
it
will

appear
coupled
with
joy
and
laughter
and
not
accompanied
by
deep

sadness;
but
if
it
be
mixed
with
phlegm,
it
is
coupled
with
inertia,
lack
of

movement,
and
quiet;
if
it
be
mixed
with
yellow
bile
its
symptoms
will
be

unrest,
violence,
and
obsessions,
and
it
is
like
frenzy.
And
if
it
be
pure

black
bile,
then
there
is
very
great
thoughtfulness
and
less
agitation
and

frenzy
except
when
the
patient
is
provoked
and
quarrels,
or
nourishes
a

hatred
which
he
cannot
forget.

78

Bartholomeus
offers
a
general
treatment
of
environmental
causes
of
depressive

changes
in
black
bile.
Such
external
influences
are
the
effects
of
the
mismanagement

of
the
“non–naturals,”
including
dietary
immoderation
and
physical
accident.
It

seems
to
cover
causes
of
all
aspects
of
depression
and
possibly
other
ailments,
from

ordinary
dysthymia
to
the
terminal
psychosis
of
rabies:

These
passions
come
somtyme
of
melancholy
meetes,
&
somtyme
of

drynke
of
stronge
wyne
that
brenneth
the
humours
&
tourneth
theym

into
ashes;
somtyme
of
passions
of
the
soule,
as
of
besynes
&
grete

thougtes,
or
sorowe
&
grete
studye
&
of
drede;
somtyme
of
the
bytnge
of

a
wood
hounde.

79

78

Ibid.,
89

79

Penelope
Doob,
Nebuchadnezzar’s
Children:
Conventions
of
Madness
in
Middle

English
Literature
(New
Haven:
Yale
University
Press,
1974)
26

80

Ventricular
Theory

The
dramas
of
humoral
change
transpired
in
the
ventricles,
which
are
cistern-‐like

lacunae
in
the
spongy
tissue
of
the
brain.
Christopher
D.
Green
argues
that
medieval

ventricular
theory,
which
remained
in
clinical
use
with
only
minor
local
revisions

until
the
seventeenth
century,
developed
much
later
than
classical
times,
and
was,

like
the
elaborate
spirit
theory
of
the
period,
a
product
of
medieval
culture:

[T]he
origin
of
the
complete
system
repeated
so
often
in
the
Middle
Ages

may
itself
have
been
Medieval;
in
the
full
form…it
was
held
by
virtually

no
one
in
the
Ancient
world.
Instead,
if
appears
that
bits
and
pieces
of
it

were
developed
here
and
there
in
the
Ancient
world,
gradually

accumulating
into
the
full
Medieval
version.

80

Early
modern
medicine
taught
that
what
they
called
the
first
cell
of
the
brain,

which
corresponds
anatomically
to
the
two
lateral
ventricles,
received
data
from
the

sense
organs
and
transformed
and
combined
it,
creating
fantasy
and
imagination.

The
middle
cell,
which
we
know
as
the
third
ventricle,
was
the
site
of
reasoning,

judgment,
and
thought,
and
the
third—now
called
the
fourth-‐-‐was
the
storehouse
of

memory.
Charles
G.
Gross
notes
that
by
the
tenth
century
this
static
picture
had

morphed
into
a
fluid
design
congruent
with
the
movement
of
the
humors.
He

compares
the
resulting
model
to
that
of
digestion,
in
which
the
first
cell
transformed

inchoate
sensory
data
into
coherent
images
before
moving
them
on
to
the
warmer

80

Christopher
D.
Green,
“Where
Did
the
Ventricular
Localization
of
Mental

Faculties
Come
From?”
Journal
of
History
of
the
Behavioral
Sciences
39(2)

(2003):
131-‐142,
133

81

central
cell,
where
it
was
further
processed
into
cognition.

81

After
immediate

usefulness
these
images
and
ideas
were
moved—possibly
through
the
cerebral

aqueduct—to
the
fourth,
where
they
were
stored
as
memory
in
the
back
of
the
head,

which
is
now
called
the
occiput.
There
is
something
intuitive
in
this,
which
speaks
to

the
common
sense
of
ordinary
life:
things
kept
indefinitely
for
possible
use
are

stored
out
of
the
way,
in
the
back.

The
theory
of
localization
of
brain
function
that
accounted
for
psychiatric

disorders
originated
in
the
works
of
Galen,
whose
treatise
On
the
Doctrines
of

Hippocrates
and
Plato
defended
the
proposition
that
the
vital
spirits,
or
powers,
had

three
sources—the
head,
the
heart
and
the
liver—as
opposed
to
the
heart
only,

which
was
argued
by
Aristotle
and
the
Stoics.

Early
modern
medicine
taught
that
what
was
considered
the
first
cell
of
the
brain,

which,
as
previously
mentioned,
corresponds
anatomically
to
the
two
lateral

ventricles,
housed
the
sensus
communis,
which
of
course
is
literally
translated
as

“common
sense.”
This
faculty—the
structural
or
material
basis
of
which
is
unclear-‐-‐
received
data
from
the
sense
organs
and
transformed
and
combined
it,
concocting
a

highly
personal
product
of
fantasy
and
imagination.
A
vermis,
or
worm-‐shaped

passage,
was
believed
to
connect
this
ventricle
with
the
second
one,
and
served
as
a

storage
place
for
representations
of
sensory
perceptions.
Whether
the
dynamic

transfer
of
images
around
the
cortex
was
physical
in
nature,
or
rather
spiritual
or

rhetorical,
is
a
question
that
cannot
be
answered
simply,
because
it
speaks
to
the

81

Charles
G.
Gross,
“The
Story
of
the
Visual
Cortex.”
Kathleen
Rockland,
ed
Cerebral

Cortex
vol
12:
Extrastriate
Cortex
in
Primates.
(New
York,
Plenham
Press,
1997)
31

82

problem
of
the
nature
of
corporeality
that
is
an
essential
concern
of
medieval

philosophy.

The
faculty
of
“imagination,”
which
was
sometimes
called
“representation,”
was

already
complex,
as
it
continues
to
be.
Green
describes
the
medieval
concept:

This
faculty
was
occasionally
divided
into
two
subfaculties,
the
first

simply
to
collect
images
of
previously
perceived
objects,
and
the
second

one
serving
to
recombine
stored
images
into
representations
of
never

before
seen
objects
(e.g.
a
man
with
wings
or
a
building
not
yet
built).

When
so
divided,
the
resulting
faculties
were
sometimes
called
the

“passive”
and
“active”
imaginations
or
occasionally
the
“fantasy”
and
the

“imagination.”
Located
in
the
middle
ventricle
was
a
faculty
called

“estimation.”
The
standard
example
of
estimation
involved
sheep
who

were
said
to
know
innately
that
wolves
are
dangerous….Humans
and

sometimes
higher
animals
were
credited
with
an
additional
faculty
to

account
for
their
ability
to
transcend
instinct
and
make
original

judgments
on
the
basis
of
past
experience.
This
faculty
was
called

“cognition,”
also
said
to
be
located
in
the
middle
ventricle.
After
the

estimations
and
cognitions
had
been
made,
the
results
were
thought
to

be
transferred
to
the
rear
ventricle
for
storage
with
the
faculty
of

memory.
Memory
differed
from
the
faculty
of
representation
in
that
it

was
thought
to
store
the
results
of
estimation
and
cognition.
Occasionally

a
faculty
of
“volition”—the
will,
so
to
speak—was
placed
at
the
rear
of

the
third
ventricle,
or
even
in
a
presumed
fourth
one.

82

Cognition
appears
to
correspond
to
abstract
thinking.
Possibly
a
diseased
fantasy

would
account
for
psychotic
delusions,
and
the
imagination
for
bizarre

hallucinations.

Precisely
how
early
theorists
arrived
at
specific
conclusions
about
brain
function

is
often
unclear,
although
it
can
sometimes
be
seen
to
have
been
deduced
from

theological
and
philosophical
theory.
Considering
that
experimentation
upon
the

brain
in
vivo
could
hardly
have
been
possible,
it
is
remarkable
that
theories
of

localization
of
brain
function
were
offered
so
early.
And
yet
the
extent
to
which

82

Green,
131-‐32

83

medieval
academics
were
able
to
anticipate
modern
biomedical
understanding
is

sometimes
uncanny.
Galen
believed
that
the
two
functions
of
the
nervous
system,

sensory
and
motor,
were
regulated
by
two
divisions
of
nerves:
“soft”
and
“hard.”

This
schema
roughly
corresponds
to
the
sensorimotor
and
autonomic
nervous

systems.
The
rigid
regulation
of
autonomic
function,
including
cardiac
and

pulmonary
action,
by
the
hypothalamus
could
certainly
be
conceived
as
a
“hard”

nervous
system.

A
diseased
portion
of
the
brain
was
called
an
aposteme,
a
term
also
used
for
the

appearance
on
visible
portions
of
the
body
of
a
boil
or
abscess.
Both
of
these
latter

terms
survived
in
later
Western
medicine
long
after
it
was
understood
that
such

eruptions
were
caused
by
the
invasion
of
microbes.
In
medieval
medicine
the

concept
was
not
of
invasion
but
of
tainting,
poisoning
or
spoiling—the
rendering
of

an
anatomical
part
useless
for
its
physiological
function—a
concept
familiar
to
us

from
the
model
of
the
furiously
multiplying
cells
of
cancer,
which
render
an
organ

foreign
and
inoperative.

Basil
Clarke
notes
that
when
applied
to
the
brain
in
the
etiology
of
mental
illness,

aposteme
corresponded
“roughly
to
the
modern
usage
of
‘lesion”:
83

a
reference
to

structural
brain
damage
due
to
trauma,
infection
or
malignant
neoplasm.
Thus

aposteme
may
have
anticipated
the
notion
of
a
brain
tumor,
which
can
also
mimic

psychiatric
illness.

The
psychic
spirits
that
communicated
so
deftly
with
the
eternal
were
the

functional
force
of
the
nervous
system.
As
we
have
seen,
they
were
generated
from

83

Clarke
86

84

the
vital
spirits,
produced
in
the
heart
from
inspired
air
and
then
circulated
to
the

brain.
There
they
were
synthesized
in
the
rete
mirabile,
a
complex
nexus
of
arteries

and
veins
believed
to
lie
near
the
brain
stem,
and
subsequently
refined
to
perfection

in
the
third
ventricle.
The
dysfunction
of
impure
animal
spirits
generated
in
the

presence
of
humoral
imbalance
resulted
in
the
manifestation
of
frenzy.

Galen
described
the
manufacture
of
psychic
spirits
as
essential
to
understanding

neurological
pathophysiology:

The
plexus
called
reticular
by
anatomists,
the
plexus
that
embraces
the

gland
itself
and
extends
for
a
great
distance
posteriorly,
is
the
most

remarkable
of
the
bodies
found
in
this
region.
Indeed,
it
extends
over

almost
the
whole
base
of
the
brain.
This
network
is
not
simple;
one

might
say
like
the
many
threads
of
fishermen’s
nets
placed
upon
the

other….This
plexus
preserves
no
slight
usefulness.
It
is
doubtful
if
any

other
part
has
so
important
a
function.
This
is
why
nature
established
it

in
the
most
secure
of
all
places.

84

It
must
be
stated
that
the
retae
mirabile
does
not
extend
across
the
base
of
the

brain;
nor
is
it
the
most
important
cerebral
part.
In
fact
this
magnificent
organ
does

not
exist
in
the
human
brain
at
all.
Galen
extrapolated
its
presence
from
the

dissection
of
the
ox.

That
the
foremost
physician
of
the
first
millennia
and
a
half
of

Western
medicine
could
have
experienced
such
an
embarrassment
should
give
us

pause
as
we
celebrate
new
discoveries
of
the
differentiation
of
the
cerebral
cortex.

84

Samuel
H
Greenblatt,
T.
Gorcht
Dagil
and
Med
H.
Epstein,
eds,
A
History
of

Neurosurgery:
In
its
Scientific
and
Professional
Contexts.
(Park
Ridge,
IL.

American
Association
of
Neurological
Surgeons,
1992)
110

85

‘Pecant
Dopamine’?

Modern
Reception
of
Ventricular
Theory

Modern
theory
locates
the
higher
cognitive
skills
of
coordination
and
planning,

language
and
conscious
control
of
emotional
response
in
the
frontal
lobes,
especially

the
prefrontal
cortex.
Memory,
learning
and
higher
level
reasoning
are
believed
to

occur
mostly
in
the
hippocampus,
which
consists
of
bilateral
structures
situated

beneath
the
temporal
lobes
on
either
side
of
the
brain,
somewhat
above
and

anterior
to
the
ears.
The
parietal
lobes,
roughly
the
sides
of
the
brain,
are

responsible
for
sensation,
reading,
and
knowing
left
from
right.
Emotion
arises
in

the
limbic
system,
especially
the
amygdala,
also
located
deep
within
the
temporal

lobe.
The
occiput,
or
rear
end
of
the
brain,
is
now
primarily
identified
with
visual

processing.
Below
the
occiput
the
cerebellum
controls
balance
and
fine
motor

coordination.
The
brain
stem
houses
basic
functions
of
cardiopulmonary
physiology,

body
temperature
and
sleep.

While
there
are
unlikely
to
be
major
revisions
in
this
scheme
the

neurophysiological
details,
and
their
implications
for
the
etiology
of
mental
illness,

continue
to
be
researched
and
debated.
The
medical
mystery
of
madness—the

disorder
that
alienates
the
human
being
from
his
divine
nature
and
from
himself,

and
the
one
disease
that
uniquely
forces
all
cultures
to
respond
to
the
question
of

what
it
means
to
be
a
human
being-‐-‐continues
to
unravel.

The
theory
is
now
dominant
that
reduced
neurotransmission
and
connectivity
is

the
neurological
basis
of
schizophrenia.
Dopamine
dysregulation
is
described,
as
in

the
physiology
text
quoted
at
the
opening
of
this
chapter,
as
“clearly….the
driving

86

force
behind
the
neurochemical
process
of
psychosis.”
85

But
the
authors
moderate

their
celebratory
tone
to
mention
the
presence
of
many
variables
of
unquantifiable

significance,
including
“biopsychosocial
contextual
factors”
such
as
stress-‐related

cortisol
secretion
and
drugs
of
abuse.

The
determination
of
contemporary
science
to
discover
physiological

determinants
of
dysfunctional
behavior
is
expressed
in
recurrent
media
reports
of

structural
differences
in
the
brains
of
patients—the
depressed,
the
schizophrenic,

the
compulsive,
the
habitually
agitated
or
attention
deficient—discovered
on
MRI

and
PET
or
CT
scans.
Since
1976
computerized
tomography
has
revealed
enlarged

lateral
and
third
ventricles
in
schizophrenics
with
reasonable
consistency.
86

Contingent
grey
matter
is
perceived
as
commensurately
shrunken.
Cerebral

correlates
of
major
depression
are
less
clear
but
are
currently
believed
to
involve

errors
in
neurotransmitter
regulation
emanating
from
an
impaired
hypothalamic-‐
pituitary-‐adrenal
axis
and
from
changes
in
the
frontal
lobe
and
shrinkage
of
the

hippocampus.
In
the
eighties
and
nineties
the
theory
that
a
deficiency
of
the

neurotransmitter
serotonin
was
a
primary
cause
of
depression—a
deficiency
that

was
to
be
treated
by
a
celebrated
new
category
of
pharmaceuticals—became

explosively
popular.
That
theory
has
largely
been
laid
to
rest.
The
drugs,
on
the

other
hand,
continue
to
be
among
the
most
commonly
prescribed.
Much
research

has
been
dedicated
to
discovering
how
they
work,
and
sometimes
even
to
whether

they
work
at
all.
We
continue
to
have
faith
in
the
existence
of
biochemical
processes

we
do
not
understand,
and
in
the
prescriptions
of
authorities.

