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François-Olivier Touati
Elma Brenner

The Introduction explains the importance and originality of the volume, presenting examples of the key findings of the chapters. Through comparison with China, it argues that the response to leprosy in medieval Europe was distinguished by the emergence of specialised institutions that did not fully isolate sufferers from society. It addresses the question of when leprosy declined in Europe, and surveys the recent findings of ancient DNA analysis regarding the global distribution of leprosy. A detailed discussion of terminology is included, in terms of both the attention paid by the chapters to the medieval terms used to refer to leprosy and its sufferers, and the fact that the authors adopt different stances on whether to use the word ‘leper’, which closely follows the medieval terminology but denotes stigma today. This issue is complicated by the fact that some people who were described as ‘lepers’ in medieval Europe did not necessarily have leprosy. The Introduction considers the nuances of the individual and collective identities of leprosy sufferers, key themes in the volume. People with leprosy lived both within and outside leprosy hospitals, and they had a wide range of social and religious identities. The Introduction also explores how leprosy sufferers lived between the states of integration and segregation, and provides a detailed overview of the volume.

in Leprosy and identity in the Middle Ages
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Saint Francis and the treatment of lepers in the central Middle Ages
Courtney A. Krolikoski

While leprosy was often associated in the Middle Ages with the stigma of sin, in the twelfth and thirteenth centuries lepers also held a special religious status that made them the ideal recipients of charity and popular devotion. The Church used this dual status of the leper to suit its contemporary needs. What resulted were two distinct but conflicting understandings of the nature of leprosy. However, during the twelfth century, and increasingly in the thirteenth century, leprosy came to be depicted as a disease of the ‘poor of Christ’. Lepers, according to this view, suffered on earth so that they could bypass purgatory. Leprosy came to be seen as an illness miraculously granted by God. This chapter considers one of the decisive factors in this shift: namely, the influence of charismatic religious figures, or saints. The impact of the saints has been largely neglected in the study of social perceptions of leprosy. As foci of great religious devotion, saints played a powerful role in the medieval world. The chapter focuses on that played by one widely known and influential saint, Francis of Assisi. Through a close reading of a selection of sources, as well by situating these sources in their historical context, it charts one man’s influence over social perceptions of what was, and in many ways remains, a highly stigmatised disease.

in Leprosy and identity in the Middle Ages
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Connections between East and West in the Middle Ages
François-Olivier Touati

The fact that leper hospitals emerged in the West around the time of the crusades has led to a belief that there is a close connection between the spread of leprosy and the heightened contacts between East and West during the period of warfare. But the examination of sources of all kinds, from historical, hagiographical and medical texts, to archaeological and iconographic evidence, reveals that the disease was present in both the East and the West prior to the crusades. It is also clear that the sick and the healthy were travelling as pilgrims to eastern holy sites before the initiation of the First Crusade in 1095. While the notion that leprosy was transmitted to the West because of the crusades must therefore be questioned, the extension of the field of observation towards the Byzantine world and the Near East is beneficial to our understanding of leprosy in medieval Europe. The western emulation of eastern attitudes towards assisting lepers is evident. Eastern influences can be discerned in the institutional form of the leper hospital, the palliative medical care offered to lepers and the manner in which lepers were treated as a special category of the sick. Furthermore, cultural influences did not travel in only one direction. The strengthening of the contacts between the various Mediterranean shores that resulted from the crusades led to the cross-influence of charitable models, shaping the foundation of leper hospitals, and the identity and treatment of leprosy sufferers, in both West and East.

