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TowardsaHistoryofEuropeanPhysicalSensibility: PainintheLaterMiddleAges
EstherCohen
ScienceinContext/Volume8/Issue01/March1995,pp4774 DOI:10.1017/S0269889700001897,Publishedonline:26September2008

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Science in Context 8, 1 (1995), pp. 47-74

ESTHER COHEN

Towards a History of European Physical Sensibility: Pain in the Later Middle Ages
They are and suffer; that is all they do: A bandage hides the place where each is living, His knowledge of the world restricted to A treatment metal instruments are giving. They lie apart like epochs from each other (Truth in their sense is how much they can bear; It is not talk like ours but groans they smother), From us remote as plants: we stand elsewhere. For who when healthy can become a foot? Even a scratch we can't recall when cured, But are boisterous in a moment and believe Reality is never injured, cannot Imagine isolation: joy can be shared, And anger, and the idea of love. W. H. Auden, Sonnets from China, Sonnet 14.

The Argument The study of pain in a historical context requires a consideration of the cultural context in which pain is sensed and expressed. This paper examines attitudes toward physical pain in the later Middle Ages in Europe from several standpoints: theology, law, and medicine. During the later Middle Ages attitudes toward pain shifted from rejection and a demand for impassivity as a mark of status to a conscious attempt to sense, express, and inflict as much pain as possible. Pain became a positive force, a useful tool for reaching a variety of truths. While this attitude stemmed from the religious wish to identify with Christ's passion, it permeated and affected all spheres of cultural expression and investigation. Late medieval medicine accepted pain, trying to relieve it only when it became dangerous to the patient. Given the existence of analgesic medicines at the time, this attitude is comprehensible only within the cultural context of that period.

* My thanks to Gigi Santow, Mary and Kenneth Gergen, Mayke de Jong, and Kenneth Stow for their help and suggestions.

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Introduction Ever since Eve was sentenced to bring forth children "in sorrow," physical pain has been considered an integral part of the human experience within the JudeoChristian tradition. The Christian myth of origin linked suffering with the Fall, thus making it inseparable from human destiny. Physical pain was the price paid for original sin, and physical pain redeemed the same sin. The entire history of the human race was encompassed within a symbolically charged cycle of suffering. No human culture can ignore the pain factor. Barring rare cases of congenital inability to perceive pain, it is a universal sensation, shared by all humans possessing functional nervous systems. The instinctive reaction to pain crying out, weeping, making a sad face is as universal a human quality as smiling from joy or pleasure (Schiefenhovel 1995). And yet this natural reaction is overlaid with cultural dictates. No two human cultures have prescribed precisely the same behavioral reaction to pain. Indeed, the original premise of the anthropology of pain is that while all humans must face pain, the difference lies in the manner in which various cultures dictate and formulate responses to the sensation. As a rule such attitudes are part and parcel of a total perception of the human body and its place within the cosmological framework. But whatever the reaction, or the means of coping with pain evolved by each culture, they are all based on the premise that the avoidance of pain is a basic human instinct. "The only universal feeling about pain is that no normal human likes it" (Zborowski 1969, 31). Cultural systems have no choice but to deal with pain. It is not only a universal sensation, it is also impossible to convey or share. "Man is born unto labor," stated Job (Job 5:7), but all scientists dealing with the experience have come up against the barrier of the utter loneliness of pain. It is essentially an individual experience, unsharable and intransmissible (Bakan 1968, 59-67). Though clinical researchers compiling "pain questionnaires" have constructed a complex vocabulary to describe the infinite varieties of physical suffering, they too are aware of the looseness and idiosyncrasies affecting all description of the pain experience, and the consequent impossibility of any absolutely objective measurement (Melzack 1983a, 1-5; Melzack 1983b, 41-47). Furthermore, people of different cultural-ethnic backgrounds are apt to respond differently and use different terms to describe their experiences (Zborowski 1969, 236-45).' In other words, all attempts to describe pain and all reactions to pain are filtered through the cultural norms of both sufferer and observer. In fact this filtering is essential. A sensation so universally experienced and so impossible to share could constitute a dangerous crack in the fabric of any cultural structure. Cultures are essentially the interpretations and structuring of shared
1 Since the publication of Zborowski's work, anthropologists of pain have taken issue with his ethnic stereotypes, arguing that culture was only one of an entire complex of individual factors physical, psychological, and cultural dictating pain reactions. See Kleinman et al. 1992, 1-3.