85

Collier
976

86

Ibid.,
977

87

Reports
of
new
findings
in
brain
research
often
include
the
disclaimer
that

whether
these
structural
abnormalities
are
primary
causes
of
mental
illness
or

secondary
effects
is
not
known.

Nor
is
it
understood
whether,
or
how,
elements
in

the
physical
and
social
environment
may
have
produced
or
exacerbated
the

changes.
Modern
investigators
of
mental
disorder
acknowledge
the
ancient
lacuna.

In
their
efforts
to
fill
it
they
are
frequently
“borne
back
ceaselessly
into
the
past.”

Colors
and
Empty
Spaces:
Aesthetics
in
Medieval
Psychiatric
Theory

In
every
case
of
mental
disorder,
ancient,
medieval
and
modern,
the
illness
is

understood
at
some
level
to
be
spiritual,
erupting
from
the
irreducibility
of

existential
experience:
the
elusive
origins
of
character
and
personality
that
we
think

of
as
the
“unconscious,”
and
which
we
now
refer
to
when
we
say
“soul.”

Illustrations
accompanying
popular
articles
on
neuroscientific
discoveries
often

depict
the
cerebral
lobes
and
structures
in
primary
colors.

The
ventricles,
or
open

spaces,
are
usually
white
or
black.
They
are
now
known
to
be
filled
with
clear

cerebrospinal
fluid.

Ironically
it
was
within
these
hollow
spaces,
and
not
in
the
surrounding
tissue,

that
early
modern
medicine
located
the
seats
of
sensory
and
intellectual
function.

The
functions
of
the
brain
were
believed
to
occur
in
the
ventricles—the
empty

spaces
where
the
spiritus
played-‐-‐rather
than
within
the
solid
structures
that
“light

up”
on
a
PET
scan.

To
the
medieval
mind
this
conclusion
was
in
no
way
counterintuitive.
Brain
tissue

is
disconcertingly
slimy
and
grey,
and
the
Church
Fathers
realized
that
the
organ

88

was,
as
Gross
writes,
“too
earthy,
too
dirty
to
act
as
an
intermediary
between
body

and
soul”
87

and
so,
in
the
theologically
reductive
science
of
those
millennia,
the

clear,
empty
spaces
within
the
brain
were
obviously
the
site
of
the
physical
and

spiritual
processes
that
animated
human
life.

Galen
had
described
the
ventricles,
or
“cells,”
although
he
assumed,
as
we
assume,

that
mental
function
occurred
in
the
solid
tissue.
The
Church
fathers,
intent
on

uncovering
the
ways
in
which
the
ancient
received
wisdom
anticipated
Christian

revelation,
discovered
the
ventricle
theory.
This
sense
of
ultimate
closure,
of
the

ability
of
the
theologian
or
scientist—who
were
often,
of
course,
one
and
the
same-‐-‐
to
explain
the
ways
of
God
to
Man,
and
to
reassure
him
of
his
place
in
a
controlled

universe:
this
scenario
sounds
luxurious
to
the
contemporary
layman,
who
is
no

longer
capable
of
being
at
home
in
the
world
in
this
fashion.

The
biomedical

professional,
whose
working
life
is
grounded
in
rationality
beyond
compromise,

may
feel
the
tug
of
this
nostalgia
also.

The
elegant
aesthetics
of
this
logic-‐-‐that
routine
encounters
with
the
physical

world,
including
what
must
then
have
been
a
more
frequent
experience
than
ours

with
the
sight
of
brains,
reveal
the
hand
of
the
Creator
through
direct
and
explicit

mechanisms—reveals
a
science
that
is
fundamentally
metaphorical.
This
in
turn
is
a

function
of
what
C.S.
Lewis
calls
the
medieval
“intense
love
of
system”:

The
business
of
the
natural
philosopher
is
to
construct
theories
that
will

‘save
appearances’….A
scientific
theory
must
‘save’
or
‘preserve’
the

appearances,
the
phenomena,
it
deals
with,
in
the
sense
of
getting
them

all
in,
doing
justice
to
them.

88

87

Gross,
34

88

Lewis,
14

89

The
ventricular
theory
of
brain
structure
as
used
in
the
etiology
of
mental

disorder
was
attenuated
during
the
high
middle
ages,
eclipsed
by
the
hegemony
of

the
humoral
theory.
Of
the
long
history
of
the
ventricle
theory,
Basil
Clarke
writes:

To
have
developed
further,
this
nucleus
would
have
had
to
be
elaborated

into
a
network
of
new
concepts
about
mental
phenomena
and
their

pathology
and
to
have
displaced
a
large
part
of
the
humoral
theory

proper.
This
did
not
happen
in
the
time,
and
the
three-‐cell
theory

remained
a
proto-‐hypothesis
of
localization
of
brain
function
without
the

necessary
additional
explanation
of
the
mechanism
by
which
these
cells

exercised
their
influence….in
the
‘head’
sections
of
medical
textbooks

these
three
parts
of
the
brain
are
really
just
a
classificatory
device.
The

relevant
cell…was
loosely
linked,
by
reference
to
the
vapour
or
pneuma,

to
the
effective
association
with
heat
and
moisture
factors.

89

The
Survival
of
the
Humors

That
alterations
of
general
bodily
health
act
upon
the
brain
to
impair
its
function

has
been
understood
since
ancient
times.
Various
mechanisms
have
been
offered

across
millennia:
the
upward
migration
of
burnt
phlegm
distends
the
ventricles,

disrupting
the
concoction
of
the
spirits;
habitually
excessive
alcohol
consumption

reduces
the
absorption
of
vitamin
B
12,
stripping
neurons
of
their
milky
myelin

sheaths
and
causing
aberrant
transmissions
that
produce
the
mania
and
psychosis

of
Korsakoff’s
syndrome.
Noncompliance
with
the
strict
dietary
regiment
required

after
elective
surgery
for
weight
loss
can
result
in
this
syndrome
also.

The
Scholastic
movement,
emerging
around
the
twelfth
century
in
the
medical

schools
of
Paris,
Bologna
and,
particularly,
Salerno,
perfected
the
use
of
rhetoric
as

the
foundation
of
elegant
medical
theory.

In
the
thirteenth
century
Gilbertus

89

Clarke,
86

90

Anglicus
offered
a
complex
symptomatology
that
included
differential
effects
on

certain
humoral
temperaments,
or
“complexions”:
mania
resulted
from
an

“infection”
of
the
first
cell,
the
seat
of
imagination.
Melancholia
was
an
infection
of

the
second,
or
reasoning,
cell.

90

Mood
disorders,
which
do
not
manifest
in
bizarre

symptoms
but
rather
in
inappropriate
reactions
to
normal
situations,
are
apparently

assumed
to
be
discrete
phenomena.
This
is
interesting
because
there
was
no
formal

recognition
of
the
distinction
between
psychosis
and
neurosis
before
the

Renaissance.

The
significance
of
single
molecules
independent
of
their
incorporation
into
fluids

or
structures,
such
as
the
neurotransmitter
dopamine
carried
by
cerebrospinal
fluid

and
hormones
in
blood,
was
not
available
to
medieval
medicine,
and
phenomena

that
we
now
perceive
as
the
biochemical
effects
of
such
entities
were
conceived
as

the
result
of
inherent
“powers”
in
various
biological
and
inorganic
materials,

resulting
from
their
natures
and
their
place
within
the
macrocosm.

Looked
at
another
way,
perhaps
the
existence
of
inherent
powers
has
not
been

disproven,
but
explained.

Hildegard
of
Bingen,
considering
the
case
of
a
lunatic
who
senses
an
impending

relapse—a
situation
familiar
in
modern
literature
from
the
suicide
of
Virginia

Wolf—prescribes
the
use
of
an
agate,
because
it
is
“born
from
certain
sand
of
water

which
extends
from
the
east
to
the
south….It
is
hot
and
fiery,
but
has
greater
power

from
the
air
and
water
than
from
fire.”

91

If
the
agate
is
worn
about
the
body,
“its

90

Ibid.,
90

91

Throop
150

91

nature
will
make
this
person
capable,
judicious,
and
prudent
in
speech,
because
it
is

born
from
air
and
fire
and
water.”

Thus
the
mental
patient
experiencing
the
prodromal
state
that
precedes
a

breakdown
should
prepare
in
advance
the
foods
he
will
require
to
sustain
himself

during
the
impending
dementia
by
cooking
them
with
an
agate:

He
will
be
resuscitated
by
the
virtue
of
this
stone
in
gently
heated
water.

Lest
he
be
injured
by
the
heat
of
this
stone,
his
foods
should
be
prepared

with
this
water
and
his
drinks
prepared
in
the
way
described.
By
their

moderation,
and
by
the
power
of
God,
the
humors
which
brought

insanity
to
him
will
be
sedated.

92

The
roles
of
the
humors,
and
the
roles
of
ineffable
forces—whether
conceived
as

spiritual,
psychological,
or
Divine/metaphysical—were
richly
debated.

And
they
are
now,
as
well.
Biochemical
theories
have
proliferated
since
the

middle
of
the
last
century,
and
breakthroughs
appear
reliably
in
the
Science
and

Health
sections
of
the
news
media.
The
same
journalistic
sections
report
tantalizing

suggestions
that
genes
have
been
located
which
correlate
with
diagnostic
categories

such
as
alcoholism,
autism,
anxiety
disorder,
and
attention
deficit
hyperactivity.

The
structure
of
the
conception
of
mental
pathology
has
not
radically
changed.

Philosopher
William
Barrett
writes:
“Faith
can
no
more
be
described
to
a

thoroughly
rational
mind
than
the
idea
of
colors
can
be
conveyed
to
a
blind
man.”

93

This
metaphor
for
the
ineffable
power
of
pure
faith
shows
the
emphatically
vivid

coloration
of
popular
diagrams
of
the
human
brain
to
be
a
modern
metaphor
of

92

Ibid.,
151

93

Barrett,
93

92

sorts—poignant
in
their
insistence
on
what
can
be
known
about
human
life,
and

enthusiastic
that
so
much
can
be
known—certainly,
all
we
need
to
know?

Although
most
current
environmental
studies
on
causation
look
for
effects
on

neurotransmission—and
extrapolate
on
perceived
structural
changes
that
may
be

primary
or
secondary—the
breakthrough
of
the
neurotransmission/dopamine

nexus
yields
to
a
plethora
of
soft
and
colorful
data.
The
emergence
of

schizophrenia—which
typically
appears
in
early
adulthood—has
been
correlated

with
maternal
depression
and/or
stress
in
pregnancy,
with
urban
birth
and
with
the

patient’s
use
of
marijuana.
At
risk
offspring
do
not
always
develop
schizophrenia;

even
identical
twins
of
schizophrenics
are
spared
more
often
than
not.
Studies
show

that
a
disproportionate
number
of
schizophrenic
Englishmen
and
Scandinavians

were
born
immediately
after
a
major
flu
epidemic
in
1957.

94

Schizophrenic
brains
have
been
found
on
radiological
imaging
to
contain

enlarged
ventricles
and
reduced
temporal
lobe
grey
matter;
limbic-‐cortical

structures
may
be
abnormally
configured,
and
hippocampal
pyramidal
cells
are

oddly
arranged.
Prefrontal
cortex
structure
deficits
have
been
observed
when

patients
were
placed
under
stress.

Describing
these
imaging
results,
the
authors
of
the
aforementioned
textbook

include
an
interesting
point:

“the
experimental
stress
was
primarily
psychological,

such
as
contingency
planning
exercises
or
divergent
thinking
during
performance
of

a
cognitive
task
that
utilized
specific
regions
of
the
prefrontal
cortex.”

95

94

Collier
977

95

Ibid,
italics
added

93

Even
more
intriguing,
it
is
unclear
that
much
of
what
we
currently
label
as
mental

illness
is
truly
“madness”
at
all.
A
predilection
for
applying
medical
labels
to
bad

behavior,
and
a
parallel
tendency
to
pathologize
eccentricity,
generate
the

nomination
of
new
diagnoses
that
can
be
arrived
at
by
means
of
check
lists
of
subtle

symptoms.
The
figuration
of

“spectrums”
around
serious
diseases
like
autism
and

bipolar
disorder
has
created
a
complex
system
of
mental
hygiene
that
medieval

people
would
find
bewildering.
The
philosophy
currently
generating
psychiatric

progress,
which
has
recently
produced
the
fifth
edition
of
the
Diagnostic
and

Statistical
Manual
of
Mental
Disorders
of
the
American
Psychiatric
Association,

includes
such
psychiatric
diagnoses
as
Disinhibited
Social
Engagement
Disorder,

Nightmare
Disorder,
Female
Orgasmic
Disorder
and
Delayed
Ejaculation,
Gambling

Disorder
and
Caffeine-‐Induced
Disorder.
These
categories
no
doubt
describe
much

real
suffering,
but
the
insistence
on
medicalizing
these—and,
potentially,
coloring

them
on
a
drawing
of
the
brain—may
indicate
that
we
have
surpassed
ancient

diagnosticians
mainly
in
hubris.

Putting
Things
Back
Together:
Network
Science
Revisited

We
live
in
an
age
in
which
biochemistry
increasingly
dominates
the

understanding
of
emotion.
Perhaps
we
are
coming
full
circle,
and
approaching
the

stance
of
pre-‐classical
Greece,
in
which
human
actions
were
helpless
responses
to

the
whims
of
the
gods.
Certainly
it
is
close
to
the
idea,
common
in
New
Age
and

Alternative
healing,
that
negativity
in
emotions
and
the
resulting
habitual
outlook

on
life
can
make
one
ill:
the
idea
so
despised
by
cancer
patient
Sontag,
whose
Illness

94

as
Metaphor
is
an
extended
argument
against
it.
If
emotions
are,
as
now
seems

likely,
fundamentally
chemical—and
if
one
can
manipulate
one’s
chemicals
through

behavioral
therapy—is
it
not
also
likely
that
one
can
give
oneself
cancer?
And
is
the

skillful
husbanding
of
one’s
chemicals,
and
the
manipulation
of
the
chemicals
of

others,
ultimately
the
subject
of
art?

It
is
hard
for
us
to
feel
at
home
in
such
a
universe.

Nostalgia
for
the
medieval

paradigm
is
easy
to
understand.

The
existential
roots
of
disorders
of
the
mind
remain
as
impenetrable
as
ever.

Having
been
forced
to
deny
ourselves
recourse
to
the
spiritual
in
science,
we
have

substituted
an
improbable
faith
in
the
limitless
potential
of
human
inquiry,
and
thus

subject
ourselves
to
a
special
anxiety—a
discomfort
of
a
particularly
modern
sort.

Sontag
has
called
this
the
anxiety
of
the
person
for
whom
there
cannot
be
a
sense
of

death
and
suffering
as
natural.
96

This
person
is
the
only
patient
for
whom
Western

biomedicine
can
be
satisfactory
on
its
own
terms.
And
yet
this
medicine
is,
as

George
L.
Engel
has
said,
“the
dominant
folk
model
of
disease
in
the
Western

world.”
97

This
medicine
can
cure
beyond
what
Avicenna
could
have
imagined.
It
cannot
fill

more
profound
needs.
That
is
categorically
impossible.
We
can
only
find
ways
to
live

with
the
resulting
anxiety,
because
the
spiritual
is
absent
from
modern
biological

science.
Spirituality
exists
parallel
to
this
science,
and
such
rituals
of
healing
are

often
employed
simultaneously
with
modern
technology,
especially
in
First
World

96

Sontag,
Illness
as
Metaphor,
54.

97

George
L.
Engel,
“The
Need
for
a
New
Medical
Model:
A
Challenge
for

Biomedicine,”
(Psychodynamic
Psychiatry
40
(1977):
377-‐396.
380

95

Asian
cultures.
These
are
not
invariably
incompatible
ways
to
understand
existence.

