Mourning under medical care: a study of a consilium by Bartolomeo Montagnana.
Bartolomeo's discussion of the case and the advice he offered shows that he regarded Johannes's state of excessive grief as a medical issue deserving a physician's care. His account of the physical effects of sorrow and the means of curing them provide insights into his understanding of the relationship between body and soul during periods of grief and intense emotional states in general. It further gives us a window into the physician's, and the eras, understanding of healthy and unhealthy emotional states. In discussing this medical case and juxtaposing it with other Italian medical references to grief written between the thirteenth and fifteenth centuries, I will examine the medical conceptualisation of the state of mourning and the degree to which it adhered to broader social and religious concerns.
Although medical texts employed no specific vocabulary to differentiate between the grief of bereavement and other kinds of sorrow, it appears that at least some physicians maintained that situations of loss could produce a particularly defined state worthy of medical attention. By focusing on the ways these medical sources incorporated the value of health--whether physical, mental, or spiritual--into their discourses, we can also reconsider some of the established concepts of grief and mourning in late medieval Italy. This, in turn, can further our understanding of the cultural and social associations between grief and order in late medieval Italy, and suggests that physicians were among the social agents who were setting the norms of grief.
I. The Consilium of Johannes of Milano
Johannes's case is known from a consilium by Bartolomeo, part of a larger corpus of about 400 cases attributed to him. (2) The consilium was a popular genre in the Italian medical community. As its name suggests, it was the equivalent of a medical consultation, sometimes providing a general account of the treatment of a particular disease; at other times, as in the Johannes's case, it reported the symptoms (not always recognised as related to a specific disease) of a particular patient. The first extant exemplars of consilia date from the thirteenth century, and by the fifteenth, the genre had become standardised and more elaborate. Most included a medical history, medical diagnosis, and a two-part course of treatment comprised of a dietary regimen of the six non-naturals, that is, air, food and drink, sleep, exercise, purgatives, and the accidents of the soul (which are, to some extent, what we currently call emotions); (3) the second part consisted of medicinal treatment, which might include potions or other remedies, and surgical procedures. (4) Consilia cases were recorded, as far as we can tell, for two reasons: to document the consultation for the benefit of the physician, patient, and/or the patients kin; and for educational purposes. Manuscripts and printed copies of the consilia, produced for the edification of students and colleagues, demonstrated how theoretical medicine could be implemented in practical cases. By expanding his list of publications, the physician might also acquire renown and hence both the discussion and treatment of cases were written with an eye to the teachings of recognised authorities as well as professional norms. Thus the consilia literature should be treated largely as professional literature, as implied by the tight condensation of the technical information and the minimal ornamentation on the manuscripts. That said, it must be noted that these cases cannot be regarded unreservedly as historical evidence: it is very possible that the actual encounter between physician and patient did not truly resemble the recorded version. What we may learn from such texts, however, is how physicians understood and presented their craft, its internal rules and norms, and the boundaries of medical practice. Bartolomeo Montagnana's consilium to Johannes of Milano may be regarded therefore as both a structured account of a medical encounter and an exemplary illustration of the treatment of ill health brought on by excessive grief.
Bartolomeo Montagnana was born in 1380 in Padua to a surgeon father. He studied medicine in the Padua studium--one of the eras leading schools of medicine--under Marsilio Santasophia, a descendant of the most famous medical family of the fourteenth century and an affluent physician in his own right. Bartolomeo was awarded his doctorate in medicine in 1402. Soon thereafter he became a teacher of medicine in Padua and a soughtafter practitioner who treated the elite of Padua and nearby cities. Among his patients we find high clergy, including Bernardino da Siena, and ruling figures and families such as the Countess of Mirandola and members of the Medici family. His ties to Treviso, Johannes's city of residence, can be seen in the summons he received in 1425 from the Doge of Treviso requesting that he treat the Count of Carmagnola, Francesco Bussone. (5) In addition to the large number of cases he recorded, Bartolomeo also wrote treatises on remedies, appropriate dosages, baths, the inspection of urines, and medical terminology.
About Johannes (or Giovanni) of Milano, we unfortunately know much less. The information in the consilium is too general and his name too common for us to identify him easily as an historical figure. There is even reason to suspect, as will be shown below, that he existed merely as an illustrative patient, a kind of John Doe. Nevertheless, this is a minor issue since it is Bartolomeo's formulation of the case and its details that interest us. His report states that Johannes held some official position in his city and had been treated previously by Bartolomeo. Johannes's alleged public persona and position seem to have had considerable impact on the treatment he received and the critical, even condemning manner in which Bartolomeo related to his grief and consequent behaviour.
The physician opens his description of the case in the usual systematic way: with a theoretical analysis of the patient's condition which, as noted above, describes Johannes as suffering from bad complexion, cold and dry, in the head. While the terminology of his analysis is conservatively medical, Bartolomeo argued that the state of deterioration was caused primarily by vehement passions of the soul, which lessened Johannes's innate heat, and he corroborated this thesis by adding:
This man was once accustomed to conducting civil business with a bare head and always acted with reverence and honesty. But now, because of the loss of his daughter, he began to officiate with a covered head, and especially with most vainglorious hoods, as is the custom today. (6)
This very short comment reveals more than first meets the eye and I will later return to discuss it more thoroughly. For now, let us just notice that its medical relevance is not at all certain: for a phlegmatic patient might have benefitted from warming his head. Instead, Bartolomeo introduced social norms and cited his patients behaviour as evidence of his dire state. The latter sheds important light on the way emotions could be perceived in medieval medical practice, in this case not according to the patient's own account of them, but through the physician's observation of his actions and a comparison of his prior and current behaviour. Bartolomeo's statement, moreover, is not devoid of judgement. Stressing Johannes's public office, and with words such as 'reverence' and 'honesty', he reproaches Johannes for his neglect of public decorum while insinuating that the patients actions have implications beyond his own health. Bartolomeo's criticism takes on a religious timbre when he accuses Johannes of 'sinful' attire, thereby categorising Johannes's excessive grief as both a public and a spiritual offence: it is not only harmful to health but also spiritually, or, morally reprehensible.