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experiences (Geertz 1973), and the intransmissible nature of the pain experience makes it imperative that all cultures impose certain patterns of prescribed reactions to it. For unless pain is structured, assimilated, and given meaning within the network of cultural symbols, responses, and social ties, it might be a disruptive element. The nature of pain might well compare with that of the equally individual and intransmissible mystical experience. Though the latter is shared by only a small elite, and only as the result of strenuous voluntary seeking, socially oriented religions have consistently suspected mysticism precisely because of its intrinsically individual nature. Pain is far more dangerous. Far from being confined to a small marginal group, it is part and parcel of every human being's destiny from birth to death. It is not limited to those who seek the experience voluntarily, nor can it be proscribed or deliberately avoided. It is thus a factor every culture must contend with in its own way. The historical study of pain in the past has met with an additional difficulty. It is not enough to distinguish between different cultural-ethnic groups and their reactions. All cultures evolve with time, and attitudes towards pain have changed and developed through the ages even within the Western cultural tradition. While modern researchers are aware that their results have been filtered through a cultural lens, the historian must contend with a triple filter. First, as now, people in the past used the vocabulary and gestures inculcated in them by their heritage to express the physical sensation (Scarry 1985,3-11). Second, unlike the anthropologist, the historian cannot record these expressions. The only evidence available to us was subsequently filtered through the media of writing and iconography, into whose durable mold the expressions were cast. In the process of recording, the formal rules of the text were imposed on the original expression and these rules, we must remember, also change over time. Is it enough then to analyze these texts according to contemporary rules in order to reach the underlying experience, or at least its original expression? Not quite. The historian must also contend with the existence of a third filter, that of time and altered cultural norms. The relativity of attitudes toward basic human emotions love (both erotic and parental), mourning, anger and the changes over time in their modes of expression have been studied by historians and philosophers alike. Foucault, Badinter, and Duby are only the best-known spokespeople of this approach. By the same token, I would argue, expressions of pain in the past were not only conveyed in a different form. The very experience was probably conditioned by the same cultural matrix that dictated the forms of expression. It is thus impossible for the modern historian even to attempt any objective assessment of pain in the past. Moreover, research has shown that now too the subjective, psychological context of pain is an integral factor of the experience at all times.2 The very tolerance level of people enduring pain under anxiety-free
2

"Cognitive-affective processes are an integral part of the total pain experience" (Melzack 1983a,

3).