But
they
are
not
the
same.

There
is
no
going
back.
As
William
Barrett
writes,
“History
has
never
allowed

man
to
return
to
the
past
in
any
total
sense.
And
our
psychological
problems
cannot

be
solved
by
a
regression
to
a
past
state
in
which
they
had
not
yet
been
brought
into

being.”

98

Transcendence
is
absent
from
Western
biomedicine.
It
cannot
be
absorbed

or
grafted
on.

98

Barrett,
26

96

CHAPTER
FIVE

“The
Insanity
of
the
Fatuously
Happy”:

Nosologies
of
Psychiatric

Disease
in
Medieval
and
Modern
Medicine

In
the
twentieth
century,
the
repellant,
harrowing
disease
that
is
made

the
index
of
a
superior
sensitivity,
the
vehicle
of
“spiritual”
feelings
and

“critical”
discontent,
is
insanity.

Susan
Sontag

99

The
corpus
of
ancient
theory
on
the
causes
of
mental
disorder
descends

essentially
intact—without
discrepancies
profound
enough
to
challenge
the

humoral
system-‐-‐from
Aristotle
and
Hippocrates
to
Robert
Burton’s
Anatomy
of

Melancholy
in
the
seventeenth
century.

Klibansky
attributes
the
stability
of
this

explanatory
system
to
its
origin
in
a
monograph
by
Constantinus
Africanus,
De

melancholia,
which
was
based
on
Galen’s
interpretation
of
the
doctrines
of
Rufus

and
experienced
a
nearly
hegemonic
reception
for
almost
seven
hundred
years.

100

Schemes
of
diagnosis
have
survived
even
longer,
coming
down
to
us
through

centuries
of
scientific
and
philosophical
evolution.

The
instinct
to
identify
the
points

at
which
eccentricity
becomes
madness,
and
to
categorize
manifestations
of
mental

illness,
is
a
very
old
one.
To
control
something,
one
must
begin
by
naming
it.

Nowhere
is
this
need
more
urgent
than
the
desire
to
control
the
uncontrollable
in

human
nature.

99

Sontag,
34

100

Klibansky,
82

97

This
dissertation
is
an
argument
that
modern
medicine
is
philosophically

irreconcilable
with
its
medieval
counterpart,
because
unlike
modern
medicine,

medieval
medicine
is
grounded
in
metaphysics.

Psychiatry
is
an
important

exception.
In
this
specialty
alone
contemporary
medicine
returns
to
the
project
that

all
medieval
medicine
assumed:
an
imperative
to
triumph
over
suffering
by

suffusing
it
with
personal
meaning.

The
meaning
of
the
decline
and
death
of
the
physical
body
is
elusive
to
both

systems
of
medicine,
but
the
experiences
themselves
are
inevitable,
and
perfectly

normal.
Although
we
feel
anger
and
grief
in
the
presence
of
death,
when
death
and

decline
arrive,
they
are
what
we
have
always
expected.
Insanity—the
sudden,

violent
wrenching
of
the
mind
from
normality;
from
one’s
loved
ones,
one’s
culture

and
from
oneself—in
the
absence
of
obvious
physical
pathology
is
never
expected.
It

is
a
transformation
of
the
self
that
questions
our
basic
understanding
of
human

nature
in
a
way
that
death
does
not.

Marie-‐Christine
Pouchelle
argues
that
in
order
to
comprehend
medieval
medicine

we
must
negotiate
“the
present
day
distinction
between
knowledge
and

symbolism”:

101

Thus
it
would
be
necessary
to
get
a
clearer
idea
of
the
function
of

metaphorization
in
cognitive
processes,
on
the
basis
of
a
proposition

which
even
the
contemporary
scientific
elite
now
takes
for
granted,
and

which
has
a
distinctly
Platonic
ring
to
it:
all
knowledge,
even
that
which

proceeds
from
the
most
advanced
of
the
exact
sciences,
is
necessarily

and
ontologically
metaphorical
as
it
relates
to
reality
itself.

102

101

Pouchelle,
11

102

Ibid,
201

98

My
search
for
commonalities
between
medieval
and
contemporary
sets
of

diagnostic
criteria
as
guides
to
clinical
practice
is
an
exercise
in
this
negotiation.

Spiritual
Psychiatry

One
way
to
understand
how
medieval
people
conceived
of
the
‘uncontrollable’
in

mental
disorder—and
how
we
conceive
of
it-‐-‐is
to
look
at
how
biomedicine
has

received
and
transformed
ancient
systems
of
behavioral
disease
classification.

Medieval
clinicians
saw
what
we
see
and
categorized
it
similarly,
but
the
uses
they

made
of
the
diagnosis,
and
the
healing
they
effected,
were
radically
different.
This

difference
reflects
a
historical
deterioration
of
the
healing
process,
because
we
have

attempted
to
fill
the
lacuna
left
by
the
metaphysical
with
the
physical
chemistry
of

pharmacology.

Medieval
medicine
did
not
possess
standardized
nosologies
in
the
modern
sense.

It
did
not
nurture
vigorous
debates
on
the
subject,
such
as
those
that
attend
the

painful
births
of
sequential
versions
of
the
Diagnostic
and
Statistical
Manual
of

Mental
Disorders,
or
the
somewhat
calmer
generations
of
the
International

Classification
of
Diseases,
drawn
up
by
the
World
Health
Organization
in
Geneva.

(The
International
Classification
is
officially
the
world’s
gold
standard,
although
it
is

less
influential
than
the
DSM.)
But
various
attempts
to
systematize
diagnostics

reveal
that
the
early
modern
experience
of
the
spectrum
of
mental
illness
was

similar
to
our
own,
and
their
attempts
to
organize
it
diagnostically
are
such
as
we

can
recognize
as
professionally
competent.

99

Basil
Clarke,
the
historian
of
mental
disorder
in
ancient
and
medieval
Britain,

suggests
that
the
urge
to
generate
systems
of
nosology
emerges
from
the
primitive

psychologies
of
spirit
theory:

These
spirits
are
generally
referred
to
natural
forces—such
spirits
could

in
theory
develop
into
formal
sciences
of
physics,
physiology,
psychology

and
pathology….
any
of
these
types
of
spirit
may
be
thought
the
cause
of

the
discomfort
or
disorder
which
could
be
labeled
‘psychiatric.’
So
far
as

there
is
found
an
association
of
particular
kinds
of
disorder
with

particular
kinds
of
spirit
action,
even
an
untidy
association,
this
is
a

beginning
of
a
nosology
or
of
a
psychodynamic
theory.

103

Spirit
theory
was
to
survive
for
millennia.
Transformed
by
the
requirements
of

Christian
philosophy,
spirit
theory
and
Galenic
humoral
theory
became
the

foundation
of
practical
medicine
in
the
early
modern
period.

The
Greek
association
of
the
Galenic
humors
with
certain
periods
of
the
year
that

favored
their
differential
production
in
quality
and
quantity
can
be
seen
to
have

gradually
evolved,
partly
through
meteorology
and
astrology,
into
a
genetic
theory

of
temperament
based
on
individual
humoral
dominance.

Temperamental

tendencies,
such
as
to
cheerfulness,
depression,
studiousness
or
gregariousness,

have
always
been
observed
to
run
in
families,
and
this
must
have
played
some
role,

although
astrological
influence
would
have
mediated
to
make
individual
fate
more

random.

The
humoral
scheme
of
personality
categorization
is
not
unlike
some
currently
in

use,
such
as
the
Briggs
Myers
scale,
which
was
derived
from
the
theory
of
Carl
Jung

and
is
used
in
therapeutic,
educational
and
industrial
settings.
Briggs
Myers

identifies
sixteen
personality
types
according
to
four
“preferences”:
extroverted

103

Clarke,
9-‐10

100

versus
introverted
orientation;
sensible
versus
intuitive
style
of
perception;

thinking
versus
feeling
as
the
basis
of
judgment;
and
judgment
versus
perception
as

structural
determinants
of
public
lifestyle,
or
one’s
behavioral
tendencies
as

perceived
by
others.

Stephen
Medcalf
compares
the
humoral
character
system
to
another
classic

theory
in
Western
psychology:

[The
Galenic
system]
is
a
very
good
classification.
Pavlov
rediscovered
it

through
the
two
kinds
of
response
that
people
show
to
stress—active

dealing
with
the
situation
(aggression)
and
simple
ignoring
of
it

(inhibition)—in
two
degrees,
controlledly
or
uncontrolledly.
There
are

then
four
character
types:
controlledly
inhibitory,
which
the
medievals

called
phlegmatic;
controlledly
aggressive,
or
sanguine;
uncontrollably

aggressive,
or
choleric;
and
finally
what
in
both
systems
is
either
a
native

character
type,
or
else
the
state
to
which
anyone
will
be
reduced
in
the

end
by
stress—that
is,
uncontrolled
inhibition,
or
melancholy.

104

The
humor
most
prominent
in
the
earliest
evolution
of
psychopathology
as
a

system
was
black
bile.
It
was
the
humor
latest
in
discovery,
having
displaced
water,

which
came
to
be
understood
as
a
more
elemental
substance.

Basil
Clarke
notes
the
early
emergence
in
Greek
thought
of

“a
tendency
for
many

symptoms
of
distress—in
practice,
doubtless,
the
obviously
psychiatric
and
those

not
fitting
into
familiar
disease
categories—to
be
referred
to
black
bile”:

As
‘bad
spirits’
have
tended
in
some
communities
to
be
an
originally

literal
belief
from
which
less
hypostatized,
more
strictly
psychological

thinking
grew,
so
black
bile
looks
like
the
beginnings
of
a
general
system

of
psychiatric
explanation.

105

104

Stephen
Medcalf,
“Inner
and
Outer.”
In
Stephen
Mecalf,
ed.,
The
Later
Middle

Ages.
(London:
Methuen
&
Co.,
1981)
109

105

Clarke
18

101

Early
modern
physicians
perceived
the
need
to
make
sense
of
the
spectrum
of

depressive
mental
illness
by
dividing
it
into
a
series
of
discrete
entities,
with

divergent
causes.
Ali
ibn
Abbas
had
discovered
in
the
ninth
century
that
different

kinds
of
melancholy—depressive,
euphoric
and
manic—could
be
attributed
to
a

genetic
foundation
that
produced
the
metabolic
tendency
toward
burning
of
either

red
or
black
bile,
or
of
blood.

106

Klibansky
notes
a
distinction,
which
he
attributes
to
Rufus,
between
a
melancholy

originating
in
the
“succus
melancholicus,”
conceived
as
an
abnormal
deposit
in
the

blood,
and
a
different
disease
resulting
from
the
presence
of
“melancholia
adusta,”

which
was
formed
by
the
scorching
of
yellow
bile.

Black
bile
became
associated
with
autumn,
and
with
an
essential
sadness
that

underlies
multifarious
psychopathologies.
The
fourteenth
century
poet
Thomas

Hoccleve
firmly
locates
the
onset
of
his
lengthy
breakdown,
which
I
believe
is

recognizable
as
a
major
depression
with
agitation
and
sporadic
features
of

borderline
psychosis,
in
the
turning
of
this
season.
His
monologue
describes
a
mind

aware
of
losing
itself:

After
that
hervest
Inned
had
his
sheves,

and
that
the
broune
season
of
myhelmesse

was
come,
and
gan
the
trees
robbe
of
ther
leves

That
grene
had
bene
/
and
in
lusty
fresshnesse,

and
them
in-‐to
colowre
/
of
yelownesse

hadd
dyen
/
and
doune
throwne
vnadar
foote,

that
chaunge
sank
/
into
myne
herte
roote.

For
freshely
browght
it
/
to
my
remembraunce,

That
stablenes
in
this
worlde
is
there
none;

There
is
no
thing
/
but
chaunge
and
variaunce;

How
welthye
a
man
be
/
or
well
be-‐gone.

106

Klibansky
87

102

Death
vunder
fote
/
shall
hym
thrist
adowne;

That
is
every
wites
/
conclusiyon.

107

This
particular
narrative
is
remarkable
in
that
it
largely
elides
the
Christian
view

of
death
and
descends
relentlessly
into
neurotic
despair,
as
Hoccleve
describes

tormenting
insomnia,
frightful
agitation,
inability
to
rise
and
function,
and

uncontrollable
tearfulness.
In
general,
Hoccleve
was
pious
and
even
doctrinaire,

organizing
his
fragile
personality
around
the
strength
of
his
culture’s
model
of
faith

and
reason,
the
power
and
integrity
of
which
has
inspired
nostalgia
in
every

generation
since.
But
in
his
bouts
of
mental
illness
this
support
fails
him,
and
he

writes
of
suicidal
ideation.

Similar
breakdowns
are
common
today,
and
are
popularly
known
as
“Seasonal

Affective
Disorder,”
or
SAD.
To
the
American
Psychiatric
Association
this
is
“Mood

Disorder
With
Seasonal
Pattern
Specifier,”
which
usually
occurs
“in
the
fall
or
early

winter
in
conjunction
with
the
shortening
day
length.”
The
category
was
created
in

response
to
studies
suggesting
that
winter
depression
may
be
responsive
to
bright

light
therapy.

Here
is
the
primary
specification,
from
the
Guidebook
for
DSM
IV:

With
Seasonal
Pattern

(can
be
applied
to
the
pattern
of
Major

Depressive
Episodes
in
Bipolar
I
Disorder,
Bipolar
II
Disorder,
or
Major

Depressive
Disorder,
Recurrent)

A) There
has
been
a
regular
temporal
relationship
between
the
onset
of

Major
Depressive
Episodes
in
Bipolar
I
or
Bipolar
II
Disorder
or
Major

Depressive
Disorder,
Recurrent,
and
a
particular
time
of
the
year
(e.g.,

107

Thomas
Hoccleve,
Complaint.
Frederick
J.
Furnival,
ed.
Hoccleve’s
Works:
The

Phillips
Manuscript
and
The
Durham
Manuscript
of
Sir
Israel
Gollancz
(EETS,
61.

London,
1892)
95.

103

regular
appearance
of
the
Major
Depressive
Episode
in
the
fall
or

winter).

Note:
Do
not
include
cases
in
which
there
is
an
obvious
effect
of
seasonal

related
psychosocial
stressors
(e.g.,
regularly
being
unemployed
every

winter

108

The
humoral
rubric
of
personality
provided
a
basis
for
diagnosis.
Asclepiades

had
distinguished
between
melancholic
disorder
of
the
imagination
and
that
of

understanding.
109

In
this
he
anticipated
the
distinction
of
severe
global
dysfunction

from
less
totalizing
disorder,
a
diagnosis
that
would
not
be
codified
until
the
term

“psychosis”
was
coined
by
Baron
Ernst
von
Feuchtersleben
two
thousand
years

later,
in
the
nineteenth
century.
Since
Freud
the
less
severe
or
more
circumscribed

disorders
have
been
classified
within
the
category
of
neurosis.
In
DSM
IV
and
V
that

crucial
designation
has
been
generally
abandoned
in
favor
of
specific
diagnostic

categories,
such
as
somatiform,
dissociative,
anxiety
or
mood
disorders.
This

dramatic
change
in
lexicon
should
serve
as
a
hedge
against
biomedical
hubris
and

scientific
positivism,
and
a
reminder
of
the
inconvenient
truth
that,
while
mental

disorder
across
historical
and
contemporary
cultures
manifests
basic
similarities,

modern
psychiatric
diagnosis
is
often
disconcertingly
soft.

One
hundred
years
after
Asclepiades
the
Roman
physician
and
surgeon
Celsus

delineated
three
kinds
of
insanities:
phrenitis,
or
chronic,
unremitting
delirium,

which
obviously
refers
to
psychosis,
especially
the
later
phases
of
schizophrenia;

melancholy,
a
general
term
which
corresponds
to
the
spectrum
of
mood
disorders;

and
delusion.