The religious tone of Bartolomeo's attitude towards grief is brought to the fore in his passage on the accidents of the soul. As mentioned above, the advice in a consilium was usually divided into two sections, a personalised regimen and medicinal remedies. Not all regimens included a passage on the accidents of the soul; among the six non-naturals this is the one most often neglected or ignored within the genre due to certain practical and theoretical qualms among physicians about its relevance to medical care. As will be discussed further below, physicians were wary of entering a domain that exceeded accepted medical practice, and the method of dealing with emotions was not as obvious in medical precepts as writing prescriptions for potions. Bartolomeo, nevertheless, was rather systematic in his approach, and his consilia, particularly those that dealt with specific patients, usually did not omit any element. Most of his advice on the accidents of the soul resembles that which was common in the genre: listing those emotions that should be avoided and others that should be encouraged, occasionally suggesting methods to foster the latter. But in Johannes's case, Bartolomeo resorted to somewhat unusual measures, revealing between the lines the challenge emotions posed for physicians. I quote the passage in full:
As much as possible sorrow should be taken out of his soul, because recuperation is impossible when the soul is occupied with suffering (passionem) for absent things. It is to add stimulus to stimulus, which is to incur the sin of ingratitude (officiperdi); this because his memory, will, and soul should all conform to the will of the most High. Indeed, the judgements of the Lord are a great abyss. For it might have been that this man would have suffered great sorrow if his daughter lived a long life, in which she was not safe from the almost endless dangers of humanity, and mostly in this unhappy time of ours subjected to the tribulations of plots, of hateful war, and of other predicaments. And so, therefore, the mind should bear that which was foreseen and done. For if he shall not do so he leads himself, because of these strong passions of the soul, to life-threatening danger. For these passions of the soul extend and move the body from that which is its nature [according] to Book Three of the Tegni [Galen's Art of Medicine, a textbook studied by all students of medicine]. (7)
Opening with a matter-of-fact statement--that no healing may occur while the patient is still experiencing the cause of his condition--Bartolomeo then suggests how to eliminate this feeling. His advice is primarily cognitive, directing the patients thoughts towards more consoling options: Johannes should consider that his daughter is safer in the afterlife than she was in this world; he should see her death as God's will and accept His judgement. Bartolomeo recommends faithful acceptance of the 'foreseen and done' as a pacifier for the emotional turmoil. Yet his recommendation for altering his patient's emotional state incorporates non-medical practice. Redirecting Johannes's thoughts serves not only to distract him from his unhealthy emotions but also encourages him to follow a religious path in which faith will serve as cure for his unhealthy grief. Thus the physician's advice comes in the mode of a sermon, intended to move the reader/listener to righteous action. The similarity to preaching is not in format alone: the content also introduces moral and spiritual convictions to medicine. With his catechistic advice, Bartolomeo the physician becomes an instructor of faith. Under the cloak of a physician concerned with his patients health, his words bring to mind the practice of consolation and the figure of the consoler, a celebrated role in the humanistic culture in which he lived.
II. Mourning and Consolation
The grief and mourning of parents who had lost their children was an obvious concern in late medieval society. Miracle narratives and saints' inquests disclose how parents in despair over their dead children were ultimately consoled. (8) Many preachers, among them the Italians Jacobus de Voragine and Bernardino da Siena, wrote and delivered sermons depicting Job as the ideal sufferer, accepting the death of his children with forbearance. Such sermons were presumably meant to instil greater patience in the lives of their listeners. (9) The social and cultural circumstances of the Italian communes, self-governed and independent, encouraged the desire to strengthen ties between its members. This desire spurred the composition of consolation writings, which evolved into a literary genre. (10) Rooted in the ancient past, preceded by the elegiac and solacing treatises and letters by such famous authors as Seneca and Cicero (following the death of the latter's own daughter), the genre has been linked intrinsically to the development of civic society. George McClure has shown that as the genre was transmitted to Christian culture, its focus shifted to theosophism, devaluing the sorrows of this world and celebrating the joys of the next. The genre was transformed again in the thirteenth century when Italian university men such as the rhetorician Boncompagno da Signa (1165-1240) and the lawyer Albertano da Brescia (c. 1195-1253) ventured onto a more civic-oriented path. Their works, which derided excessive grief and ridiculed it as feminine, unchristian, and unbecoming to persons of high social rank, set the accepted style and manner of mourning. They composed specific phrases for recitation at funerals (in Boncompagnos case) and laid out the prudent reaction to death, while criticising vendetta (in Albertano's case).
Carol Lansing understood these works as part of Italian communes' social attempt to curb and manage excessive displays of grief and mourning within the rising cities of the thirteenth century. (11) This concern was further manifested in most contemporaneous Italian cities by sumptuary laws that regulated behaviour and expenditure at funerals, as well as general mourning practices down to the garments of the mourners. (12) Such regulations and laws were part of the wider attempt at self-definition in the process of state formation. According to Lansing, these regulations were an attempt to define transgressions related to sexuality and gender as harmful to the construction of an orderly vita civile. (13) Mourning and expressions of grief, as will be further discussed below, were occasions of possible disruption to gender norms, posing the threat of mourners displaying effeminate behaviour. Thus, Lansing found that in some cities the recurrent civic laws against crying and expressing grief in public were actually enforced: men who trespassed were arrested and charged. In Orvieto, municipal officials sent spies to funerals to investigate whether mourners violated the laws by pulling out their hair, shouting in lament, or attempting vendettas. According to Lansing, this concern about the society's emotional countenance was related to the larger quest for social stability within the developing political form of the communes. (14) Death, especially of politically influential persons, was considered a valid disruption of the social order; facing death, both symbolic and real, required restraint in order to uphold the security of the commune. Hence the importance attached throughout the next two centuries to maintaining order at funerals and adhering to conventions of mourning and condolences, alongside increasing consideration of the nature of grief and its possible relief.
Sharon Strocchias study of death rituals in Florence examined the funerary ceremonies of celebrated Florentine men. These revealed a great social and economic investment in the construction of complex symbolism: the rites and procedures were clearly meant to represent social status and hierarchy. Highly stylised affairs, they represented the contemporary fashion for 'dignified' grief and solemn mourning practices. (15) The imprint of this socially sanctioned mode of experiencing grief seems to be etched in Bartolomeo's judgement of Johannes, whose unbounded reaction and excessive tears did not conform to accepted normative and 'healthy' behaviour. The association of normativity and health in relation to death and mourning can also be seen in humanist writings of the period.