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conditions (such as laboratory tests) was found to be much higher than that of ill or wounded people, whose physical sensations were aggravated by fear of death and annihilation (Beecher 1952, 157-62, cited in Zborowski 1969, 16). If the physical experience of twentieth-century sufferers has been so significantly affected by the context of the pain, it is fairly safe to assume that the feelings of people in the past were equally affected by the specific circumstances of their distress. Fear of the pain and its associations undoubtedly aggravated it, while acceptance probably reduced the sensation. And fear or acceptance are part of the cultural-historical context that is indeed within the historian's domain. This setting, it must be stressed, is not a medical one. Pain is not a medical fact but a human one. Even given the modern prevalence of medical care and ideas a phenomenon unprecedented in human cultures people do not resort to physicians in order to express pain. Nor does the medical profession dictate the modes of expression. It is a primal human event, and its context belongs to the realm of general human culture. While medical opinion forms an integral part of this culture, it is more apt in this instance to be influenced by the context than to shape it. In order to study attitudes toward physical anguish I have adopted an integrative approach, attempting to examine a number of disciplines either dealing with or expressing physical sensations. The multifaceted nature of human experience is bound to influence the thinking and writing of people at any given time. The most dedicated and abstruse of philosophers exists within a given reality, eats its food, smells its smells, wears its clothes, and feels the same aches and pains other humans feel. The same is true of the poet, the painter, the physician, and the surgeon. Beliefs concerning the human body and its sensations cannot therefore be classified as "history of science" and left there. They belong in the history of the entire scope of human experience and reactions to that experience. However, one must be careful to distinguish among types of disciplines and, consequently, the sources they provide us. Disciplines attempting to describe and convey the pain experience are bound to approach the subject in a manner different from those investigating the nature, meaning, and uses of pain. The former, comprising all expressive art forms, are bound to convey their message by use of specific artistic codes, thus providing us with an insight into the cultural imperatives dictating the manner of both venting and describing physical anguish. The latter philosophy, medicine, and law attempt to place the pain experience within certain conceptual frameworks regarding human destiny, history, and physiology. Consequently, their explanations and prescriptions must be viewed within the context of these frameworks. Thus seen, they illuminate strategies of pain control and manipulation, addressing the most basic question of all: should one ease or aggravate other people's physical pain at all, or merely recommend toleration? As all our evidence has been filtered through the cultural-temporal lens of the European context, it is important first to examine various culturally conditioned responses to pain in Western society. By analyzing the varieties of pain expressions

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and attitudes we may achieve an integrated profile of contemporary approaches toward the experience of pain. It is not the purpose of this paper to provide any conclusive answers. Exhaustive research on the subject remains to be done. Rather, I would like to delineate the cultural context of late medieval pain-related attitudes and to attempt the formulation of a thesis explaining the coalescence of one coherent attitude. To understand the uniqueness of the attitude toward pain in the later Middle Ages, an attitude I have termed philopassianism, it might be useful to examine some of the prevalent cultural attitudes toward pain. Each culture evolves a set of imperatives dictating the correct responses of its members in any given pain situation. Though these imperatives are not invariably obeyed, they largely do shape behavior in the face of physical suffering. Modern Western culture, on the whole, considers physical pain an evil best avoided, or at least alleviated. The growth of anesthesia during the past century, not only in surgery but also in other physically traumatic situations, is proof of this attitude. Even such situations as childbirth, where pain is culturally acceptable, have become occasions for the use of sedation. While rejection might not be the universal attitude among medical practitioners, it is the culturally prevalent one. Physical suffering is not considered inevitable or unavoidable. On the contrary, modern Western culture seeks as much as possible to eradicate all types of pain. The pain inflicted by medical treatment (be it surgery or merely a dental filling) is invariably anesthetized beforehand. One expects the treatment of any sickness automatically to include an alleviation of pain symptoms. Even nonmorbid painful situations, such as premenstrual cramps, have become the object of pharmaceutical attention. The painkilling industry is a fact of major economic proportions in modern Western culture. One might argue that only a culture that had developed its pharmacopoeia to the present extent could afford this attitude. The choice not to suffer is, after all, predicated on the existence of means that can put a term to suffering. But that would be placing the cart before the horse. Many primitive societies are familiar with the analgesic qualities of various plants, yet they do not resort to them in situations in which modern Westerners would automatically demand relief. More important, in many societies the acceptance of pain is a cultural imperative. This attitude concerns not only involuntary pain but, more significantly, deliberately and ritually inflicted pain. The ability to withstand severe pain without recoiling is often a test in rites of passage and initiation (Zborowski 1969, 40). The infliction of mutilation and pain, especially in rites of passage to maturity, is not a universal factor. It is most common in societies that sanction violence in general and whose members are likely to be exposed during their lifetime to violence. Such rites are almost invariably practiced on males, expected both to inflict and to suffer violently induced pain during their lifetime. In all those ceremonies, the young men undergoing pain are expected to manifest impassivity in other words, to endure without flinching.