108

Francis
233

109

Klibansky
91

104

The
classic
psychiatric
symptoms:
paranoia,
delusion,
visual,
auditory
and

olfactory
hallucination,
grandiosity,
thought
insertion,
ideas
of
reference,
flight
of

ideas,
eating
disorder
and
intractable
depression,
are
all
recognizable
in
written

records
of
ancient
Babylonia,
Mesopotamia,
and
Greece,
and
in
Europe
throughout

the
early
modern
period.
These
symptoms
were
expressed
by
patients,
and

interpreted
by
their
attendants,
in
culturally
unique
ways,
as
they
are
in
diverse

societies
today.
In
many
contexts
these
symptoms
are
regarded
as
partaking
of
the

sacred,
at
least
partially,
or
potentially.
But
they
are
almost
always
understood
to
be

pathological.

The
modern
organization
of
mental
disorder
into
categories
in
what
we
would

now
recognize
as
diagnostics
can
be
traced
to
twelfth
century
scholasticism.
It
is
in

the
Scholastic
period
that
we
begin
to
see
the
awakening
of
the
modern
urge
to

parse
and
“pin
down”
symptoms
into
syndromes.
Changing
diagnostic
structures

continue
to
be
superimposed
on
the
same
problem
behaviors
after
a
thousand

years.
Cases
were
noted
in
which
the
imagination
was
disturbed,
while
memory
and

reason
remained
intact.

Classic
cases
were
those
of
patients
who
believed
that
their

heads
were
made
of
fragile
crockery;
these
persons
would
structure
their
daily
lives

around
the
protection
of
their
fragile
craniums.
Others
were
convinced
that
they

had
no
heads
at
all.

On
the
other
hand,
a
man
who
threw
glass
vessels
out
the
window,
followed
by
a

child,
was
possessed
of
an
intact
imagination
and
memory,
but
impeded
in
faculties

of
reason
and
judgment:
“because
he
did
not
know
that
the
vessels
were
fragile
and

the
child
vulnerable,
and
because
he
thought
it
correct
and
useful
to
throw
such

105

things
out
of
the
window
as
though
they
were
harmful
in
the
house.”

110

Klibansky

notes
that
diseases
of
the
memory,
traditionally
assigned
to
the
large
and
somewhat

general
category
of
“melancholy,”
began
to
be
more
commonly
seen
as
a
special

form
of
cognitive
illness,
or
“lithargia.”
111

The
association
with
lethargy
may

represent
a
general
clinical
state
of
unexplained
torpor
and
possibly
what
we
now

describe
in
clinical
screening
of
medical
patients
as
“altered
mental
status,”
which

can
result
from
a
number
causes
rooted
in
organic
or
environmental
pathology
or

toxicity,
many
of
them
transient.
A
particularly
odd
early
modern
case
of
an
isolated

symptom
is
the
reported
incidence
of
patients
who
forgot
the
names
of
their

kinsmen
during
plague,
only
to
resume
normal
mentation
after
the
crisis.
These

were
assumed
to
have
transient
memory
disorders
that
did
not
affect
imagination

or
reasoning.
The
scenario
of
attempting
to
retain
cognitive
integration
in
the
face
of

severe
emotional
crisis
is
not
suggested,
but
may
be
assumed.

“Lying
on
Tombs”:
A
Medieval
DSM

The
highest
level
of
development
for
this
psychiatric
project
in
the
Middle
Ages

may
be
seen
in
the
texts
that
compose
the
syllabus
of
the
medical
school
at
Oxford
in

the
fourteenth
century.
112

The
indispensible
references
were
Hippocrates’
Regimen

in
acute
diseases
and
Aphorisms;
Galen’s
Liber
Tegni;
Issac
Judaeus’
work
on
fevers;

and
the
Latin
translations
from
the
Arabic
of
Rhazes’s
Liber
Continen
,
the
Al-Maliki

110

Klibansky
93.
This
was
a
well
known
story,
here
quoted
in
the
Practica
nova
of

Giovanni
da
Concorreggio
of
1509.

111

Ibid.,
92

112

This
list
is
from
Clarke,
87-‐88.

106

(Liber
Regius)
of
Haly
Abbas,
the
Canon
and
Poem
of
Avicenna,
and
the
ninth
century

Isagoge
of
Johannitius.
More
contemporary
inclusions
were
practical
clinical

reference
works
by
continental
and
English
authors:
Roger
of
Salerno,
Ricardus

Anglicus,
Henry
of
Winchester,
Gilbertus
Anglicus,
and
Bartholomeus
Anglicus;
the

Lilium
medicine
of
Bernard
de
Gordon;
the
Rosa
medicinae
of
John
of
Gaddesen;
and

the
Practica
of
John
of
Arderne,
and
the
Breviarium
Bartholomaei
of
Johannes
de

Mirfield.

In
all
these
texts,
the
ancient
works
and
the
medieval
productions,
the
diagnosis

and
treatment
of
madness
were
woven
into
the
general
discussion.
Typically
the

discourse
moved
back
and
forth
between
mental
and
physical
illness,
without

demarcation.

Anecdotal
evidence
introduced
by
authorities
was
retained
as
scientific
fact
for

over
a
thousand
years.
The
retention
of
these
classic
and
often
amusing
clinical

narratives
is
a
function
of
a
larger
phenomenon
in
which
old
knowledge
is
not

discarded
but
remains
ensconced
in
a
culture’s
body
of
knowledge,
although
its

function
may
slightly
change.
Thus
Klibansky
notes
that
the
retention
of
this

sometimes
idiosyncratic
body
of
data
“was
a
case
not
of
decay
and
metamorphosis,

but
of
parallel
survival.”
113

A
modern
example
might
be
the
preservation
of
respect

for
the
intellectual
achievement
of
Freudian
theory
and
its
continued,
if
waning,

application
in
the
arts,
even
as
its
cultural
importance
gradually
dwindles
and
its

clinical
use
has
virtually
disappeared.
Modern
alternative
health,
which
asserts
a

113

Klibansky
3

107

distrust
of
statistical
analysis,
also
makes
use
of
ancient,
anecdotal
and

contemporary
folk
and
traditional
data.

The
medieval
medical
books
of
British
and
continental
origin
were
not
original

creations,
but
compilations
from
ancient
authorities.
The
Middle
Ages
were
patient

centuries,
listening
to
the
music
of
the
spheres.
The
‘breakthrough’
that
would
solve

and
explain
was
going
to
be
the
Apocalypse.

There
was
a
sort
of
medieval
DSM,
although
it
was
not
a
single
consistent

document.
An
eighth
century
Arab
physician,
Najab
ud
din
of
Samarkand,
had
a
nine

part
classification
rubric
for
madness,
which
he
summarized
as
“a
state
of
agitation

and
distraction,
with
alteration
and
loss
of
reason,
caused
by
weakness
or
disease

affecting
the
brain.”

114

However,
this
text
did
not
take
hold
in
Europe.

European
systems
of
psychiatric
diagnosis
included
a
famous
one
in
the

Compendium
Medicine
of
Gilbertus
Anglicus,
c.
1230,
outlined
by
Basil
Clarke:

Gilbertus
gave
many
psychiatric
symptoms—auditory
hallucinations,

depressions,
loud
violence,
irrational
fears
(the
sky
might
fall)
and

threatening
visions,
such
as
monks,
and
black
men
coming
to
kill,
and

demons.
The
monks
at
least
were
not
from
Galen.
There
were
also

insomnia,
headaches,
splendor
in
oculis
(photophobia?
aura?),

wandering,
downcast
eyes,
variations
of
appetite.
He
sketched
several

‘syndromes’:
a
‘choler’
syndrome
included
shouting,
anger,
over-‐activity

and
eye
motion.
The
picture
of
a
‘blood’
syndrome
included
euphoric

laughter,
high
color,
fast
pulse,
red
eyes—and
a
lot
of
black
hairs
on
the

chest.
(There
are
few
statements
as
lax
as
the
last
point,
and
it
perhaps

referred
to
a
typical
physical
build
or
was
a
misapprehension
derived

from
humoral
thinking.)
The
‘black
bile’
syndrome
involved
depression,

distress,
suspicion
and
withdrawal,
with
lying
on
tombs
and
sleeping
too

much.

115

114

Clarke
89

115

Ibid.,
91

108

Gilbertus
offered
a
complex
symptomatology
that
included
differential
effects
on

different
humoral
temperaments,
or
“complexions”:
mania
resulted
from
an

“infection”
of
the
first
cell,
the
seat
of
imagination;
melancholia
was
an
infection
of

the
second
or
reasoning
cell.

116

This
eleventh
century
passage
of
Constantinus
Africanus
opens
with
what
could

be
a
clinical
description
of
bipolar
disorder,
or
possibly
mild
psychosis,
or
even

agitated
depression:

We
say
that
their
moods
constantly
fluctuate
between
irascible

excitement
and
a
peaceable
frame
of
mind,
recklessness
and
timidity,

between
sadness
and
frivolity,
and
so
on.
The
conditions
[incidents]
cited

apply
to
the
animal
soul;
but
the
activities
of
the
rational
soul
are

strenuous
thinking,
remembering,
studying,
investigating,
imagining,

seeking
the
meaning
of
things,
and
fantasies
and
judgments,
whether
apt

[founded
in
fact]
or
mere
suspicions.
And
all
these
conditions—which

are
partly
permanent
forces
[mental
capacities],
partly
accidental

symptoms
[passions]—can
turn
the
soul
within
a
short
time
to

melancholy
if
it
immerses
itself
too
deeply
in
them.

117

A
similarly
poetic
description
of
what
seems
to
be
bipolar
psychosis
is
offered
by

Melanchton
in
the
fifteenth
century:

When
melancholy
originates
from
the
blood
and
is
tempered
with
the

blood,
it
gives
rise
to
the
insanity
of
the
fatuously
happy,
just
as
the

cheerful
madness
of
Democritus
is
said
to
have
been,
who
used
to
laugh

at
the
foolishness
of
mankind
and
by
his
unruffled
mind
prolonged
his

life
to
the
hundred-‐and-‐ninth
year.
But
when
melancholy
originates
in

the
red
bile
or
is
tempered
with
much
red
bile,
there
arise
horrible

ravings
and
frenzies.

118

Both
passages
describe
a
spectrum
of
labile
disturbance
in
temperament.
It
is

impossible
not
to
assume
that
these
authors,
four
centuries
apart,
are
adumbrating

116

Ibid.,
90

117

Klibansky
84

118

Ibid.,
89

109

an
“umbrella”
diagnostic
system
for
the
many
forms
of
mood
disorder.
Yet
another

attempt
to
codify
the
same
phenomena
for
the
DSM-‐V
has
recently
unleashed
a

storm
of
professional
and
political
criticism
for
subsuming
a
variety
of
mild
or

eccentric
variants
under
the
rubric
of
clinical
pathology.

Medical
literature
of
the
medieval
period
that
deals
with
madness
often
lacks

clear
definitions
among
diagnostic
categories
and
even
between
specific
patients

and
case
studies.
The
frustration
of
being
unable
to
give
names
to
disease
states—a

precondition
to
effectively
addressing
them—is
still
reflected
in
contemporary

medical
literature
by
the
use
of
generalized
diagnoses
such
as
“Psychosis
not

otherwise
specified
(PNOS)”
and
the
“spectrums”
developed
around
autism
and

bipolar
disorder.

(This,
as
we
shall
see,
was
not
the
case
with
acedia,
a
disease

endemic
to
religious
orders,
symptoms
of
which
were
clearly
circumscribed
from

ancient
times.)

The
thirteenth
century
De
proprietatibus
rerum
by
Bartholomeus
Anglicus

presented
representative
scientific
theory
and
was
a
well-‐known
practical
manual

because
of
its
adoption
by
the
Minor
Friars,
whom
Clarke
calls
practitioners
of

“domestic
medicine”
and
“general-‐purpose
welfare
workers.”
Clarke
identifies

Bartholomeus’s
“main
‘psychiatric’
categories…frenesis,
amentia,
lethargy,
epilepsy

and
(doubtfully)
his
notion
of
paralysis.”

119

It
is
probably
too
fanciful
to
suggest
that

this
last
was
a
medieval
documentation
of
conversion
reaction.

True
frenesis,
or
frenzy,
which
Bartholomeus
attributes
to
a
clogging
of
the
brain

with
corrupted
choleric
humor,
is
sometimes
hard
to
distinguish
from
“perafrenzy.”

119

Clarke
92

110

The
latter
seems
generally
to
have
been
a
less
severe
affliction,
caused
by
“fumosyte

&
smoke,”

120

and
amenable
to
corrections
of
diet
and
the
regulation
of
emotions

through
calming
milieu
therapy.
(The
prefix
‘pera’
seems
to
be
the
same
as
our

prefix
“para,”
meaning
“ancillary
or
auxiliary,”
as
paramedics
are
to
doctors.)
The

metaphorical
connection
of
this
diagnostic
category
with
the
ephemeral
physical

phenomena
of
smoke
and
fumes
suggest
an
etiology
in
transient,
possibly

environmental
influences,
and
perafrenzy
has
more
manifestations
of
mood

disorder
and
fewer
psychotic
features.
The
symptomatology
of
perafrenzy
again

includes
idiosyncratic
and
anecdotal
features,
including
“black
skin,
dryness,
pain,

fainting,
and
the
evaporation
of
the
spirits.”

Bartholomeus
depicts
a
medieval
manic
cycle
in
extremis,
with
histrionics
and

inappropriate
emotional
and
social
response
beginning
to
verge
into
psychotic

delusion,
including
a
truly
frightening
delusion
of
grandeur
in
which
the
patient
is

personally
responsible
for
protecting
the
earthly
globe
from
oblivion:

Also
it
comyth
in
a
madness
&
of
dysposicion
of
malencolye
whan

suche
hath
lykynge
and
laughe
alwaye
of
sorowfull
thynges,
and
make

sorowe
&
dolour
for
Ioyefull
things.

And
suche
holden
theyr
peas
whan
they
sholde
speke
and
speke
tomoche

whan
they
shold
be
styll.
Also
some
trowe
that
they
ben
erthyn
vesselles

and
drede
to
be
towched
lest
they
breke.
And
some
wene
they
close
&

conteyne
the
worlde
in
theyr
hondes
&
alle
thyge
in
theyr
delynge,
&

therefore
they
put
not
theyr
hondes
to
take
mete:
they
drede
the
worlde

sholde
fall
&
be
loste
ÿf
they
streyght
out
theyr
hondes….
121

Major
delusions
of
grandeur,
including
the
figuration
of
oneself
in
eschatological

scenes
and
the
assumption
of
the
identities
of
Biblical
personae,
remain
a
very

common
feature
of
contemporary
psychosis.

120

Doob
25

121

Ibid.,
24

111

Bartholomeus
subscribed
to
the
distinction
posed
by
Platearius,
whose
Practica

distinguished
between
true
madness,
an
infection
of
the
anterior
cerebral
ventricle,

which
caused
the
loss
of
the
imaginative
faculty,
and
melancholy,
an
infection
of
the

midbrain
that
caused
the
loss
of
reason.
The
reason
versus
imagination
dichotomy

appears
to
be
an
early
acknowledgement
of
the
psychotic
/
neurotic
distinction.

Thus
the
normal
function
of
imagination,
or
ability
to
differentiate
the
imagined,
the

remembered,
the
hoped
for
and
the
feared
from
what
was
transpiring
in
real
time,

becomes
disorganized;
the
patient
begins
to
live
in
an
imaginary
world,
and
to
react

to
it
in
the
real
one.
In
melancholy,
on
the
other
hand,
“reason”
is
impaired:
the
real

is
acknowledged,
and
yet
perceptions
of
loss
and
fear
are
unreasonable,
such
that

the
person
becomes
miserable,
immobile
and
unproductive,
and
“feynt,
ferdful
in

herte
without
cause.”