Coluccio Salutati (1331-1406) is identified by both Sharon Strocchia and George McClure as one of the main influences on the development of a new model of grieving which, to borrow William Reddy's term, gave rise to an emotional regime which glorified private and intellectual mourning practices. (16) Rejecting expressive displays of sorrow, Salutati followed his predecessor and teacher Petrarch and proffered long ruminations on grief and mourning and the influence of death on the living. According to McClure, one of the main novelties of such humanistic texts was a negation of stoic appeals for indifference to death, advocating instead a profound acceptance of personal and worldly sorrow. (17) Thus, in a letter to Francesco Zabarella (1360-1417), Salutati laid out his view on the function of consolation, noting that if one wishes to ease another mans sickness he should experience pain himself. (18) As McClure observes, this passage formulates the strong communal interest motivating consolation writings which, as Salutati put it, could create a bond between the grieving person and the person grieving with him ('con-solator'). (19) Hence pain could be beneficial to the social formation; it facilitated friendship based on shared grief and suffering. In consoling a friend, one could be comforted for one's own losses. However, while the shared experience of pain was considered a requisite for friendship, and pain or sorrow were socially accepted emotions, these concepts called for a very limited definition of 'useful sorrow'.
The use of medical language and allusions to physical sickness and pain in humanistic writings reveal an important element in the complexity of the acceptance of worldly sorrow. In De remediis utriusque fortune, for example, Petrarch defined sorrow as a malady which demands a remedy, and Coluccio Salutati's letters often equate grief with illness or define it as an illness of the soul. (20) Salutati sharply criticised ongoing conditions of illness of the soul, as seen in a letter to Pellegrino Zambeccari (1350-1400). Here desperation and unhappiness, particularly in the face of physical sorrows, are described in terms borrowed from medicine--'bitter humour' and 'corrupting illness', for example--to position them as being in opposition to the path of faith. (21) The notion of unhealthy sorrow as developed in these texts is comparable to Bartolomeo's consilium and his classification of Johannes's grief as an unhealthy state. In both Salutati's letters and in Bartolomeo's consilium, health and sickness are used to signal the acceptable and unacceptable degrees of grief. Both, moreover, comprehend this differentiation as an aspect of spiritual health and Christian conviction: bitterness and despair stand in opposition to faith in God's will.
Another aspect of the culture of consolation that resonates in Bartolomeo's consilium is the description of a mourner's health as a communal affair, a condition that involves not only the sufferer but also his kin and his friends and, in Johannes's case, the institutions of the city. Mourning and consolation were discussed primarily through the prism of relationships, which served in turn as an adhesive of the social structure, facilitating the formation of personal ties and political alliances. Margaret L. King's study of the corpus of letters written to Jacopo Antonio Marcello after his son Valerio's death bears witness to the political and economic benefits of consolation letters, which fostered intimate and familial relationships among figures of influence. King's detailed analysis of these letters further shows how praise of Venice and references to Marcello's heroism were woven into the letters as flattery or as exhortation in order to strengthen the appeal for Marcello's consolation. This ideal of grief, comprising deep contemplation and considerable emotional restraint, was thus a marker of social and cultural standing as well as a reflection of faith. (22)
In Johannes's case, Bartolomeo's social concern is evident in his somewhat surprising identification of his patient's behaviour as vainglory. It was usually the sin of acedia, or accidia (sloth) that was associated with grief and mourning. For example, Bartolomeo's contemporary, Antoninus, Archbishop of Florence (1389-1459), instructed confessors, when interrogating penitents about the sin of accidia, to ask them whether they were 'saddened to such great degree because of some adversity that he or she became gravely sick on account of the great sorrow, the loss of sleep, not eating, and similar things'. (23) Contrary to this traditional view of the offence of extreme grief, Bartolomeo accused his patient of vainglory, a sin not only against God but also against one's fellow man and generally manifested in excessive self-adoration and ostentation. In the same manual of confession, Antoninus further instructs his readers to determine a penitent's degree of vainglory by investigating '[whether] the penitent dressed in an excessive manner beyond his status or condition or the custom of his land'. (24) Johannes's infringement of the custom, in Bartolomeo's diagnosis, echoes this definition of sin. Defining Johannes's sin as vainglory rather than accidia Bartolomeo relates to his patient's illness as a social breach as much as, if not more than, a personal malady. This focus on the social dimension of Johannes's emotional state can also be seen in the very diagnosis of mourning as the root of poor health. In light of the preoccupation with mourning in the period discussed here, it may be argued that such a diagnosis was already under the influence of the fifteenth century's social outlook.
As can be gathered from the above examples, within this periods cultural setting the image of the grieving father became a trope, a contrived figure through which humanist, religious, and civic ideals could be articulated. (25) Celebrated authors and orators of the period, whether they were laymen or clerics, referred to the laments of fathers, and used the image to convey their ideals of emotional behaviour and the countenance of the honourable man. Giannozzo Manetti's (1396-1459) consolation dialogue with his friends is, for example, an address on the issue of fatherhood and manhood.The dialogue examines the appropriate boundaries of the display of fatherly affections and excessive emotionality among men. (26) Authors such as Leon Battista Alberti and Giovanni Dominici submitted that fathers were responsible for the future of the commune and their pedagogic role in raising their sons was a fundamental pillar of society. The family was thus seen as a hub for the transmission of civic and religious ideals and the father as the leading figure in conveying them. (27) This notion of fatherhood was deeply bound to norms and standards of masculinity. Rachel Moss's study on fatherhood in medieval English texts suggests considering fatherhood as the marker of the transition from adolescence to adulthood, and a recurrent point for affirming masculinity through the assumption of authority and social duties. (28) Although she focuses on English society, her approach seems to be relevant to contemporaneous Italian society as well. Preserving the countenance of masculinity was vital to this authoritative and educational role, especially in face of troubles. (29) Coping with bereavement was, therefore, a litmus test of the father's emotional strength and stability on the one hand, and his utter devotion to the education of his sons on the other.
The pervasiveness of this topos in the period, with its complex commentary on norms of health and sickness, communal responsibility, and social status, is the ground from which Bartolomeo's advice sprang. It is therefore noteworthy that he recommended, albeit in abbreviated form, consolatory tactics that resemble those proffered by Marcello's consolers not many years later: the bereaved should remember that if his daughter were still alive she might have been subjected to much misery and pain, from which death in fact had saved her.