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This phenomenon is not limited to American Indian and Australian tribes. Even pain-rejecting modern society will demand impassivity under certain circumstances. Young football players might automatically be injected with Novocaine at the dentist's, but are expected to sustain sports injuries without crying out. The norm is restricted not only to specific circumstances but also to specific age, sex, and social groups. Vocal and physical expressions of anguish permissible to little children or to women of various ages crying, groaning, screaming are not socially acceptable for grown men outside a hospital ward. Finally, impassivity is often a yardstick of social status, displays of pain sensitivity being considered both vulgar and ill-mannered. Impassivity consists in the ability to tolerate pain without any visible or audible reaction. It does not entail insensitivity to pain. On the contrary, the virtue of impassivity lies in the strength manifested by the sufferer who feels the pain without showing it. The capability of transcending pain completely, or impassibility, is a different category. Eastern religions have made impassibility a goal attainable after long and arduous spiritual discipline. The ultimate aim of this training is not merely transcendence over pain but an overall freedom from physical sensations. In the West, impassibility was merely a dispensation from pain without total insensibility. Furthermore, it was never considered something any person could achieve by training. It was a miraculous quality, a gift from heaven granted only occasionally to saints and martyrs. The three attitudes rejection, impassivity, and impassibility do not exclude one another. A combination of any two or of all three can be found in various historical and cultural settings. For example, cultures demanding impassivity during rites of passage may well allow sedation (and thus rejection of pain) in sickness or surgery. By the same token, no culture expects impassibility from all its members or attributes it to them. Indeed, such a norm would fly in the face of human nature. Impassibility, whether congenital or acquired, is invariably the hallmark of a small elite, while the rest of society conforms to other pain-related behavioral norms. All three reactions are founded on the basic premise that pain is a negative force. One must do one's best to deal with it, but one need not seek it. In this, all three cultural attitudes accord with basic physiological instincts that dictate the shunning of pain (Schiefenhovel 1995). The rise and development of philopassianism in the later Middle Ages and early modern period is therefore an extraordinary phenomenon. It is the complete opposite of the instinctive human reaction to pain: the deliberate, conscious attempt to feel as much physical anguish as possible. It is both diametrically opposed to human instincts and unique within the history of human cultures. Philopassianism is emphatically distinct from modern masochism. One did not seek pain in order to derive sensual pleasure from it. The physical sensation was invoked because it was considered useful, not pleasurable. The uses of pain were manifold, depending on the circumstances and the object. In the widest sense of the term, it might be said that pain was seen as an avenue to

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knowledge. Knowledge of the body, of the soul, of truth, of reality, and of God. Whether self-inflicted or caused by others, physical pain was a way of affirming the boundaries of identity.

Historical Background The different attitudes toward physical pain did not emerge concurrently, nor was their role in Western culture continuous. Rejection is undoubtedly a new phenomenon, closely tied to the cultural and scientific developments of the last two centuries. Conversely, impassivity has a long history in the West. Its reappearance in the last centuries is tied to what Norbert Elias has termed the civilizing process. Like other parallel processes, it first grew normative among the higher classes, becoming integrated in common consciousness only during the last century or so (Elias 1982). Nevertheless, the roots of impassivity lie much deeper than those of rejection, for it was a well-documented pre-Christian norm. Stoic philosophy (later transmuted into the patristic teachings of Clement of Alexandria) saw a virtue in the ability to ignore, and thus master pain. Apatheia, or the ability to free oneself completely of one's passions, was the philosopher's ideal. The passions, in Stoic terms, were not the physical sensations inevitable corollaries of possessing a body but the emotions triggered by such physical stimuli as hunger, pain, fear, or desire (Brown 1988,130-31). Through wisdom one could achieve the control, if not the eradication of bodily sensations. This norm, restricted to rarefied philosophical circles in imperial Rome and late antique Alexandria, reappeared in a different guise in later centuries. The development of the noble ethos of the high Middle Ages made impassivity a status symbol. Pain and its expression were held in contempt as manifestations fit only for the female and the unfree. Dolor was Eve's punishment, and thus both a penalty and a female attribute. It was also practically synonymous with labor, Adam's sentence of manual labor, restricted in practice to the unfree. Though chivalric literature abounds in descriptions of battles, wounds, and mutilations, the heroes of these epic poems hardly ever express any pain response to all this mayhem. In short, they prove both their manhood and their nobility by their capacity for impassivity (Duby 1988, 203-9). There is ample evidence that impassivity ceased being the hallmark of nobility during the later Middle Ages and early Modern period. Kings and peasants, noblemen and workers, were equally permitted to give voice loudly to physical anguish. The detailed descriptions of their own sufferings and illnesses left by Renaissance scholars, who simultaneously perceived themselves as noble, reflect the change in attitude. Impassibility has a shorter history in the West. Paradoxically, impassibility first appeared within the context of the one religion that had succeeded in socializing the experience of pain. The centrality of pain to Christianity is of overwhelming importance. Pain comprised both the penalty for original sin and the redemption