In
general
the
generations
of
theorists
prior
to
Descartes
did
not
overtly

acknowledge
the
“organic
versus
inorganic”
quandary.
Still,
as
mentioned
in
the

chapter
on
theories
of
causation,
some
forms
of
madness
were
more
obviously

rooted
in
external,
and
possibly
transient,
physiological
causes.
Here
are

Bartholomeus’s
diagnostic
criteria
for
a
form
of
frenesis,
or
true
frenzy,
which
he

attributes
to
a
meningeal
lesion
caused
by
dysfunction
of
the
red
choleric
humor:

Dyscolouryd
vryne
durynge
the
feuer,
with
woodnes
and
contynuall

wakynge;
meuynge
and
castynge
abowte
the
eyen;
Ragynge,
stretchynge,

and
castynge
of
hondes;
meuynge
&
waggynge
of
heed;
gryndynge
&

knockynge
togyders
of
teeth.
Alwaye
he
wol
aryse
of
his
bedde;
now
he

syngeth,
now
he
laughyth;
now
he
wepith,
and
bytith
gladly
and
rentyth

his
warden
and
his
leche.
Selde
is
he
style
but
he
cryeth
moche.

122

122

Ibid.,
25

112

Frenesis
here
looks
very
much
like
dementia
secondary
to
sepsis,
which
is
indeed

characterized
by
agitation,
physical
aggression,
paranoia,
crying
out—and,
should

the
infection
have
progressed
to
the
point
of
renal
failure,
amber
colored
urine.
A

meningeal
lesion—either
a
contained
abscess
or
the
wider
inflammation
of

meningitis—could
certainly
be
a
cause
of
neurological
sepsis,
although
systemic

sepsis
can
originate
in
the
infection
of
many
organ
systems.

This
is
from
Bartholoemus’s
De
proprietatibus
rerum,
c
1260,
cited
from
the
1398

translation
by
John
Trevisa.
It
appears
to
be
a
description
of
major
depression,

agitated
type,
with
accompanying
anxiety;
a
disease
he
attributes
to
the
burning
of

black
bile,
which
corrupts
that
humor
into
a
pathological
state.
Note
that
this
is
not
a

reactive
depression,
or
an
exaggerated
response
to
grief
or
loss,
but
an
endogenous

depression:

Þe
pacient
is
feynt,
ferdful
in
herte
without
cause….And
soo
yf
we
aske
of

suche
why
they
fere
&
wherfore
they
ben
sory,
they
haue
noon
answere.

Some
wene
that
they
shoulde
dye
anon
unreasonably;
some
drede

enmyte
of
some
woo;
some
loue
&
desir
deth….

123

Gilbertus
Anglicus
differentiated
epilepsy
from
apoplectic
fits
and
fainting.
This

seems
a
clear
anticipation
of
the
differential
diagnosis
of
psychogenic
non-‐epileptic

seizures,
or
pseudoseizures,
a
diagnosis
that
can
be
so
difficult
to
make
by

observation
alone
that
it
can
be
definitively
diagnosed
only
by

electroencephalography.
Such
seizures
are
sometimes
feigned
for
secondary
gain
in

histrionic
and
borderline
illnesses,
but
are
now
believed
to
be
genuine
neurological

123

Ibid.,
23-‐24

113

events
of
psychogenic
origin,
common
in
hysterical
type
psychiatric
illnesses
and

conversion
syndrome.

Margery
Kempe,
on
pilgrimage
in
Jerusalem,
probably
exhibited
a
pseudoseizure,

or
at
least
her
fellow
pilgrims
thought
she
did:

&,
whan
Þei
cam
vp
on-‐to
Þe
Mownt
of
Caluarye,
sche
fel
down
pat
sche

might
not
stondyn
ne
knelyn
but
walwyd
&
wrestyd
wyth
hir
body,

spredyng
hir
armys
a-‐brode,
&
cryed
wyth
a
lowde
voys
as
Þow
hir
hert

xulde
brostyn
a-‐sundyr,
for
in
Þe
cite
of
hir
sowle
sche
saw
verily
&

freschly
how
owyr
Lord
was
crucifyed…sche
myt
not
kepe
her-‐self
fro

krying
&
roryng
Þow
sche
xuld
a
be
ded
Þerfor.

124

Upon
her
return
to
England
this
pattern
intensifies,
so
that
she
is
visited
by
these

neuropsychiatric
events
at
first
weekly,
then
daily,
until
at
one
point
she
receives

fourteen
in
one
day.
This,
unsurprisingly,
results
in
the
generalized
weakness
of

muscle
fatigue.
The
events
may
have
increased
in
frequency
and
duration
in

response
to
intensified
public
disapproval—or
possibly
to
increased
attention
in

general.
Again,
her
spectators
are
largely
unsympathetic:
“ne
Þei
wolde
not
beleuyn

but
Þat
sche
myth
an
absteynd
hir
fro
crying
ʒf
sche
had
wold.”

125

We
are
told
that

they
express
the
wish
that
she
could
be
put
to
sea
in
a
bottomless
boat.

Pseudoseizures
are
an
example
of
the
fact
that
the
determination
of
the
ways
in

which
mental
illness
is
specifically
neurological,
as
opposed
to
the
ways
in
which
all

behavior
is
neurological,
can
seem
hopelessly
fraught.

124

Sanford
Brown
Meech
and
Hope
Emily
Allen,
eds.
The
Book
of
Margery
Kempe.

EETS
212
(London:
Oxford
University
Press,
1940;
rpt.
1961)
68

125

Ibid.,
69

114

Interestingly,
Gilbertus
noted
that
psychiatric
patients
in
general
strongly
tended

to
refuse
their
medications.
Noncompliance
with
medication
remains
one
of
the

biggest
management
problems
in
contemporary
practice.
This
is
generally
ascribed

to
the
common
patient
complaint
that
the
medications
are
over-‐sedating—or,
more

intriguingly,
that
patients
“don’t
feel
like
themselves”
while
taking
them.
But
early

modern
psychotropic
medication
is
unlikely
to
have
mimicked
the
effects
of

contemporary
pharmacology.
This
recipe
for
melancholy
in
late
medieval
Spain,
for

example,
does
not
have
chemical
similarities
to
current
antidepressant

formulations:

“one
ounce
each
of
senna
[Cassia
senna]
and
epithymon;
two
ounces
of

lavender
sugar;
take
one
spoonful
each
day.”

126

Anatomy
of
Melancholy

Robert
Burton’s
Anatomy
of
Melancholy,
written
around
the
same
time
as

DesCartes
was
writing,
is
generally
agreed
to
reflect
medical
views
of
mental
illness

that
had
been
largely
stable
since
late
antiquity.
It
is
an
exhaustive
and
wonderfully

readable
compendium
of
causes,
symptoms
and
cures,
mostly
presented
in
a
tone
of

inconclusive
speculation.
Aside
from
this
lack
of
hubris
(possibly
attributable
to
his

own
long
term
clinical
depression)
it
reads
at
times
like
an
early
modern
DSM,
and
it

is
much
more
ambitious.

Burton’s
use
of
the
term
melancholy
is
broad,
but
most
often
refers
to
what
we

understand
as
depression.
He
speculates
on
origins
in
lifestyle,
“either
in
disposition

126

Solomon,
73

115

or
habit,”

127

and
of
course
in
the
humors.
Often
he
addresses
questions
of
agency,
as

in
the
misuse
of
the
Galenic
non-‐naturals:
exercise
and
repose;
sleep
and

wakefulness;
food
and
drink;
surfeit
and
excretion;
and
the
emotional
passions.
His

organization,
including
diagrams
and
flow
charts,
would
be
recognizable
in
medical

texts
today.
Consider
this
discussion
of
the
specifications
of
melancholy,
presented

early
in
the
volume
to
carve
it
out
from
other
types
of
mental
illness.
It
is
generally

defined
as
a
state
in
which
the
patients
“dote
in
most
things,
or
in
all,
belonging
to

election,
will,
or
other
manifest
operations
of
the
understanding”:

The
most
general
class
is
dotage,
or
anguish
of
the
mind,
saith
Aretaeus,

of
a
principal
part,
Hercules
de
Saxonia
adds,
to
distinguish
it
from

cramp
and
palsy,
and
such
diseases
as
belong
to
the
outward
sense
and

motions;
depraved,
to
distinguish
it
from
folly
and
madness
(which

Montaltus
makes
the
suffocation
of
the
mind,
to
separate)
in
which
those

functions
are
not
depraved,
but
rather
abolished;
without
an
ague,
is

added
by
all
to
sever
it
from
phrenzy,
and
that
melancholy
which
is
in
a

pestilent
fever.
Fear
and
Sorrow
make
it
differ
from
madness
[note:

probably
a
neurotic
/
psychotic
distinction]:
madness
without
a
cause
is

lastly
inserted,
to
specify
it
from
all
other
ordinary
passions
of
Fear
and

Sorrow.
We
properly
call
that
dotage,
as
Laurentius
interprets
it,
when

some
one
principal
faculty
of
the
mind,
as
imagination,
or
reason,
is

corrupted,
as
all
melancholy
persons
have.
It
is
without
fever,
because

the
humour
is
most
part
cold
and
dry,
contrary
to
putrefaction.
Fear
and

Sorrow
are
the
true
characters,
and
inseparable
companions,
of
most

melancholy,
not
all,
as
Hercules
de
Saxonia
well
excepts;
for
to
some
it
is

most
pleasant,
as
to
such
as
laugh
most
part;
some
are
bold
again,
and

free
from
all
manner
of
fear
and
grief,
as
hereafter
shall
be
declared.

128

He
notes
the
opinions
of
ancient
authorities
as
to
cause
(“a
privation
or
infection

of
the
middle
cell
of
the
head”)
and
notes
that
it
is
generally
defined
as
“a
kind
of

dotage
without
a
fever,
having
for
his
ordinary
companions
a
fear
and
sadness,

127

Robert
Burton,
The
Anatomy
of
Melancholy.
(Oxford,
1628;
rpt
Kila,
MT:

Kessinger
Publishing,
nd.)
125

128

Ibid.,
149

116

without
any
apparent
occasion.”
It
follows
upon
a
brief
speculation
as
to
causes,

including
some
question
as
to
whether
a
plethora
of
black
bile
is
a
cause
or
an
effect.

As
mentioned
in
the
discussion
of
etiology,
this
ambivalence
is
clearly
a
proto

modern
problem.

Madness
and
Creativity

Refinements
of
ancient
ideas
became
elaborate
with
the
logical
and
rhetorical

flowering
of
the
Scholastic
era.
Albertus
Magnus
considered
Aristotle’s
Problem

XXX,
the
assertion
that
the
melancholy
temperament
produced
great
and
creative

men,
and
boldly
restructured
it
by
claiming
that
exceptional
giftedness
resulted

from
a
happy
coincidence
when
a
person
with
a
melancholic
temperament

experienced
the
environmentally
caused
“melancholia
adusta,”
a
result
of
the

burning
of
the
black
bile:
if
this
process
proceeded
to
a
moderate
extent
only,

exceptional
giftedness
would
be
produced,
because
a
bit
of
heat
would
overcome

the
disadvantages
of
the
natural
coldness
and
dryness
of
the
melancholic

temperament
and
transform
it
into
the
warm
and
moist
physiological
environment

in
which
thoughts
and
ideas
are
engendered.
This
was
a
compromise
designed
to

overcome
what
Albertus
held
to
be
the
natural
disadvantages
of
the
melancholic

temperament,
and
make
a
genius
out
of
him
who
was
otherwise
destined
to
be,
in

Klibansky’s
words,
“the
unamiable,
gloomy,
dirty,
misanthropic,
suspicious
and

occasionally
kleptomaniac
creature
that
the
document
of
the
temperaments
had

made
him.”

129

This
also
represents
an
early
conception
of
mental
disorder
as

129

Klibansky
70

117

integrated
into
a
behavioral
continuum,
with
diagnoses
made
at
points
on
which

behavior
is
perceived
as
making
certain
departures
from
the
“normal
curve.”
This

prefigures
the
contemporary
debate
about
the
pathologizing
of
eccentric
behavior,

which,
it
is
argued,
makes
it
increasingly
“harder
to
be
normal.”
It
is
also
the
origin

of
the
trope
of
the
suffering
of
an
unstable
mind
as
essential
to
creative
genius.

Timothy
Leary’s
Dead

Somewhat
later
in
the
thirteenth
century
Antonio
Guainerio
of
Padua
revisited

the
predilection
of
depression
for
creativity.
Guainerio
was
a
physician
and
also
an

iatromathematician—a
scientist
specializing
in
the
medical
applications
of

mathematics,
mechanics
and
astrology.
This
discipline
was
a
product
of
the

development
within
Scholasticism
of
the
beginnings
of
medical
specialization
and

self-‐conscious
professionalism,
and
also
an
early
example
of
interdisciplinary

studies
in
the
arts
and
sciences.

Guainerio’s
theory,
like
those
of
his
contemporaries
William
of
Augverne
and

Albertus
Magnus,
presented
melancholy
as
potentially
benign—and
possibly

pregnant
with
creativity.
Guainerio
distained
the
role
of
spirits
and
demons
in

causing
mental
illness,
as
did
most
scientists,
but
he
went
on
to
substitute
an
elegant

explanation
that
was
also
metaphysical.
It
was
based
on
the
assertion
that
all

intellective
souls
are
born
equal,
and
endowed
with
all
the
knowledge
they
will
ever

obtain.
Once
incarnated
however,
the
soul
becomes
dependent
upon
bodily
organs

for
the
ability
to
“know”,
and
thus
immediate
access
to
primal
knowledge
is
lost.

118

Large
interpersonal
differences
in
knowledge
and
talent
subsequently
appear
over

the
lifetime
of
the
body,
due
to
physical
genetics
and
environmental
influences.

130

The
originality
of
Guainero’s
theory
lay
in
the
argument
that
profound

experiences-‐-‐such
as
certain
moments
of
the
deep
scholarship
classically
identified

with
acedia—cause
some
souls
to
become
momentarily
“unbound,”
and
to

experience
ecstasy.
During
these
events
the
soul
becomes
again
directly
intuitive

and
recalls,
or
“knows
again,”
all
that
it
knew
at
its
creation:
it
regains
its
native

intuition.
The
world
is
no
longer
foreign
and
irreducible.

The
insertion
of
this
“Timothy
Leary”
phenomenon
is
a
largely
unsung
event
in

the
long
history
of
the
theology
of
depression.
It
seems
to
me
very
likely
that

Guainero
personally
observed
conditions
we
would
now
diagnose
as
bipolar
mania

and/or
more
disorganized
psychotic
states,
or
at
least
that
he
read
accounts
of

these,
prior
to
conceiving
this
breakthrough.
Consider
this
discussion
on
madness

and
creativity,
recorded
with
Dr.
Julea
Leshar
McGhee,
attending
psychiatrist
at
Los

Angeles
County
/
USC
Medical
Center:

Dr.
McGhee:
Creativity
is
a
definite
quality
of
bipolar
disorder.

Classically
patients
who
are
manic
are
extremely
creative,
so
you’ll
see
a

lot
of
people
in
Hollywood
or
in
the
arts,
painters
and
writers,
who
are

manic,
because
it
sort
of
connects
you
to
a
whole
part
of
yourself
that’s

not
only
creative
but
very
productive.

Although
it
gets
to
a
point
where

it
drops
off
when
it
gets
really
bad:
but
in
the
early
stages
they
don’t

sleep,
they’ve
got
lots
of
energy,
and
their
mind
is
going
really
fast.
They

have
all
these
creative
ideas-‐-‐only
some
of
which
are
really
good;
but

they
don’t
necessarily
distinguish.
But
classically
that’s
when
they
make

beautiful
music
or
great
writing
or
painting
or
whatever
artistic
side
they

have.
That’s
documented.