III. Bartolomeo Montagnana as Consoler?
As we have seen, the concerns regarding the social and spiritual expressions of grief which defined the late medieval Italian culture of dying can be traced in Bartolomeo's consilium. Though Johannes's grief is not overtly characterised as effeminate, his offence to society and to its orderly conduct is perceived as a sign of the patient's ill-health. Bartolomeo's advice incorporated Christian and to some extent humanist traditions of consolation. There are, however, significant differences between his advice and the literature of consolation, which emphasises the physician's particular role regarding the phenomenon of unhealthy grief. These deviations are related both to Bartolomeo's own professional position and to the fact that he incorporated and treated the patient's grief as an element of the medical care he provided. Although he was clearly acquainted with and influenced by the prevailing language and culture of mourning and consolation, he himself offered no condolences. As mentioned earlier, offering condolences was regarded as an experience of sharing another's pain; therefore it was essentially an act that could only occur between peers. Dispensing harsh judgement along with prescriptive therapy, Bartolomeo the physician is not a friend of Johannes but an authority figure. His authoritative tone is ingrained in his instructions for regimen and remedy and is further emphasised by his reproach of Johannes's ongoing sorrow as a sin of ingratitude ('officiperdus'), and his choosing to cover his head as vainglory. In warning against sin, and even more in diagnosing it in his patient's behaviour, Bartolomeo assumed a spiritual/religious role similar to that of a confessing priest or preacher whose authority is clearly delineated.
The rhetoric of religious care extends the scope of the medical discipline. By employing it, Bartolomeo implied that his office was concerned not only with healing the body but also with healing the soul and furthering the patient's salvation. I will return to this significant overlapping of disciplines below. Nevertheless, it must be recognised that Bartolomeo's position remains that of a physician. Although his consilium carries religious overtones, reflecting the Christian approach that discounts this world's woes and advocates devout acceptance of God's mysterious ways, its ultimate intent is not religious. It is not by chance that Bartolomeo's passage on the accidents of the soul concludes with a reference to Galen and to his teaching on the impact of emotions on the body. Bartolomeo aimed to lead his patient to physical, and therefore worldly, health, a goal that was not at odds with the spiritual path he depicted. On the contrary: sorrow that led to sickness, as seen in Antoninus's definition of accidia, was considered a mortal sin. Antoninus was not alone in linking ill health with sinful sorrow or grief; the Milanese Bartolomeo de Caimi (fl. 1449-96) issued a similar definition of sinful behaviour, and Domenico Cavalca (1270-1342) urged his readers to refrain from sorrow over afflictions, for it consumes the body. (30) Nevertheless, Bartolomeo's medical advice presents a different relationship between spiritual life and physical health, with health its primary goal. Within the medical consilium, the role of faith is to heal and guard the body by preventing passions from leading to an imbalance in the body's complexion. Though he was influenced by and attuned to the culture and beliefs of his environment, Bartolomeo offered advice that was first and foremost that of a physician.
IV. The Medicine of Grief
To appreciate the medical context in which Bartolomeo Montagnana was writing, it is necessary to broaden our framework beyond the singular case of Johannes of Milano. Here, however, some disappointment arises. I have found only one other consilium which discusses bereavement as a patient's primary illness. (31) This is quite a short case by Giovanni da Genoa (Johannes de Ianua), who practised medicine in Venice and was most probably also a physician and surgeon to Pope Clement VI in the mid-fourteenth century. (32) His patient was a certain nobleman who was diagnosed as suffering from melancolia mirachia (abdominal melancholy). His symptoms were typical of melancholy: he was fearful and worried and had lost weight. The 'primitive' causes of his state were defined as worries, fears, and sorrow over the death of his parents. (33) No further support is offered for this claim, which implies that the physician deemed it a reasonable assessment: sorrow over the death of one's parents was cause enough for melancholy. Despite Giovanni's affirmation of the emotional cause of the onset of his patient's illness, his consilium goes on to recommend only therapy of the body; he makes no mention of a regimen for the accidents of the soul or some kind of consolation. This type of treatment is in fact quite common in cases of melancholy, particularly during the fourteenth century. (34)
Another case which might hint that loss contributed to a melancholic state appears in the consilia collection of Gerardo de Berneriis (fl. 1450). A patient who had had several miscarriages was prescribed a regimen and treatment to prevent melancholy. Here too, apart from advice not to leave her alone, no direct reference is made to the possibility of her being in a state of grieving. (35) Other cases dealing with miscarriage allude both to grief and to a state of sorrow following childbirth. (36) In one such case, found in Bartolomeo's consilia, the patient, Elizabeth, the wife of Christopher of Muzzano, was reported to have miscarried several times. Bartolomeo noted that finding a cure for this woman was important in order to undo the great unhappiness ('infelicitatem tantam) brought on by her prior miscarriages. Among the many possible causes for the woman's predicament, Bartolomeo put forth the woman's vehement anger, wrath, and sorrow, all of which drew the spirits towards the heart and brain and away from the womb, leaving it with diminished inner-heat. In contrast to the case of Johannes, here Bartolomeo refrained from moral judgement and religious admonition. This is further apparent in his decision later in the text to note only that all the 'above described causes should be avoided', rather than dictating a full regimen. Though the importance of avoiding sorrow was mentioned thereafter as necessary for successful pregnancy, it was not in reference to this particular patient. (37) The absence of extra-medical remarks in this consilium implies that Bartolomeo did not consider the woman's sorrow improper despite the fact that he did consider it harmful to her health and to the prospects of bearing a child. In fact, it would seem that he took it upon himself to help the patient recover from distress by finding her a cure--a statement that might suggest acceptance of her mental state, if not actual sympathy.
A number of additional cases mention that reflecting on death could be hazardous to health. The Sienese physician Ugo Benzi (1376-1439) advised a female patient suffering a phlegmatic complexion to refrain from participating in funerals, (38) and Bartolomeo Montagnana suggested to a Dominican friar named Thomas that he should not think of stories about death or stories of martyrs. (39) None of these cases addresses the spiritual ramifications of the patients' grief, although they do exhibit the significant association between mourning and cognitive or mind related illnesses. In devoting attention to the emotional state of his patient, Bartolomeo relied on this connection between grief and the faculties of the soul, but his decision to turn to spiritual advice does seem an uncommon method.