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of humanity. And pain was perceived, most importantly, as a purely human attribute. All the Christological controversies of late antiquity stemmed from the dilemma created by the belief in Christ's divinity, as a purely divine Christ could not suffer in the body, thus redeeming the sins of humanity. For Christianity, pain was thus from the very beginnings a central historical and cosmological force rather than an individual, evanescent experience. Consequently, it became part of communal consciousness, a fact of great social importance (Bakan 1968, 67). This was something of a mental revolution in the world of late antiquity. The social codes of the late empire did not consider pain a sensation befitting freemen. The entire health routine prescribed by ancient medicine for gentlemen of position was meant to avoid illness and pain (Rousselle 1983, 7-13). Judicial torture was normally restricted to slaves and inflicted on freemen only under suspicion of treason (Mommsen et al. 1922, Digesta 48:14, "De quaestionibus"). The idea that pain was not only universal and unavoidable, but also necessary for human salvation revalidated and socialized physical suffering. A religion that had accomplished such a major revolution regarding the human body, that had deliberately made its God into a suffering man, could hardly be expected to create its heroes in an impassible, super-human mold. And yet that is precisely what Christianity did. Early Christian martyrs displayed a number of supernatural characteristics, all connected with their extraordinary ability to withstand pain. Some were indeed impassible, testifying that they felt no pain under torture (Shaw 1993; Musurillo 1972, 67, 79-91; Brown 1988, 73-75).3 Others were able to withstand an agony fatal to the normal human frame (Musurillo 1972,67). Even before their ordeals, martyrs were apparently aware of possessing this superhuman tolerance, thus facing pain with a courage born of the knowledge that their experience would not be the utterly lonely normal sensation of pain. They shared the test with each other and with Christ.4 One might well explain the martyrs' impassibility on those occasions in purely human terms. They welcomed their death as a moment of supreme victory, a triumph to be rejoiced in; and their psychological state in the arena could well go far toward explaining their lack of physiological response. Furthermore, contemporary accounts of martyrdom were not invariably clear-cut, some stressing the martyrs' suffering, others insisting on their impassibility. But both hagiography and theology denied this view. Medieval authorities insisted that martyrs were impassible because their flesh was materially and supernaturally different from normal human flesh. This difference was sometimes visibly and miraculously manifested in the absence of all signs of torture on martyred bodies (Musurillo 1972, 69).
3 I have deliberately avoided later mythical martyrologies and passions, confining myself to the evidence of contemporary accounts concerning figures of unquestionable historicity. 4 "What I am suffering [dolo] now, I suffer by myself. But then another will be inside me who will suffer for me, just as I shall be suffering [passurasum] for him," explained Felicitas while enduring the pangs of childbirth prior to her execution (Musurillo 1972, 123-25).