130

Klibansky
96

119

MHF:
So
in
a
way,
at
least
with
some
diagnoses
at
early
phases,
they
could
be
more

in
touch
maybe
with
the
primal
threats;
with
Death
and
Evil;
closer
to

transcendence;
to
art…

Dr.
McGhee:

There
are
different
diseases
though;
you
can
get
psychotic

when
you
are
manic.
Psychotic,
meaning
you
lose
reality;
and
that’s
when

your
creativity
is
going
to
drop
off.
In
schizophrenia
they
don’t
have
that

creative
component
that
we’re
talking
about.
That
is
particular
to
the

diagnosis
of
bipolar
disorder.

Psychotics
are
the
most
profoundly
cognitively
impaired
of
all
the

diseases.
In
the
old
days
when
they
had
long
term
hospitals
for

schizophrenics
[the
caretakers]
just
sort
of
watched
the
disease
progress

without
medication;
they
just
sort
of
sat
there
with
a
book
and
watched

the
disease
progress
from
beginning
to
end.
And
if
you
look
at
a

schizophrenic
now,
when
they
get
old
their
cognitive
function
has
been

so
impaired
that
you
can’t
tell
if
they
are
demented
or
not,
so
that
is
the

difference
between
schizophrenia
and
the
other
diseases.
(emphasis

added)

To
the
modern
mind
Guainero’s
description
of
the
earth-‐bound,
incarnated
soul
is

a
depiction
of
profound
loss:
a
scenario
no
less
tragic
for
being
what
we
would

regard
as
philosophical
and
artistic
rather
than
scientific.
Indeed,
it
is
ineluctably

disturbing:
a
figuration
of
the
human
being
left
isolated
within
the
body;

maneuvering,
with
ambivalent
sensory
powers
that
gradually
weaken
and

constantly
disappoint,
in
a
world
that
is
frightening
and
unknown.
This
existential

state
is
represented
clinically
by
the
modern
medical
patient
with
pseudocoma,
or

“locked-‐in
syndrome”:
a
person
who
is
neurologically
impaired,
possibly
as
a
result

of
degenerative
disease
or
chemotherapy,
and
remains
intellectually
intact
but

completely
unable
to
communicate,
while
the
inert
body
is
kept
alive
by
technology.

In
other
words,
the
metaphorical
character
of
this
medieval
scientific
theory
is

translatable
into
a
twenty
first
century
context,
where
it
is
malevolently

transformed
by
the
modern
scientific
elision
of
the
metaphysical
hope
of

120

redemption.
Guainero’s
scenario
of
ultimate
release
is
pulled
into
the
Black
Hole
of

modernity.

But
of
course
this
is
a
function
of
looking
back
anachronistically
from
our

vantage
point,
in
an
intellectual
culture
in
which
the
tragedy
of
the
human
situation

is
openly
entertained—and
usually
assumed.
We
have
lost
the
faith,
and
often
even

the
hope,
that
our
situation
of
isolation
and
limitation
is
merely
a
sojourn.

Good
Wine
and
an
Enema:
Treatment
and
Healing

Interspersed
with
symptomatology
were
discourses
on
causes
and
treatment.

Gilbertus
Anglicus
suggested
removal
of
the
foul
products
of
corrupt
humors
with

“clysters,”
or
enemas,
and
phlebotomy,
and
also
the
burning
of
small
areas
on
the

cranium
believed
to
communicate
with
the
front
and
middle
ventricles,
or
“cells.”

131

Supportive
to
this
was
a
therapeutic
environment
of
rest,
good
food
and
light
wine,

and
pleasant
diversion,
including
a
bath
followed
by
a
gentle
rubdown
(cum
mapa

subtili
et
molli).

Gilbertus
regarded
catalepsy,
a
neuropsychiatric
state
of
motor
weakness
and

rigidity,
as
a
form
of
epilepsy
and,
although
he
admits
to
having
never
known

epilepsy
to
be
curable
except
in
children
who
outgrew
it,
he
listed
some

documented
treatments,
including
human
bone
ash
and
the
rib
of
a
hanged
man.

Clarke
cites
a
fascinating
clinical
diagnostic
tool
devised
by
Avicenna
in
the
tenth

century
to
diagnose
lovesickness,
which
uncannily
anticipates
both
Freudian
word

association
and
forensic
lie
detectors.
The
physician
records
pulse
changes
in

131

Clarke
91

121

association
with
the
presentation
of
special
words
in
a
planned
sequence.
Some
of

these
denoted
local
sites,
from
towns
to
personal
homes,
progressing
in
specificity

to
the
names
of
individuals.
On
the
basis
of
these
results
the
clinician
would
locate

the
source
of
the
depression
in
a
certain
lady,
and
devise
a
treatment
plan
based
on

negative
association:
“The
girl’s
face
is
the
patient’s
cure.”

132

Aversion
treatment
was
used
for
such
cases
of
depression.
One
version
was

employed
to
treat
an
extreme
reaction
to
rejection
by
a
lover:
a
hideous
old
woman

was
hired
to
insult
and
denigrate
the
lost
love
to
her
swain,
breaking
the
power
of

her
charms
over
his
wellbeing.
Since
the
person
so
prone
to
extreme
reactions
to

emotional
abandonment
would
presumably
possess
a
suggestible
personality

structure,
the
experience
of
seeing
the
love
object
in
this
new
light
could
potentially

be
a
watershed.

The
use
of
shock
treatment
for
depression
also
has
medieval
roots.
The

effectiveness
of
such
an
approach
has
long
been
noted,
although
its
side
effects
have

made
it
controversial:
the
danger
and
extreme
discomfort
of
early
twentieth
century

insulin
shock
and
the
memory
loss
associated
with
electroshock
have
caused
both

treatments
to
be
regarded
as
more
abuse
than
therapy,
much
like
the
therapeutic

beatings
that
were
prescribed
for
early
modern
patients
from
time
to
time.

(Typically
this
treatment
modem
was
reserved
for
the
healthy
young
adult.)
In

contrast,
the
following
treatment
for
“faintness
of
the
spirits”—presumably
a

depressive
category
or
categories—may
have
been
rather
brief
and
the
results
more

effective:

132

Ibid,
89

122

The
patient
being
laid
on
the
anvil
with
his
face
uppermost,
the
smith

takes
a
big
hammer
in
both
his
hands,
and
making
his
face
all
grimace,
he

approaches
his
patient;
and
then
drawing
his
hammer
from
the
ground,

as
if
he
designed
to
hit
him
with
his
full
strength
on
the
forehead,
he
ends

in
a
feint,
else
he
would
be
sure
to
cure
the
patient
of
all
diseases;
but
the

smith
being
accustomed
to
the
performance,
has
a
dexterity
of
managing

his
hammer
with
discretion;
though
at
the
same
time
he
must
do
it
so
as

to
strike
terror
in
the
patient;
and
this,
they
say,
has
always
the
desired

effect.

133

The
restraint
of
the
limbs
with
leather
or
chains
was
prescribed,
as
it
is
now
(no

chains
anymore;
even
the
traditional
leather
belts
have
been
replaced
over
the
past

ten
years
with
more
hygienic
plastic).
The
contemporary
legal
requirements
of

elaborate
documentation
of
the
physician’s
order
and
of
medical
necessity;
of
the

failure
or
contraindication
of
sedative
medication,
which
is
referred
to
as
“chemical

restraint,”
and
is
considered
more
humane;
and
the
ritual
notation,
sometimes
every

fifteen
minutes,
of
the
monitoring
of
patient
environment
and
vital
signs
are

testimony
to
our
reluctant
acceptance
of
the
requirement,
in
some
situations,
to
fall

back
on
controlling
madness
with
timeless,
primitive
means:
“The
medycynes
of

theym
is
that
he
be
bounde
that
he
ne
hurte
not
himself
and
other
men.”

134

It
was

observed,
then
as
now,
that
the
use
of
restraints
should
be
weighed
against
their

tendency
to
enrage
the
patient
further.

Perafrenzy
is
particularly
amenable
to
milieu
therapy.
The
reference
to
excessive

study
implies
that
clerical
acedia
would
fall
into
the
category
of
a
perafrenzy.

Documentation
that
monks
who
left
the
cloister
and
married
were
cured
of
their

depressions
support
this
hypothesis.

133

Ibid.,
108

134

Doob
27

123

True
frenzy
was
a
dark
and
complex
problem.
Bartholomeus
offered
clinical

advice
that
the
frenetic
patient
should
sometimes
be
deprived
of
sensory

stimulation,
presumably
to
lighten
the
load
of
internal
stimuli:
“Dyuerse
shapes
of

faces
and
semblaunt
of
payntynge
shall
not
be
shewed
tofore
hym,
leest
he
be

encomryd
with
woodnesse.
All
that
ben
abowte
hym
shall
be
commaundyed
to
by

styll
and
in
scylence:
men
shall
not
answere
to
his
nyce
wordes.”

135

This
seems
to

be
following
the
same
principle
as
the
modern
isolation
room—which,
like

restraints,
is
considered
an
extreme
measure,
the
necessity
of
which
must
be

carefully
documented.
The
passage
also
includes
the
warning
that
chronic
patients

may
become
adept
at
manipulation.

“An
Enormous
Loathing”:
The
Noonday
Demon
of
Acedia

Not
all
medieval
psychiatric
diagnoses
are
transferrable
to
a
modern
context.

When
a
member
of
the
clergy
exhibited
severe
depressive
symptoms,
these
were

usually
diagnosed
as
a
special
ailment.

This
diagnosis,
called
acedia
or
accidie,

appears
at
a
point
at
which
the
metaphysical
matrix
of
medieval
psychology
is

particularly
thin:
the
appearance
of
a
disease
for
which
the
cultivation
of
holiness
is

revealed
to
be
medically
pathogenic.
This
is,
to
the
medieval
mind,
a
moment
of
pure

and
dangerous
absurdity.

As
early
as
380
Chrysostom
wrote
an
exhortation
to
a
monk
named
Stagirius,

who
suffered
from
“terrifying
nightmares,
disorders
of
speech,
fits
and
swooning;
he

135

Ibid.,
26

124

despaired
of
his
salvation,
and
was
tormented
by
an
irresistible
urge
to
commit

suicide”:

and
what
rendered
him
completely
desperate
was
the
fact—a
very

natural
one,
the
physicians
would
have
said—that
none
of
this
had
come

upon
him
until
his
entrance
into
monastic
life,
and
that
he
could
see

some
of
his
fellow
sufferers
immediately
cured
of
their
illness
when
they

came
out
into
the
world
again
and
married.

136

Instead
of
a
seasonal
rhythm,
this
form
of
melancholia
had
a
circadian
one.
It
was

called
the
“midday
demon,”
because
it
was
said
to
visit
scholarly
clerics,
particularly

cloistered
ones,
in
the
tedium
of
afternoon.
But
acedia
is
more
than
boredom

progressing
to
ennui.
Most
recorded
cases—what
we
would
now
loosely
term

“clinical”
cases,
meaning
that
they
are
concerning
enough
to
come
to
professional

attention,
now
typically
in
“clinics”—appear
to
have
involved
a
spectrum
of
acute

manifestations.
Numerous
texts
document
the
afflicted
clergy
as
suffering
from

lethargy,
muscle
aches,
hopelessness,
inability
to
concentrate,
sleep
disorders,

persistent
anhedonia
and
suicidal
ideation.

A
culture
that
consigned
a
large
portion
of
the
population
to
lives
of
social

isolation
and
paucity
of
stimulation
apparently
incurred
a
significant
public
health

problem.
Kilbansky
notes
that
“the
existence
of
a
mental
illness
which
overtook
the

pious
and
unworldly,
not
in
spite
of
their
piety
and
unworldliness,
but
because
of
it,

should
have
appeared
a
particularly
vexing
problem
for
Christian
moral

philosophy.”

137

136

Klibansky
76

137

Ibid.,
75

125

The
concept
of
acedia
originated
in
ancient
monasticism
and
evolved
over

centuries,
undergoing
extensive
codification
by
the
Scholastics
and
persisting
into

the
Renaissance.
Such
a
culturally
fraught
situation
naturally
generated

ambivalence.
Originally
these
depressive
symptoms
were
identified
with
the
sin
of

sloth,
and
this
connection
persisted—as
it
still
does,
to
some
extent.
But
the
problem

could
not
always
be
adequately
addressed
by
attribution
to
lassitude
and
solipsism.

The
question
of
personal
agency
in
patients
with
mild
or
early
depression
is

implicit
in
many
treatments
of
acedia.
This
one,
by
Evagrius,
an
Egyptian
desert

monk
of
the
fourth
century,
appears
to
blame
the
disease
rather
than
the
patient
in
a

manner
that
is
congruent
with
contemporary
practice:

[The]
“noonday
demon”
is
the
most
oppressive
of
all
demons.
He
attacks

the
monk
about
the
fourth
hour
and
besieges
his
soul
until
the
eighth

hour.
First
he
makes
the
sun
appear
sluggish
and
immobile,
as
if
the
day

had
fifty
hours.
Then
he
causes
the
monk
continually
to
look
at
the

windows
and
forces
him
to
step
out
of
his
cell
to
gaze
at
the
sun
and
to

see
how
far
it
still
is
from
the
ninth
hour…..the
demon
sends
him
hatred

against
the
place,
against
life
itself,
and
against
the
work
of
his
hands,

and
makes
him
think
he
has
lost
the
love
among
his
brethren
and
that

there
is
none
to
comfort
him.

138

The
Carthusian
monk
Adam
Scot
takes
a
similar
approach
eight
hundred
years

later,
describing
the
torment
of
acedia
as
an
inexplicable
visitation
rather
than
a

failure
of
nerve:

Oftentimes,
when
you
are
alone
in
your
cell,
a
certain
inertia,
a
dullness

of
the
mind
and
disgust
of
the
heart
seize
you.
You
feel
an
enormous

loathing
in
yourself.
You
are
a
burden
to
yourself,
and
that
internal
joy

you
used
so
happily
to
experience
has
left
you.
The
sweetness
that
was
in

you
yesterday
or
the
day
before
has
turned
into
great
bitterness;
the

138

Siegfried
Wenzel,
The
Sin
of
Sloth:
Acedia
in
Medieval
Thought
and
Literature.

(Chapel
Hill:
University
of
North
Carolina
Press,
1967)
5

126

stream
of
tears
with
which
you
used
to
be
bathed
so
abundantly
has

totally
dried
up.
The
spiritual
vigor
in
you
has
withered,
your
inner
calm

lies
dead.
Your
soul
is
torn
to
pieces,
confused
and
split
up,
sad
and

embittered.
When
you
try
to
appease
her,
you
cannot
do
it.
Your
reading

does
not
please
you;
prayer
brings
no
sweetness;
you
cannot
find
the

customary
sweet
showers
of
spiritual
meditations.

139

Still,
while
the
tone
is
overtly
sympathetic,
the
sufferers
in
both
accounts
are

depicted
as
indecisive
and
ineffectual.
This
ambivalence
about
depression
and
those

who
claim
it
persists
today,
and
may
be
inescapable
when
talking
about
non-‐
psychotic
mental
disorders
in
which
the
patient
is
perceived
to
retain
some
degree

of
volition.