Looking beyond individual cases and the genre of the consilium, however, an account strikingly similar to Bartolomeo's can be found in a commentary on Galen's Tegni by the thirteenth-century physician Taddeo Alderotti (1215-1295). Galen's compendium of basic medical knowledge was taught in the faculties of medicine throughout the later Middle Ages. Taddeo, an extremely influential practitioner and teacher at the University of Bologna, instructed the leading physicians of the late thirteenth and early fourteenth centuries. His commentaries continued to be used as teaching tools for later generations: they were copied in manuscripts and eventually printed. Galen's discussion of emotions appears in the third book of the Tegni, in the same passage that Bartolomeo mentions in his consilium. It is a brief statement which remarks only that accidents of the soul should be avoided because of the harm they might cause the body:
It is indeed required to abstain from intemperance of the passions of the soul, namely, from anger, sorrow, and joy and fury and fear and envy and worries. Since these expel and move the body from that which is its balance according to nature. (40)
The brevity of this statement compelled Taddeo to expound on its meaning and implications. He offered a long discourse on the relevance of emotions to medicine, and the physician's ability and authority to treat emotions. To understand his argument fully one must go further back to the most influential commentator on the Tegni, All ibn Ridwan (or as the Latin authors referred to him, Haly Rodoan), an Egyptian physician of the eleventh century whose commentary often accompanied Galen's text. Haly pointed out that the accidents of the soul are an unusual case within the six non-naturals: they influence the soul more than the body and thus the care of them was more properly the responsibility of philosophers. Physicians who treat emotions, he asserted, cross the boundaries of their profession. (41) Taddeo, and a few other physicians who followed him in the thirteenth and fourteenth centuries, understood Haly's text as a prohibition against the medical treatment of emotions. In response, they set out to prove why emotions were indeed related to medical care. Taddeos main thesis was that, since accidents of the soul might cause humoral imbalance and thus endanger the health of the body, it was incumbent upon the physician to take them into account. (4) Without explaining precisely how the physician ought to 'consider' emotions --perhaps an intentional ambiguity--Taddeo did provide an example. First he mentioned the biblical figure Job as proof that an excess of emotions such as sorrow, albeit natural, might injure the body. According to Taddeo, Job's sorrow was in proportion to his dire reality, the loss of his fortune and sons; nonetheless, the physician maintained that such great sorrow is harmful to health, and if Job had wished to preserve his well-being he should have found a way to counter his sorrow. (43) Taddeos clever medical reference to Job makes use of the Christian archetype of human resolution and faith in the face of adversity (particularly that of the loss of children). Even Job, he suggested, was in need of medical information about balance and temperance, for even his celebrated and virtuous response to tribulations was not free from the potential dangers of excess sorrow. In a staunch claim on behalf of medical care for the bereaved, Taddeo goes on to note that the danger posed by emotions is even more acute for those with more choleric or melancholic complexions. To mitigate the power of emotions, he declared it necessary to restore reason through the health of the body and the soul, either as a precautionary measure or as a remedy. He explains:
If someone has his best son die on him, this is indeed a cause of great sadness, therefore the guardian physician should beware lest the father should know of his [son's] death and indeed, when he is bound to know, the physician wishing to protect him needs to urge him that if he grieves excessively he may fall into a sin of the soul and to an illness of the body. (44)
A reading of Taddeo's text is convincing evidence that Bartolomeo was aware of his predecessor's commentary and perhaps even recorded the case of Johannes as a confirmation of actual practice. The similarity between the two further affirms the ongoing preoccupation with mourning and the proper response to the death of children in late medieval Italy. It further testifies to the ongoing concern about the physical health of grieving individuals. Taddeo's commentary, however, also highlights the significance of Bartolomeo's consideration of mourning and bereavement within medical treatment. Grief (and, more generally, emotion) was rooted in religious and social contexts and it was difficult to disassociate it from them. Commenting on a patient's excessive bereavement therefore comprised a social and cultural judgement which, at least according toTaddeo, was not the physician's natural prerogative. Herein lies the notable difference between Taddeo and Bartolomeo: while the first regarded the medical care of the bereaved as inevitable but awkward, the latter expressed no reluctance about relating to the moral aspects of his patient's emotional state.
This shift in the physician's view of his own role is part of a larger-scale process in the period that is beyond the scope of this article. Due to its relevance here it is, however, worthwhile to mention the discussion of sorrow which appears in the treatise of Bartolomeo's contemporary, Benedetto Reguardatti da Norcia (1398-1469) which is representative of this change. Benedetto was a physician to the noble and powerful, such as Bianca Maria Visconti and Cosimo de' Medici, before becoming a government official in several cities. Between 1427 and 1430 he wrote Libellus de conservatione sanitatis, a rather long regimen of health according to the six non-naturals. In an extensive chapter on emotions, he included a few paragraphs that dealt specifically with mourning. A prudent and strong man, he remarked, should never fall into despair because of the death of a loved one. (45) In this turbid world, death is expected, he said; but, because the consequent sorrow might result in death, it is important to guard against such sorrow through the consolation of friends. (46) In this admonition against sorrow and particularly the grief of mourning, Benedetto amalgamated humanist and religious ideas into his medical advice, presenting them as one inseparable form of knowledge. His regimen is yet one more instance in which norms of grief and appropriate reactions to death are discussed within the domain of health. Benedetto's association of health with strength and wisdom further confirms the contemporaneous formulation of masculinity, which as we saw above, was deeply rooted in the various ways of addressing death that were promulgated by different cultural and social elements, and further suggests that medicine contributed its share to this concept of masculinity.
In summary, two trends are apparent in the medical approach to grief. The first, gleaned from the cases of consilia, clearly identifies the danger that grief and contemplation of death may pose to a person's health but recommends that it be treated through 'conventional' medical practice, that is, regimens and medications that will restore balance to the patient's body and soul. The second, for which we admittedly have even less evidence, is a more daring approach; it incorporates religious and humanist discourses into what is still primarily a medical effort. These two approaches towards grief in the medieval medical practice represent a wider debate, which can be mentioned here but briefly, on the relevance and proper method of treating emotions in medical practice. Medicine was conflicted at the time by the question of whether to introduce and include extra-medical concepts into medical practice, and if so to what degree. Bartolomeo's bold decision to include them in the case of Johannes of Milano represents a somewhat unusual solution to this dilemma.