in Leprosy and identity in the Middle Ages
From England to the Mediterranean

The chapters in this volume, by established scholars and early-career researchers in history and archaeology, shed new light on the identities and experiences of people affected by leprosy (Hansen’s disease) in medieval western Europe. Building on recent research that challenges the view that people with leprosy were excluded and stigmatised, the book demonstrates the complex and varying status of the illness and its sufferers. The authors provide case studies from Italy, Germany, France and England between the eleventh and fifteenth centuries, with some chapters adding a broader global perspective. The source material includes archival documents, archaeological data, hagiography and artworks. The book makes a new contribution to our understanding of social provision for people with leprosy, with chapters exploring how leprosy hospitals sat at the boundary between integration and segregation. It also describes how some sufferers lived outside institutional settings. The central question of identity enables consideration of how people with leprosy related to each other, and the extent to which their lives were transformed by the disease. While leprosy had a significant impact on social, professional and religious identities, people retained aspects of their previous identities after developing the condition. Furthermore, the collective identity of leprosy sufferers was shared by individuals who were labelled ‘lepers’ but did not have the illness. The book reveals the cultural and social significance of leprosy, a disease with deep metaphorical and spiritual associations. It also demonstrates how people with leprosy exerted their agency, although their perspectives are usually absent from the sources.

Reinventing medieval leprosy for the modern world, 1850–1950
Kathleen Vongsathorn and Magnus Vollset

By the nineteenth century, most Europeans considered leprosy a matter of the past. When it was ‘rediscovered’ in Europe and the tropical world, people looked to history to inform contemporary understandings of the disease. Using medical journals and textbooks, leprosy histories, policy documents, newspaper articles, and philanthropic publications, this chapter discusses modern perceptions of medieval leprosy. First, it shows how medieval leprosy gained and lost relevance as medical and scientific debates changed over time. The past was reinvented to correspond with the present, in which leprosy’s contagiousness and the supposed efficacy of segregation in medieval Europe were cast as models for modern action. Next, the chapter explores popular conceptions of leprosy. When Europeans began encountering leprosy again in the nineteenth century, writers and medical practitioners drew parallels between medieval Europe and the contemporary tropics, while differentiating them from modern Europe. The contrast drawn between ‘civilised’ modern Europe and its ‘primitive’ medieval past was part of an attempt to preserve the superior, ‘civilised’ identity of Britain, in particular. Leprosy has long been a disease of contradictions, and while modern Europeans were casting medieval Europeans in a negative light, they were also looking to their ancestors for positive inspiration towards philanthropy. Overall, this chapter explores the tension between ‘old’ and ‘new’ ideas about leprosy, showing how perceptions of leprosy’s history, if conflicting, became deeply ingrained in the conceptualisation and management of leprosy in the modern world.

in Leprosy and identity in the Middle Ages
Charlotte Roberts

Leprosy has always been very much a socially defined disease. It has been suggested that people with leprosy in the past suffered as a consequence of not only the disease itself, but also the associated stigma. Is there solid evidence that supports this suggestion? This chapter focuses on the evidence of leprosy in skeletons buried in the Middle Ages and beyond. It aims to challenge the traditional view that the management of leprosy in past communities reflected the ostracisation and marginalisation of sufferers. It considers skeletons with leprous bone changes buried in various funerary contexts, primarily in Europe. Previous and often current opinion is that people with leprosy were segregated into leprosy hospitals. However, the majority of skeletons with signs of the disease are not found in leprosy hospital cemeteries, and in some cases the burials appear to indicate that those buried were of ‘special’ or enhanced status, and were certainly not marginalised within the cemetery. This recent research indicates that people with leprosy were probably more accepted within their communities than previously thought.

in Leprosy and identity in the Middle Ages
The archaeology and history of an English leprosarium and almshouse
Simon Roffey

Leprosy hospitals have received considerable attention from historians in recent years, but there is still comparatively little archaeological research concerning their origins, early form and development over time. There has also been very little work towards synthesising historical data with archaeological evidence. This chapter discusses the origins and development of English leprosy hospitals with reference to the important excavations at Saint Mary Magdalen, Winchester, England, one of the earliest and most comprehensively excavated examples. Research at Winchester, involving the excavation of both building structures and cemeteries, as well as the study of related historical materials, provides an important insight into the development of a particular form of medieval institution, and the identities of those who lived there. Saint Mary Magdalen had relatively humble beginnings as a small hospital for leprosy sufferers, but later developed into a much larger hospital with wider functions, and subsequently became an almshouse. Particular emphasis is placed on the early phases of the site, where analysis of the early cemetery (late eleventh–early twelfth century) indicates skeletal evidence for leprosy in over 85 per cent of excavated examples, a much larger percentage than has previously been recorded at any British site. The graves were anthropomorphic in shape and contained men, women and children, including a medieval pilgrim. This cemetery, together with evidence for associated timber buildings and a chapel, suggests a small, relatively high-status, religious community of leprosy sufferers.