I
will
not
attempt
to
treat
the
theological
development
of
acedia
at
length,
except

to
emphasize
that
although
it
encompassed
classic
symptoms
of
illness,

concentrated
on
the
depressive
continuum,
acedia
was
unique
among
behavioral

diagnoses
in
that
it
was
almost
always
considered
more
as
a
character
flaw
than
a

psychiatric
disorder.
The
normative
prescription
was
for
intensified
prayer
and

discipline:
the
opposite
of
the
soothing
regimen
of
milieu
therapy
recommended
for

secular
melancholics.
A
modern
analogy
might
be
made
with
post
traumatic
stress

disorder,
military
victims
of
which
were
excoriated
for
cowardice
in
the
wars
before

the
early
twenty
first
century.
Other
incidences
of
mental
disorder
that
relate

directly
to
personal
or
social
situation,
such
as
post
partum
depression
and

complicated
grief
disorder,
are
not
similarly
stigmatized.

When
the
original
explanation,
that
of
blaming
the
victim
for
insufficient

discipline,
proved
inadequate
to
address
extreme
and
intractable
disability,
another

139

Ibid.,
33

127

could
be
deployed:
madness
was
a
suffering
visited
by
God
upon
His
finest,
just
as

He
delivered
physical
torment
to
His
martyrs,
as
a
special
gift.
William
of
Auvergne’s

reading
of
Aristotle’s
Problem
XXX
supported
the
idea
of
suffering
as
a
price
of

excellence.
William
declared
the
melancholic
temperament
to
be
the
one
most

favorable
for
salvation-‐-‐as
opposed,
for
example,
to
the
dull
lassitude
of
the

phlegmatic,
which
does
not
lend
itself
to
creativity,
and
“benefits
none
of
the

faculties
of
the
soul.”

140

In
a
triumph
of
Christian
scholarship,
William
argued—in

Klibansky’s
words—that
while
“too
deep
an
immersion
in
supernatural
matters
and

too
glowing
a
fervor
might
cause
a
melancholic
complexion
to
develop
into
a

melancholic
disease,”
this
outcome
is
properly
interpreted
as
a
gift
of
holy
suffering

and
an
investment
in
the
soul’s
salvation.
He
asserted,
moreover,
that
even
in
the

deepest
throes
of
illness
such
holy
scholars
retained
the
gift
of
revelation.

In
this,
Klibansky
notes,
William
was
“speaking
entirely
as
a
theologian,

concerned
far
less
with
the
scientific
basis
of
the
Aristotelean
thesis
than
he
was

with
its
interpretation
in
terms
of
Christian
moral
philosophy.”
Presumably
he
was

not
thinking
clinically,
either.
It
is
difficult
for
us,
living
in
a
culture
in
which

theology
is
no
longer
regarded
as
an
intrinsic
factor
in
human
health
and
an

indispensable
sociological
force,
to
comprehend
that
William
was
not
necessarily
in

conflict
with
medicine.
A
modern
clergyman
who
considered
mental
illness
to
be
a

gift
of
suffering
would
not
find
his
contribution
respectfully
considered
by
the

medical
community.

140

Klibansky
73

128

While
academic
physicians
shared
with
William
of
Auvergne
the
assumption
that

protracted
periods
of
intense
thought
were
productive
of
psychiatric
illness,
in

practice
they
considered
this
a
medical
risk
factor
rather
than
an
exalted
lifestyle.

Klibansky
describes
the
medical
view
of
the
state
as
one
of

“alienation.”
141

It
was,

broadly
speaking,
a
‘hygiene’
problem,
meaning
a
misuse
of
the
non-‐naturals:
in
this

case,
the
“passions.”
Governing
the
passions
required
husbanding
emotional
and

intellectual
energies
to
effect
balance
and
moderation.
Genetic
temperament
could

predispose
the
patient
to
a
given
mental
malady,
and
subsequent
immoderate
use
of

the
non-‐naturals
could
seal
his
fate.
“Mental
hygiene,”
a
somewhat
precious

construct
of
modern
public
health,
finds
a
clear
parallel
in
the
medieval
emphasis
on

the
proper
uses
of
foods
and
the
regulation
of
physical
habits,
the
control
of
the

emotions,
and
perseverance
in
Faith,
which
translates
loosely
into
minimizing

anxiety
and
maintaining
an
optimistic
outlook.
These
factors
are
also
particularly

emphasized
today
within
the
alternative
health
industry.

Madness
as
Metaphor

The
diagnosis
of
acedia
is
particularly
useful
for
the
examination
of
madness
as

metaphor
in
the
medieval
mind,
because
it
posed
an
explicit
challenge
to
the

Christian
medical
paradigm
and
required
an
urgent
response.
The
solution
was
to

escape
this
logical
and
philosophical
problem
by
sequestering
it—writing
a
codicil,

so
to
speak—and
creating
a
footnote
diagnosis,
in
which
this
form
of
major

141

Ibid.
94

129

depression
was
attributable
to
either
of
two
dramatically
divergent
etiologies:
a

clear
and
purposeful
Divine
visitation
in
response
to
spiritual
excellence,
or

mediocrity
and
failure
of
nerve.
In
either
case
the
illness
was
diagnosed
in
a
way

that
similar
symptoms
in
secular
citizens
were
not.

As
in
cases
of
demonic

possession,
the
treatment
of
acedia
was
removed
from
medicine
and
relocated

within
the
scope
of
clerical
practice.

Thus
David
of
Augsburg,
who
generally
insists
on
blaming
the
patient,
adds
the

disclaimer
that
overabundance
of
melancholic
humors
can
play
a
role:
“in
which

case
it
behooves
the
physician
rather
than
the
priest
to
prescribe
a
remedy.”

Although
William
Langland
did
not
address
the
clerical
disease
per
se,
his

treatment
of
the
problem
of
depression,
in
which
he
showed
considerable
interest,

also
tends
toward
the
ethical
as
opposed
to
the
medical
view.
He
suggests
that

severe
dejection
is
the
result
of
a
long
period
of
laziness
and
dissolution.
Never
one

to
push
the
theological
envelope,
Langland
is
confident
that
the
condition
should
be

addressed
with
energetic
works
of
a
virtuous
nature.
He
does
not
consider
the

question
of
a
suicidal
outcome.
He
does,
however,
acknowledge
the
loss
of
Faith
as
a

possibility,
albeit
only
as
an
aside:

Thus
it
goes
with
people
who
falsely
all
their
lives

Lived
in
evil
and
did
not
cease
from
it
until
life
forsook

them;

Then
the
fear
of
despair
drives
away
grace

So
that
the
thought
of
mercy
cannot
come
into
their
minds.

Good
hope,
which
should
help
them,
turns
into
wanhope—

Not
that
God
has
no
power,
not
that
He
is
not
mighty
enough

To
amend
all
that
is
amiss,
or
that
His
mercy
is
not
greater

Than
all
our
wicked
deeds,
as
holy
Writ
says,
Misericordia

Eius
super
omnia
opera
eius,--

But
before
His
justice
can
turn
into
mercy,
some
restitution

is
needed;

130

Sorrow
is
enough
satisfaction
for
the
man
who
cannot
repay

God.
(II.
305-‐14)

William
of
Augsburg,
on
the
other
hand,
confronts
suicide
as
a
frequent
outcome

of
acedia:

The
first
[kind
of
accidia]
is
a
certain
bitterness
of
the
mind
which
cannot

be
pleased
by
anything
cheerful
or
wholesome.
It
feeds
upon
disgust
and

loathes
human
intercourse.
This
is
what
the
Apostle
calls
the
sorrow
of

the
world
that
worketh
death.
It
inclines
to
despair,
diffidence,
and

suspicions,
and
sometimes
drives
its
victim
to
suicide
when
he
is

oppressed
by
unreasonable
grief.
Such
sorrow
arises
sometimes
from

previous
impatience,
sometimes
from
that
fact
that
one’s
desire
for
some

object
has
been
delayed
or
frustrated….The
second
kind
is
a
certain

indolent
torpor
which
loves
sleep
and
all
comforts
of
the
body,
abhors

hardships,
flees
from
whatever
is
hard,
droops
in
the
presence
of
work,

and
takes
its
delight
in
idleness.
This
is
laziness
proper.

142

Ironically,
the
specifically
clerical
illness
seems
sometimes
to
have
culminated
in

the
ultimate
insult
to
Christian
philosophy:
and
if
this
happened
often
enough
to
be

mentioned
in
multiple
sources,
the
actual
incidence
may
have
been
significant.

From
a
certain
viewpoint
of
historical
criticism
it
would
be
possible
to
argue
that

acedia
is
an
artifact:
a
discrete
diagnostic
entity,
specific
to
medieval
society
and
to

monastics
in
particular,
and
one
which
has
no
modern
parallel.
But
historical
and

contemporary
studies
in
medical
anthropology
suggest
that
the
existence
of
such
a

culturally
sequestered
disease
is
unlikely,
and
that
acedia
should
be
considered
a

unique
cultural
expression
of
a
depressive
event.

In
either
case,
the
history
of
acedia
is
a
testimony
to
the
pathology
of
despair—
the
elephant
in
the
room
for
early
Christian
psychiatry.
Borrowing
Sontag’s

description
of
the
perception
of
death
in
contemporary
culture,
existential
despair

142

Wenzel
160

131

in
the
Middle
Ages
is
“the
obscene
mystery,
the
ultimate
affront,
the
thing
that

cannot
be
controlled.
It
can
only
be
denied.”

143

We
are
necessarily
less
reticent

about
despair:
we
are,
in
fact,
“at
home”
with
it.
That
is
the
reason
for
our
cultural

nostalgia
for
what
we
think
of
as
medieval
life.

“The
Sleep
Necessary
to
Life”:

The
Question
of
Suicide

Acedia
is
an
important
diagnostic
in
medieval
psychology,
created
to
support
its

intellectual
structure
at
a
point
at
which
the
membranous
filter
separating
the

eternal
and
the
temporal,
the
mundane
and
the
eternal,
is
torn,
and
a
brief
glimpse

of
absurdity
becomes
possible.

The
problem
of
‘acedial
suicide’
is
therefore
particularly
fraught.
Christianity

offers
no
scenario
for
intentional
escape
from
earthly
suffering,
other
than

martyrdom
or
holy
war.
More
importantly,
this
theology
insists
that
physical
self-‐
murder
is
worse
than
pointless:
it
dooms
the
sufferer
to
immensely
greater
torment

for
a
timeless
eternity.
Suicide
is
not
an
option
for
someone
who
actually
believes

this.

It
is
therefore
impossible
to
escape
the
implication
that
the
systemic
breakdown

represented
here
is
not
merely
Langland’s
notion
of
a
failure
of
Faith,
or
of

doubtfulness
of
the
ability
or
willingness
of
God
to
forgive
and
to
save.
It
is
a
critical

foundering
of
Belief
itself.
This
suggests
an
implicit
acknowledgement
of
the
Absurd:

a
largely
unexamined
presence
in
medieval
culture.
Paul
Tillich
writes:

Even
if
the
so-‐called
arguments
for
the
“immortality
of
the
soul”
had

argumentative
power
(which
they
do
not
have)
they
would
not
persuade

143

Sontag
54

132

existentially.
For
existentially
everybody
is
aware
of
the
complete
loss
of

self
which
biological
extinction
implies.
The
unsophisticated
mind
knows

instinctively
what
sophisticated
ontology
formulates:
that
reality
has
the

basic
structure
of
self-‐world
correlation
and
that
with
the
disappearance

of
the
one
side,
the
world,
the
other
side,
the
self,
also
disappears,
and

what
remains
is
their
common
ground
but
not
their
structural

correlation.

144

Suicidal
ideation
in
the
medieval
person
who
lives
for
holiness
is
an
implicit

acknowledgement
that
God
might
not
exist.
Seven
centuries
later,
another
kind
of

philosopher
would
write:
“There
is
but
one
truly
serious
philosophical
problem,
and

that
is
suicide.”

145

Just
as
medieval
people
eschewed
the
demarcation
of
boundaries
between

physical
and
behavioral
illness—barriers
that
modern
psychiatry,
as
we
have
seen,

is
increasingly
discarding
as
imaginary—the
boundary
between
clinically
crazy
and

spiritually
incorrect
was
indistinct,
and
persons
who
experienced
profound

religious
doubt
were
sometimes
perceived
by
others
as
mad.
They
in
turn
might

experience
these
episodes
as
periods
of
illness,
and
the
anxiety
and
dread
attendant

upon
them
could
be
such
that
this
evaluation
was
often
realistic.

An
atheist

impulse—or
even
the
suggestion
of
such-‐-‐was
not
only
profoundly
antisocial;
it
was

potentially
destructive
of
the
basis
of
personal
sanity
in
a
way
in
which
no
non-‐
normative
belief
could
be
similarly
dangerous
today.

The
eleventh
century
monk
Otloh
of
St.
Emmeram,
who
wrote
a
spiritual
memoir

described
by
Michael
Goodich
as
unusually
self-‐aware
and
rivaling
Augustine
in
its

144

Paul
Tillich,
The
Courage
to
Be.
(New
Haven:
Yale
University
Press,
1952)

42.

145

Camus,
Sisyphus,
3.

133

frankness,
146

experienced
a
period
of
broken
sleep,
during
which
he
would
awaken

heavily
fatigued
(a
phenomenon
we
would
now
call
“non
restorative
sleep”)
and

with
generalized
body
aches.
These
are
classic
symptoms
of
medieval
acedia,
and
of

fibromyalgia
today.
His
anxiety
and
depression
are
soon
personified
in
the

appearance
of
the
Devil,
who
excoriates
him
verbally,
relentlessly
goading
the
monk

to
blaspheme:

“Do
you
think,”
he
said,
“that
such
an
evil
man
can
be
pardoned
by
God,

the
strictest
judge
of
all?
How
is
it
possible,
since
it
is
written,
‘Scarcely

the
just
will
be
saved’
[Peter
4.18].
Stop
wanting
what
ought
not
to
be

desired,
but
rather
strive
for
what
is
attainable.”

147

Otloh’s
Devil
does
not
argue
that
God
does
not
exist.
This
is
evidence
that
the

integrity
of
the
rational
faculty
survives
his
breakdown:
the
imaginary
interrogator

himself
could
not
‘exist’,
if
God
did
not.
Instead
the
Devil
argues
only
that
God
will

fail
to
save
Otloh,
who
is
therefore
a
fool
to
deny
himself
worldly
pleasure
in
an

effort
to
petition
for
what
will
not
be
granted.

And
yet,
in
the
worst
throes
of
the
depression,
Otloh
himself
entertains
a
detailed

atheistic
argument,
while
refusing
to
name
it
as
such.
It
is
a
fascinating
narrative
of

medieval
self-‐revelation,
only
part
of
which
is
also
self-‐aware:

although
I
never
lost
my
faith
(by
the
grace
of
God)
or
the
hope
of
help

from
heaven,
I
felt
tormented
for
a
long
period
of
time
by
doubts

concerning
the
knowledge
of
Holy
Scripture
and
even
the
very
essence

(essentia)
of
God
Himself.
Although
in
the
course
of
other
delusions
I

experienced
a
moment
of
peace
and
a
refuge
of
hope,
in
this
case
I

experienced
scarcely
any
solace
for
many
long
hours.
In
the
past,
I
had

been
strengthened
by
Holy
Scripture.
I
had
been
aided
against
the

arrows
of
death
by
the
arms
of
faith
and
hope.
In
this
case,
however,
I

was
surrounded
by
every
doubt
and
blindness
of
mind,
so
that
I
was

146

Ibid.,
159

147

Ibid.,
160-‐161

134

unsure
there
was
any
truth
whatsoever
in
Sacred
Scripture,
and
whether

God
was
in
fact
omnipotent….
148

Unable
to
surrender
to
such
profound
doubts,
Otloh
again
personifies
them
as

coming
from
the
Devil:

Oh
most
foolish
of
mortals,
can’t
you
prove
from
your
own
circumstances

that
both
the
evidence
of
Scripture
and
the
imagination
of
every
creature

lack
both
reason
and
order?
Haven’t
you
noticed
by
experience
that,
on

the
one
hand,
the
reports
found
in
divine
books
and,
on
the
other
hand,

the
lives
and
behavior
of
men
contradict
each
other?
Do
you
actually

believe
that
those
thousands
of
men
who
neither
observe
nor
accept

Holy
Scripture
are
in
error,
as
a
person
like
you
has
seen
so
far?....Idiot!

those
Scriptures
in
which
you
put
your
trust
concerning
the
person
of

God
and
many
religious
questions
merely
provide
explanations
about

how
those
who
composed
the
Scriptures
once
lived.
People
lived
in
those

days
as
they
do
today.
As
you
know,
upright
religious
persons
today
say

one
thing
and
do
another….If
there
were
such
a
person
as
God
and
if
He

were
omnipotent,
this
kind
of
confusion
and
diversity
in
all
matters

would
not
exist.