It is notable, though not unexpected, that none of the medical authors surveyed here considered the possibility of healthy grief, nor did they identify the symptoms or stages that mark the transition from 'healthy' to unhealthy grief. This can be attributed to their almost single-minded focus on hazardous states and their assumption that all 'unhappy' emotions were injurious to the body. Here again, the emphasis on the physical diverges from the moral and religious approaches, which welcomed and even encouraged clearly defined displays of grief and sorrow for political, social, and spiritual purposes. (47)
V. Complicated Grief
Todays psychiatric world has been in turmoil recently over a new approach to grief appearing in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 published by the American Psychiatric Association); namely, the cancellation of the 'grief exclusion' and the inclusion of a new disorder, Complicated Grief. This exclusion had precluded a diagnosis of major depression in those who were within two months of loss. (48) Complicated Grief instead relates to grief that is prolonged beyond the common period of recession of grief, considered to be six to twelve months. (49) As one of the central motivations behind the inclusion of certain states of grief within the spectrum of abnormal disorders is to expand medical coverage, chiefly medication, for it: the ostensible consequence of these two changes is the identification of grief, whether short or prolonged, in medical terms. Two of the central questions driving this heated debate are related to the ongoing historical problem I have been discussing here. Firstly, there are the questions of just who should determine what is excessive, non-normative, grief, and how, and to what degree, should social and cultural conventions be considered. Secondly, the questions of what the proper means of treating grief are and whether medication is the answer, or if spiritual, moral, or psychological solutions are called for.
The case of Johannes of Milano demonstrates that these are fundamental, ongoing questions; their answers are shaped and reshaped through time. It highlights the development of the professional role of physicians with their emerging participation in the transmission of social convention. As physicians became more prominent figures in society, this social and cultural function grew and in turn altered the nature of medical care. Bartolomeo Montagnana's analysis of Johannes's illness, imputing it to grief that exceeded the bounds of appropriate behaviour, was inevitably influenced by contemporaneous cultural norms regarding the outward display of bereavement. Such cultural assumptions doubtlessly shaped Bartolomeo's understanding of Johannes's feelings of sorrow and his assessment of tears as valid or illicit, healthy or harmful. Offering his patient a form of Christian consolation further reveals that Bartolomeo considered the most useful therapy for such grief to be spiritual, and not merely medical in the strict sense. Moreover, it shows that Bartolomeo himself assumed that he had the authority to impart this kind of therapy.
Tel Aviv University
(1) Bartholomaeus Montagnana, Consilia Montagnane (Lyon, 1525) (hereafter Consilia), fol. 12r. The case also appears in Oxford, All Souls, MS 75, fols 179r-180v. Translations are the author's own.
(2) Tiziana Pesenti, Professori e promotori di Medicina nello Studio di Padova dal 1405 al 1509. Repertorio bio-bibliografico (Padova: LINT, 1984), pp. 141-57; Franco Bacchelli, 'Montagnana, Bartolomeo', in Dizionario Biografico degli Italiani, 75 (Rome: Istituto della Enciclopedia Italiana, 2011), available online at <http://www.treccani.it/enciclopedia/ bartolomeo-montagnana_(Dizionario-Biografico)> [accessed 22 November 2014].
(3) The medical texts employ several roughly parallel terms--accidentia anime, motus animi, passiones anime, or animi--for a variety of emotional states and affects. I choose to use the modern term 'emotions' for clarity's sake when applicable. For an analysis of what phenomena these terms congregate and what processes they imply, see Na'ama Cohen-Hanegbi, 'Accidents of the Soul: Physicians and Confessors on the Conception and Treatment of Emotions in Italy and Spain, 12th-15th Centuries' (unpublished doctoral thesis, Hebrew University of Jerusalem, 2011), pp. 65-108.
(4) Jole Agrimi and Chiara Crisciani, Les Consilia medicaux, trans. CarolineViola (Turnhout: Brepols, 1994); Chiara Crisciani, 'L'lndividuale nella medicina tra medioevo e umanesimo: I Consilia', in Umanesimo e medicina: ll problema dell"individuale', eds Roberto Cardini and Mariangela Regoliosi (Rome: Bulzoni, 1996), pp. 1-32; Nancy G. Siraisi, 'L'"individuale" nella medicina tra medioevo e umanesimo: I "casi clinici', in ibid., pp. 33-62.
(5) Augusto Serena, La cultura umanistica a Treviso nel secolo decimoquinto (Venice: R. Deputazione venta di storia patria, 1912), p. 27.
(6) Consilia, fol. 12v: 'iste vir consuevit civilibus occupationibus agere capite discooperto semper reverentia consuete honestatis. Ex casu autem filie sue oportuit ipsum capite cooperto exercitari et maxime cum magna caputeorum vanagloria sicut hodie moris est.'
(7) Consilia, fol. 12v: 'quanto magis potest tristitiam ab anima sua excludat, propter quid enim oportet occupare animam circa passionem rei amisse cum recuperatio est impossibilis. Est enim addere stimulum stimulo quod est incurrere vitium officiperdi, ita quod memoriam suam voluntatem et animam omnino conformet voluntati altissimi. Iudicia enim dei abyssus multa. Fortasse enim vir iste tristitiam maiorem valde recepisset ex longa vita filie sue, que ab humanis periculis fere infinitis non erat tuta, et maxime in hoc tempore nostre infelicis etatis subiecte tribulationibus insidiarum odii belli et aliorum discriminum. Equo itaque animo tolerandum est quod provisum et factum evenit. Aliter enim periculum sue vite grande valde preparat sibi vir iste ex forti passione anime. Tales enim passiones exterminant et mutant corpus ab ea que est secundum naturam consistentia tertio tegni.'
(8) Nicole Archambeau ('Tempted to Kill: Miraculous Consolation for a Mother after the Death of Her Infant Daughter', in Emotions and Health, 1200-1700, ed. Elena Carrera (Leiden: Brill, 2013), pp. 47-66) discusses in detail how Saint Delphine of Puimichel was reputed to have healed a mother suffering from feelings of sorrow and vengeance after the death of her daughter. Many cases are described in Ronald C. Finucane, The Rescue of the Innocents: Endangered Children in Medieval Miracles (Basingstoke: Macmillan, 2007), pp. 207-10; and Alexander Murray, Suicide in the Middle Ages, 2 vols (Oxford: Oxford University Press, 1998-2000), i (1998), 258.