in Leprosy and identity in the Middle Ages
Elliott Joslin’s diabetes research, 1898–1950
Oliver Falk

According to the conviction that accounting isn’t necessarily subordinate to economics, the chapter does not deal with accounting practices in a classical sense but aims to highlight the use and value of calculative practices in treatment and research. By examining Elliott Joslin’s principles and practices of diabetes therapy, it shall be shown how he used calculative and administrative techniques as a tool to combine both therapeutic measures and scientific investigation. Drawing on archival materials of the Joslin Diabetes Center, as well as on Joslin’s published manuals, textbooks, and early seminal articles, it shall, first, be shown how Joslin systematised his patient files for comparing cases and evaluating new therapies. Second, it will be shown how Joslin begun to conceptualised diabetes in rather epidemiological and socio-medical terms at the same time, which subsequently led to new collaborations between physicians, government authorities, life insurance companies, and patients bound together by accounting practices. Finally, it is focused on Joslin’s relationship with his patients and how the qualitative and quantitative information he gathered could be used in therapy and research.

in Accounting for health
The Mennonite church, the US National Institutes of Health, and the trade in healthy bodies, 1950–70
Laura Stark

Accounting shapes the epistemic possibilities of medical knowledge – and shows how practices seemingly ancillary to bioscience can alter both organisational and human bodies, as well as the available ways for living in each. From the 1950s through 1990s, members of Anabaptist churches, who joined ‘voluntary service’ programmes, were able to ‘volunteer’ as Normal Control human subjects at the US National Institutes of Health. Each group had a ‘unit leader,’ who worked informally as the churches’ local account. As documented in traditional archives and in a publicly available ‘vernacular archive’, Anabaptists were both accounting and being accounted for. First, Mennonites appeared literally in the legers of NIH. They were essential research materials whose time the government purchased for a given price. Accounting practices helped NIH and the Anabaptist churches temporarily to align their missions, which had the structural effect of allowing a moral market in healthy civilian bodies to emerge. Second, Anabaptists were enrolled at NIH in experiments, including studies of metabolism, for which bodies were seen as in vivo accounts through which scientists could record input and output. As a mode of attention in metabolic medicine, accounting clarifies when and how categories such as age, gender, and race, were made real and they reinforced shared social biases. Third, Anabaptists were doing the physical labour of bookkeeping at NIH. Their labour of accounting, and the practices of peer surveillance and discipline it required, enforced the embodied discipline that clinical researchers capitalised upon without needing to assert directly.

in Accounting for health
Calculation, paperwork, and medicine, 1500–2000

Accounting is about ‘how much’ and is usually assumed to be about money. It is viewed as a financial technology related to the administration of finances, costing, and the calculation of efficiency. But this book suggests a broader understanding of accounting, linking related perspectives and lines of research that have so far remained surprisingly unconnected: as a set of calculative practices and paper technologies that turn countable objects into manageable units, figures, and numbers that enable subsequent practices of reckoning, calculating, valuing, controlling, justifying, communicating, or researching and that generate and appear in account- or casebooks, ledgers, lists, or tables.

And Accounting for Health involves both money and medicine and raises moral issues, given that making a living from medical treatment has ethical ramifications. Profiting from the ‘pain and suffering of other people’ was as problematic in 1500 as it is in today’s debates about the economisation of medicine and the admissibility of for-profit hospitals. In current debates about economisation of medicine, it is hardly noticed that some versions of these patterns and problems has been with health and medicine for centuries – not only in the modern sense of economic efficiency, but also in a traditional sense of good medical practice and medical accountability.

Spanning a period of five centuries (1500–2011) and various institutional settings of countries in the Western world, Accounting for Health investigates how calculative practices have affected everyday medical knowing, how these practices changed over time, and what effects these changes have had on medicine and medical knowledge.