149

Otloh
is
spared
the
contemplation
of
suicide
by
a
spontaneous
recovery.

Interestingly,
this
is
not
figured
in
the
context
of
dialogue
with
supernatural

personages,
but
as
an
inchoate
visitation.
At
a
certain
point
he
cries
out
in
despair:

“Who
are
you,
Omnipotent
One?....I
can
no
longer
endure
such
pain.”

150

The
pain
is

then
lifted,
apparently
without
requiring
resolution
in
rational
argument:
“Without

any
delay
not
merely
was
I
freed
by
God’s
grace
not
only
from
the
slightest
shadow

of
doubt,
but
such
a
light
of
knowledge
shone
in
my
heart
that
I
was
never
again
to

suffer
the
deadly
darkness
of
doubt.”

148

Michael
Goodich,
ed.
The
Other
Middle
Ages:
Witnesses
at
the
Margins
of

Medieval
Society
(Philadelphia:
University
of
Pennsylvania
Press,
1998,
162,

italics
added.

149

Ibid.,
163,
italics
added.

150

Ibid.,
164

135

Otloh
escapes
the
dark
night
of
the
soul
by
renouncing
reason.
He
refuses
to

accept
the
rock
of
Sisyphus,
and
it
is
interesting
to
speculate
as
to
whether
he
could

have
moved
it.

William
Barrett
has
defined
faith
and
reason
as
“fundamentally
different

functions
of
the
human
psyche.”

151

He
argues
that
Christianity,
unlike
the
faith
of

the
ancient
Hebrews
that
predated
the
Greek
invention
of
rational
philosophy,
is

not
only
faith
beyond
reason,
but,
if
need
be,
against
reason.
This

problem
of
the
relation
between
faith
and
reason,
stated
by
St.
Paul,
is

not
only
the
root
problem
for
centuries
of
Christian
philosophers
to

come,
it
is
the
root
itself
of
later
Christian
civilization.

152

Otloh’s
resilient
mental
health
and
instinct
for
self-‐preservation
rescues
him
in

the
end,
but
profound
religious
doubt
of
this
sort
sometimes
led
to
dangerous

despair
and
to
suicide.
This
is
a
possibility
to
one
who
is
convinced
of
the

inevitability
of
perdition,
whose
impulse
to
escape
immediate
distress
has
reached

such
a
pitch
that
it
culminates
in
the
mindless
impulse
to
flee
this
guilt,
the

complexity
of
which
he
does
not
understand.
This
is
the
suicide
of
Judas.

Such
was
Dante’s
self-‐murdered
Pietro
delle
Vigne,
the
thirteenth
century
Italian

diplomat
falsely
accused
of
treason
and
imprisoned
by
Frederick
II,
who
faces

eternity
transformed
into
a
tree
in
the
seventh
circle
of
hell,
the
Wood
of
the

Suicides:

My
mind,
because
of
its
disdainful
temper,

believing
it
could
flee
distain
through
death,

made
me
unjust
against
my
own
just
self….(70-‐72)

151

Barrett
93

152

Ibid.,
92,
italics
added.

136

Like
other
souls,
we
shall
seek
out
the
flesh

that
we
have
left,
but
none
of
us
shall
wear
it;

it
is
not
right
for
any
man
to
have

what
he
himself
has
cast
aside.
We’ll
drag

our
bodies
here;
they’ll
hang
in
this
sad
wood,

each
on
the
stump
of
its
vindictive
shade.
(103-‐108)

In
this
context,
the
words
of
Camus,
who
referred
to
faith
in
supernatural
sources

of
salvation
as
“the
sleep
necessary
to
life,”
are
worth
quoting
at
length:

In
a
sense,
and
as
in
melodrama,
killing
yourself
amounts
to
confessing.

It
is
confessing
that
life
is
too
much
for
you
or
that
you
do
not

understand
it….Living,
naturally,
is
never
easy.
You
continue
making
the

gestures
commanded
by
existence
for
many
reasons,
the
first
of
which
is

habit.
Dying
voluntarily
implies
that
you
have
recognized,
even

instinctively,
the
ridiculous
character
of
that
habit,
the
absence
of
any

profound
reason
for
living,
the
insane
character
of
that
daily
agitation,

and
the
uselessness
of
suffering.

153

I
submit
that
it
is
not
anachronistic
to
argue
that
the
idea
of
the
absurdity
of
the

human
condition
was
accessible
to
medieval
understanding.

Possession

The
idea
that
early
modern
explanations
of
mental
disorder
inevitably
derived

from
demoniacal
and
other
spiritual
possession,
possibly
effected
through
magic
or

witchcraft,
became
ensconced
in
twentieth
century
medievalism
through
the
work

of
influential
medical
historians
such
as
Gregory
Zilboorg,
the
Russian

psychoanalyst
who
died
in
1959,
and
Franz
G.
Alexander
and
Sheldon
T.
Selesnick,

authors
of
The
History
of
Psychiatry,
published
in
1967.

The
debunking
of
the
‘possession’
hypothesis
has
not
been
thorough-‐-‐and
this
is

not
a
completely
bad
thing.
While
the
horror-‐movie
fascination
of
possession
theory

153

Camus,
Sisyphus,
5

137

has
been
historically
misleading,
it
has
its
roots
in
two
larger
truths,
which
are
the

metaphysical
nature
of
the
medieval
understanding
of
mental
illness
and
the

importance
of
public
spectacle
in
affirming
communal
beliefs
and
norms
in
the

medieval
period.

Possession
was,
moreover,
a
diagnostic
category.
It
was
honored,
if
often
in
the

breach,
by
academic
medicine,
and
it
was
included
in
a
thorough
professional

differential
diagnosis.
If
true
possession
was
determined,
the
physicians
would,
as

we
now
say,
“endorse”
the
diagnosis
and
“sign
off”
on
the
case,
which
would
then
be

remanded
to
the
clergy
for
further
treatment.

When
this
diagnosis
was
decided
upon—determined,
after
serious
consideration,

not
to
represent
an
artifact-‐-‐physicians
may
have
regarded
it
as
in
similar
situations

now,
when
clinicians
encounter
the
unexpected:
an
exciting
discovery;
a

professional
“eureka”
moment.
If
Gilbertus
Anglicus
had
access
to
a
medical
journal,

he
might
have
submitted
such
a
finding,
with
a
title
like
“An
Unusual
Case
of

Phrenesis
Secondary
to
Demoniac
Possession:
Case
Report
and
Review
of

Literature.”

Ironically,
titles
like
this,
while
unusual,
may
be
found
in
contemporary
medical

libraries.
This
exotic
neuropsychiatric
phenomenon
is
still
with
us:
a
particularly

strange
case
of

“parallel
survival.”
A
PubMed
search
on
psychiatry
and
possession

today
yields
many
hits.
Most
of
these
authors
consider
the
phenomenon
as
it
is

integrated
into
the
patient’s
personal
belief
system
and
manifests
in
pathological

ways,
usually
as
hallucinations
or
dissociative
states.
Some
suggest
that
the
belief

138

can
be
mobilized
in
effecting
individual
cures,
and
virtually
all
counsel
respect
for

the
belief
as
a
matter
of
dignity.

On
the
other
hand,
possession
is
occasionally
treated
as
a
diagnosis
by

mainstream
professionals
whose
therapy
is
religiously
focused.

154

While
these
studies,
and
the
journals
in
which
they
are
published,
are
in
general

regarded
as
outliers,
such
references
can
be
found
on
PubMed.

The
Conference
on
the
Liturgical
and
Pastoral
Practice
of
Exorcism
hosted
in

Baltimore
by
the
United
States
Conference
of
Roman
Catholic
Bishops
in
2010
was

called
in
order
to
guide
practicing
clergy
in
differentiating
candidates
for
exorcism

from
those
for
whom
medical
referral
would
be
more
appropriate.
Organizer

Thomas
J.
Paprocki
explained:
“Not
everyone
who
thinks
they
need
an
exorcism

actually
does
need
one….It’s
only
used
in
those
cases
where
the
Devil
is
involved
in

an
extraordinary
sort
of
way
in
terms
of
actually
being
in
possession
of
the

person.”
155

Training
of
priests
as
specialists
in
exorcism
is
on
the
rise
in
Italy
and

Spain,
as
well
as
in
the
Third
World.

Spiritual
and
demoniacal
possession
can
be
said
to
remain
a
diagnostic

alternative
in
the
Western
world.
This
remarkable
factoid
is
unexamined
and
should

be
incorporated
in
any
thorough
exploration
of
the
commonalities
between

medieval
and
modern
views
of
mental
disorder.

154

See
M.
Kemal
Imak,“Schizophrenia
or
Possession?”
Journal
of
Religion
and

Health
53
(2014):
775-‐777.
Also
Betty
Stafford,
“The
Growing
Evidence
for

“Demonic
Possession:
What
Should
Psychiatry’s
Response
Be?”
Journal
of
Religion

and
Health
44
(2005):773-‐777.

155

“For
Catholics,
Interest
in
Exorcism
is
Revived,”
(New
York
Times,
Nov.
12,
2010)

A
11-‐13

139

Because
the
Middle
Ages
lacked
concepts
of
statistics
and
data
collection
we

cannot
assume
that
the
diagnosis
of
possession
“in
the
field”
was
more
than

peripheral,
by
modern
standards.
The
lyrical
and
dramatic
were
probably
more

often
depicted
than
were
the
repetitious
and
intrusive,
which
describes
so
much
of

deranged
behavior
as
it
is
actually
experienced
in
the
community.
Possession
and
its

treatment
usually
became
matters
of
public
concern,
involving
the
community
in

exorcism
rituals
of
elaborate
street
theatre.
Thus
they
functioned
as
a
spiritual

nexus
between
psychology
and
art
that
speaks
to
the
archetypal
connection

between
these.
Michael
Goodich
writes:

As
in
other
cultures,
the
exorcism
ceremony
involved
both
the
victim
and

the
audience
in
a
ritualized
drama
in
which
certain
cultural
signs
and

messages
were
being
conveyed
which
are
as
clear
to
the
participants
as

speech
itself.
The
aim
is
to
restore
a
marginalized
person
to
both
mental

health
and
the
community
of
the
faithful.
The
victim
finds
herself
or

himself
in
a
liminal
situation,
becoming
the
vehicle
for
the
transmission

of
certain
shared
values.

156

The
starring
role
of
the
victim
in
the
drama
was
elaborate
and
formulaic.
Even

allowing
for
the
looseness
of
the
concept
of
the
‘first
person
account’
in
early

modern
journalism,
it
seems
fair
to
speculate
that
some
degree
of
artifice
was

involved.
It
is
intriguing
to
speculate
on
the
degree
to
which
any
particular
victim

may
have
been
mentally
disordered.

The
incubus
who
had
possessed
a
demoniac
named
Christianella,
who

had
been
brought
to
the
church
for
the
occasion,
spoke
through
her,

saying:

“The
time
has
now
come
for
my
exit
and
for
Christianella’s

liberation.”
After
being
conjured
up,
the
demon
said,
“When
I
leave
her,
I

will
break
a
lamp
and
leave
Christianella
as
if
she
were
dead.”
After
so

doing,
even
though
the
woman
was
illiterate,
the
demon
again
spoke

156

Goodich,
152

140

through
her
perfectly,
saying,
“Take
the
clothes
off
her
back,
cut
the
hair

from
her
head,
and
hang
it
on
the
tomb
as
evidence
of
this
miracle,
lest
I

have
the
power
to
return.”

157

Then
as
now,
exorcism
was
performed
by
theological
personnel
rather
than

medical,
and
only
after
the
case
had
been
determined
to
have
a
distinctly
spiritual

etiology.
But
the
role
of
possession
as
public
theatre,
in
which
the
genuinely
afflicted

may
have
made
uses
both
conscious
and
subliminal
of
the
social
role
of
possession

to
achieve
personal
integration
and
even
authority
in
the
community,
and
from

which
the
community
itself
derived
a
sense
of
cohesion
and
affirmation
of
shared

values,
continues
to
be
rightly
considered
a
defining
fact
of
medieval
sociology.
I
will

argue
that
this
theatricality
was
a
major
factor
in
the
social
integration
of
the
non-‐
normative
personality
of
Margery
Kempe.

The
integration
of
the
spiritual
and
the
figurative,
or
the
empirically
‘imaginary,’

into
the
medieval
model
of
personal
health
is
nowhere
more
literal
than
here.
As
a

clinical
diagnosis,
albeit
retrospectively
overemphasized,
possession
is
the

ontological
fallacy
that
symbolizes
the
Otherness
of
medieval
insanity
in
relation
to

modern
mental
illness,
and
also
the
Otherness
of
medieval
medicine
in
general.

About
twenty
years
ago,
I
think,
I
witnessed
a
dialogue
of
sorts
between
the

Creator
of
the
Universe
and
an
elderly,
homeless
woman
who
was
a
life
long

schizophrenic.
It
occurred
as
she
lay
in
her
isolation
room
in
a
public
hospital
in
Los

Angeles,
being
treated
for
an
infection
with
methicillin-‐resistant
staphylococcus

aureus.

157

Ibid.,
153

141

They
each
had
quite
distinctive
voices,
differing
in
pitch
and
phonation,
although

she
did
not
attempt
ventriloquism.
Throughout
the
encounter
she
glared
at
God

unflinchingly;
He
apparently
did
not
move
from
His
corner
of
the
ceiling.
God
was
at

all
times
aloof
and
somewhat
disengaged,
speaking
slowly
about
generalities
and

eternal
matters
and
repeating
truisms
in
Biblical
phrases
and
sonorous
tones,
even

declaring,
at
one
point,
“I
Am
who
Am.”

The
conversation
deteriorated
to
the
point
where
she
felt
compelled
to
become

rather
forceful.
Her
voice
was
deeper
than
His,
and
resonant,
rising
to
a
scream;
her

delivery
was
Shakespearean:
“I
need
you
to
get
my
nephew
to
go
to
the
bank
and

cash
my
check.
I
need
you
to
do
it
today.”
(pause)
“DO
IT!”

(another,
longer
pause)

“DO
IT!”

Someone
called
a
“Code
Green,”
and
the
County
Police
arrived
and
restrained
her

to
her
bed
with
four
point
leather
belts.
(This
would
not
happen
today,
because
the

guidelines
for
use
of
physical
restraints
have
become
considerably
stricter,
and
an

uncomplicated
tirade
against
the
Almighty
would
probably
only
elicit
an
injected

sedative,
at
most.)
It
did
not
surprise
her,
and
it
did
not
seem
to
upset
her

particularly.
She
accepted
this
as
the
conclusion
of
the
encounter,
and
seemed

content
with
the
results.
She
rested,
awaiting
the
appearance
of
her
nephew,
and

soon
the
restraints
were
removed.
Later
in
the
shift,
the
nephew
arrived.

It
seems
possible
that
many
forms
of
disorder,
possibly
including
psychosis,

might
find
healing
and
acceptance
through
the
community
acknowledgement,

whether
positive
or
negative,
afforded
by
such
rituals.
The
degree
of
conscious

participation
as
opposed
to
sublimation,
concluding
in
the
climactic <