(9) Job was a highly venerated saint in the later Middle Ages. His 'lessons' appeared in the prayers of the 'Office of the Dead' recited often by the laity and daily by the clergy. He also figures repeatedly in funerary sermons in which the beloved are advised to accept the judgement of the Lord. See, for example, Niccolo Lugaro, Sermones aurei funebres cunctos alios excellentes noviter inventi (Paris, 1512); Jacobus da Voragine, Sermones aurei, dominica XVII post trinitate (Paris, 1528), sermo I; Lawrence L. Basserman, The Legend of Job in the Middle Ages (Cambridge, MA: Harvard University Press, 1979), pp. 57-64; Domenico Cavalca, Specchio de peccati, ed. Francesco del Furia (Florence: Tipografia all Insegna di Dante, 1828), pp. 41,51.
(10) Louis Haas, The Renaissance Man and his Children: Children and Early Childhood in Florence, 1300-1600 (Basingstoke: Macmillan, 1998), pp. 170-72; Philip Gavitt, Charity and Children in Renaissance Florence: The Ospedale degli Innocenti 1410-1536 (Ann Arbor: University of Michigan Press, 1990), pp. 290-95.
(11) Carol Lansing, Passion and Order: Restraint of Grief in the Medieval Italian Communes (Ithaca, NY: Cornell University Press, 2008), pp. 153-71.
(12) Funeral regulations appear already in the laws of ancient Greece and Rome, revealing an ongoing concern to limit expenditure and noise in ceremonies. Catherine Kovesi Killerby (Sumptuary Law in Italy 1200-1500 (Oxford: Oxford University Press, 2002), pp. 10-13, 72-75) argues that from the thirteenth century onward religious, economic, and social considerations brought more force to these laws, and they were issued and executed more elaborately. This certainly seems to have been the case regarding regulations of the display of mourning.
(13) Carol Lansing, 'Gender and Civic Authority: Sexual Control in a Medieval Italian Town', Journal of Social History, 31 (1997), 33-59.
(14) Lansing, Passion and Order, pp. 58-72.
(15) Sharon T. Strocchia, Death and Ritual in Renaissance Florence (Baltimore: Johns Hopkins University Press, 1992), pp. 116-18.
(16) William M. Reddy, The Navigation of Feeling: A Framework for the History of Emotions (Cambridge: Cambridge University Press, 2001), pp. 124-29.
(17) George McClure, Sorrow and Consolation in Italian Humanism (Princeton: Princeton University Press, 1991), pp. 106-08; Coluccio Salutati (Epistolario, Volume 3, ed. Francesco Novati (Rome: Tipografia del Senato, 1896), p. 413), for instance, mentions Job and other biblical mourning fathers as justification for his own grief for his dead son (rather than as an example of acceptance of Gods will).
(18) Salutati, p. 412.
(19) McClure, pp. 79-80.
(20) See Francesco Petrarca, Rimedi all'una e all'altra fortuna, ed. Enrico Fenzi (Naples: La scuola di Pitagora editrice, 2009), p. 224. Petrarch includes a long list of sorrows under the chapters dealing with tristitia and miseria, including grief over loss of loved ones.
(21) Salutati, pp. 141-42.
(22) Margaret L. King, The Death of the Child Valerio Marcello (Chicago: University of Chicago Press, 1994), pp. 24-27.
(23) Antoninus of Florence, Confessionale (Strasburg, 1490), fol. 60r: 'Si etiam ita contristatur de aliquot casu adverso quod incurrit grandem infirmitatem propter nimiam tristiciam perdens somnum dimittens cibum et huiusmodi.'
(24) Antoninus of Florence, Confessionale, fol. 62v: ' [si] fecit excessum in portatura vestium ultra suum statum vel conditionem vel non secundum morem patrie.'
(25) Bernardino da Siena (Le prediche volgari, ed. P Ciro Cannarozzi (Pistoia: Alberto Pacinotti, 1934), pp. 150-51) explained the greater virtue of inverted contrition by comparing this religious grief to that of a father whose son has died, but he cannot shed tears due to his immense sorrow.
(26) James R. Banker, 'Mourning a Son: Childhood and Paternal Love in the Consolateria of Giannozzo Manetti', History of Childhood Quarterly, 3 (1976), 351-62. The dialogue of Manetti with his friends shows this well, as the text goes beyond consolation into discussions of fatherhood and manhood.
(27) Giovanni Dominici, Regola del governo di cura familiare (Florence: Libreria Editrice Fiorentina, 1927), pp. 101-07. For the articulation of masculinity through fatherhood and the emphasis on fathers' emotional ties with their offspring, see Juliann Vitullo, 'Fatherhood, Citizenship, and Children's Fames in Fifteenth-Century Florence', in Framing the Family: Narrative and Representation in the Medieval and Early Modern Periods, eds Rosalynn Voaden and Diane Wolfthal (Tempe: Arizona Center for Medieval and Renaissance Studies, 2005), pp. 181-91.
(28) Rachel E. Moss, Fatherhood and its Representations in Middle English Texts (Woodbridge: Brewer, 2013). See, especially, her discussion on reluctant fathers on pp. 56-60; for a discussion of the association between fatherhood, masculinity, and legitimate rule, see Patricia Simons ' Alert and Erect: Masculinity in Some Italian Renaissance Portraits of Fathers and Sons', in Gender Rhetorics: Postures of Dominance and Submission in History, ed. Richard C. Trexler (Binghamton: Medieval & Renaissance Texts & Studies, 1994), pp. 163-86 (esp. 166-67).
(29) For a discussion on the challenge grief poses to masculinity, see Allison Levy, 'Augustine's Concessions and other Failures: Mourning and Masculinity in Fifteenth-Century Tuscany', in Grief and Gender: 700-1700, ed. Jennifer C. Vaught (New York: Palgrave, 2003), pp. 81-94.
(30) Bartolomeo de Caimi, Interrogatorium sive confessionale (Nuremberg, 1477), fol. 47v; Domenico Cavalca, Specchio de' peccati, p. 52. Nirit Ben-Aryeh Debby (Renaissance Florence in the Rhetoric of Two Popular Preachers: Giovanni Dominici (1356-1419) and Bernardino da Siena (1380-1444) (Turnhout: Brepols, 2001), p. 100) cites Giovanni Dominici (1356-1419) as having encouraged a noblewoman who was in a state of grief (though not in mourning) not to neglect her health; see also Giovanni Dominici, Regola del governo, pp. 62-63. Although illness was often seen as an opportunity for spiritual advancement, this did not imply that medicine and the care of the body were avoided. As Angela Montford (Health, Sickness, Medicine and the Friars in the Thirteenth and Fourteenth Centuries (Aldershot: Ashgate, 2004), pp. 178-79) has shown, within religious communities there was substantial investment in various kinds of therapies and various regulations that fostered thoughtful care of the body in order to prevent harm to the soul.
(31) The corpus of consilia includes more than a thousand of both printed and manuscript cases written in Italy between the thirteenth and fifteenth centuries. The genre and the printed collections have been described by Agrimi and Crisciani in Les Consilia medicaux (see n. 4) and I have been able to go through all of them. I am still in the process of studying the unpublished manuscripts.
(32) The exact identity of the consilium's author is uncertain. That he practised medicine in Venice is learned from another consilium in the manuscript in which this case is found, but it also seems safe to assume that he was the same Giovanni da Genoa who served as physician to Pope Clement VI. See George Sarton, Introduction to the History of Science, 3 vols (Baltimore: Williams & Wilkins, 1947), Ill, 245; Ernest Wickersheimer, Dictionnaire biographique des medecins en France au Moyen Age (Geneva: Droz, 1979), p. 424; William J. Courtenay (Parisian Scholars in the Early Fourteenth Century: A Social Portrait (Cambridge: Cambridge University Press, 1999), p. 176) found documentation for one Johannes de Janua who studied for a degree in medicine during 1329, and later, in 1343, practised as both physician and sirugicus.
(33) Munich, Bayerische Staatsbibliothek, MS CLM. 205, fol. 103v: 'cause enim primitive fuerunt sollicitudines et timores et tristicie propter mortem parentum.'
(34) Cf., for example, the consilium to a melancholic patient in Gentile da Foligno, Consilia (Pavia, 1488), chap. 3, fol. 1v.
(35) Gerardus de Berneriis, I Consilia di Gerardo de Berneriis di Alessandria, ed. Flavio Ballestrasse (Pisa: Giardini, 1970), pp. 31-33.
(36) Miscarriage is mostly discussed in a general manner and not with respect to particular patients. For the most pertinent to the discussion of grief, see Gilbertus Anglicus, Compendium medicine (Lyon, 1510), fol. 308r. See especially the chapter on 'pains of the womb after childbirth', which includes a discussion of the grief and pains that follow premature miscarriage.
(37) Consilia, fols 289v-292r.
(38) Ugo Benzi, Consilia ad diversas aegritudines (Pavia, 1496), fol. 69r.
(39) Consilia, fol. 23r.
(40) 'Liber Tegni Galieni', in Articella (Venice, 1483), fols 151r-210r (fol. 186v): 'Abstinere vero manifestum est quoniam ab intemperamentia oportet omnium anime passionum scilicet ire tristicie et gaudii et furoris et timoris et invidie et sollicitudinis. Exterminant enim hec et mutant corpora ab ea que est secundum naturam consistentia.'
(41) 'Liber Tegni Galieni', fol. 186v.
(42) Taddeo Alderotti, Commentum in microtegni (Naples, 1522) (hereafter Commentum), fol. 162v; Per-Gunnar Ottosson, Scholastic Medicine and Philosophy (Naples: Bibliopolis, 1984), pp. 259-61. The treatment of emotions, especially within the regimina tradition, is discussed by Pedro Gil-Sotres in his commentary, in Arnau de Vilanova, Opera medica omnia Arnaldi de Villanova. x.1: Regimen sanitatis ad regem Aragonum, eds L. Garci'a-Ballester, J. A. Paniagua, and M. R. McVaugh (Barcelona: Seminarium Historiae Scientiae Barchinone, 1996), pp. 805-06.
(43) Commentum, fol. 162v: 'Sed quia ipsum in se est superflua quantitates, ita quos habet virtutem concitare ad superfluum motum spiritus et caloris, verbi gratia ponatur quod homo optime compositionis habeat omnia tristabilia in pecunia persona et filiis que habuit Iob. Dico quod ipse tristabitur proportionate quantitate illius nocumenti nihilominus si deberet conservari oporteret quod tam grandi tristitie opponeretur.'
(44) Commentum, fol. 162v: 'Si alicui mortuus sit optimus filius, hoc quidem est grande tristabile, deberet igitur medicus conservator procurare, ne pater sciret mortem eius: et etiam dato quod sciret, debet ipse qui vult se conservare sibi suadere quoniam si minus tristaretur posset cadere in vitium anime et egritudinem corporis.'
(45) Benedetto Reguardati da Norcia, Libellus de conservatione sanitatis (Rome, 1475), fol. 129r: 'Sed nunquam tali morte prudentem aut fortem virum contingit interire.'
(46) Benedetto Reguardati da Norcia, Libellus, fols 129r-129v.
(47) In addition to the practices discussed above of esteemed consolation and ritualised mourning, there is, of course, the flourishing culture of contrition in the period.
(48) This removal may entail diagnosis of depression and consequently medication of bereaved people in close proximity to their loss. The reasoning behind this change is that the depression of bereavement is not unlike depression caused by other stressors. But the change has been the subject of much criticism, within and outside the psychiatric community, for pathologising the natural state of grief or, alternatively, for overlooking the particular nature of prolonged grief as distinguished from depression. Richard A. Friedman argues against the medicalisation of grief in his 'Grief, Depression, and the DSM-5', New England Journal of Medicine, 366 (2012), 1855-57. Arguing for the particularity of prolonged grief is Richard A. Bryant, 'Grief as a Psychiatric Disorder', British Journal of Psychiatry, 201 (2012), 9-10.
(49) According to Bryant ('Grief as a Psychiatric Disorder', p. 9), while normally 'people report remission in acute distress by 6-12 months following the death', 10-15 per cent of bereaved people remain preoccupied with the death longer than this and are thus suffering from the disorder. See also M. Katherine Shear and others, 'Complicated Grief and Related Bereavement Issues for DSM-5', Depression and Anxiety, 28 (2011), 103-17.
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