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Augustine started the trend by claiming that the dead bodies of all saints were incorruptible (Augustinus 1899, XIII.20). But the growing stress in later centuries on Christ's own passibility made it impossible to continue attributing impassibility to his martyrs. Thomas Aquinas attributed this characteristic to two human categories, both exempt from the laws of nature and neither of them undergoing martyrdom. Adam and Eve had enjoyed it before the fall, being immune from sickness, corruption, and death.5 The spiritual bodies of the blessed in Paradise possessed it to an even greater measure, since they were entirely free of the physical body and its passions (LeMay 1955,108-20). According to Thomas, impassibility was clearly distinct from insensibility. The blessed retained their senses, being fully able to smell, see, hear, touch, and taste the pleasures of Paradise. The only feeling they lacked was pain (Thomas Aquinas 1866, pars tertia, suppl, q. 82). But in so doing, Thomas and his fellow theologians had removed the possibility of impassibility from the human realm. It is no chance that the transformation from an earthly lack of sensation, albeit one belonging to saints, to heavenly experience was accomplished during the thirteenth century. By then, Christ's own sufferings had come to play a central role in the religious imagination, and it had become inconceivable that Christ's own witnesses should have been deprived of sharing his experience. Together with other supernatural physical qualities such as incombustibility,6 impassibility became in Baroque imagination a permanent characteristic of the blessed in Paradise. Preachers dwelt ecstatically both on the freedom it granted from pain and disease and on the exquisite pleasures derived from this quality. "Impassibility . . . has the delightful quality of enabling every sense to cull an overwhelming abundance of pleasure from its corresponding excitant" (Zuccarone 1671, 325, quoted in Camporesi 1988, 26). The various attitudes toward pain, therefore, are not only culturally conditioned. They are also dependent on temporal developments within every single culture. So much so that, at any given time, those articulating prevalent perceptions (as Thomas Aquinas did) are forced to infuse a new meaning into old terms in order to reconcile them with contemporary views. By the later Middle Ages, neither rejection, nor impassivity, nor impassibility were the goal of those seeking perfection. Their goal was philopassianism.

The Late Medieval Context A phenomenon so startlingly comprehensive and so unusual certainly requires an explanation. The simplest argument namely, that an age afflicted with as many
5 In this, Thomas flatly contradicted Hugh of Saint Victor, who insisted that man before the Fall had the capacity to suffer, but could choose not to sin and hence not to suffer. (Hugh of Saint Victor 1951, bk, 1, pt 5, chap. 18, 107-108). 6 A characteristic subsequently transmitted to Protestant myths as well. See Scribner 1987.

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scourges as the later Middle Ages might naturally try to discover some virtue in its suffering does not unfortunately hold in the face of chronology. For the roots of philopassianism are clearly discernible already in the twelfth and thirteenth centuries, long before the plague, wars, famines, and rebellions of the fourteenth century. Furthermore, philopassianism is notoriously absent in the early Middle Ages, though the exposure of European populations to pain and disease was certainly massive then too. Any comprehensive explanation must be far more complex. In order to understand philopassianism, it is first necessary to examine at least some of the forms it assumed and the functions it served in late medieval culture.

The Body as Symbolic Entity Beyond the basic physical fact of the body's existence and sensations, contemporary culture saw in it a multivocal symbol functioning on various levels according to different contexts. It was a mirror reflecting several religious and scientific verities, a complex of symbolic messages. Each limb was connected with a different zodiacal sign, and the total shape of each body was equally influenced by astrological forces (Husson 1978, 84-91; Radbruch 1938). Roger Bacon went so far as to criticize physicians who "do not study the heavenly bodies upon which all alteration of bodies in the lower world depends... a physician who knows not how to take into account the positions and aspects of the planets can effect nothing in the healing arts except by chance" (Bacon 1924, 144-45). The body's different forms both defined and manifested social gradations, so that noblemen appeared both in literature and in medical texts as well-formed and strong, while simple folk bore an ugly, malformed appearance (Le Goff 1985, 84).7 Each gesture and motion of the body, each posture in space, carried symbolic weight, in and out of ritual situations (Schmitt 1990). The human body was thus a microcosm, reflecting the surrounding macrocosmic elements and spheres of the universe. The same quarternary order controlled both body and universe: the four humors, four qualities, and four temperaments of the body reflected the four constitutive elements of nature. Humidity and dryness, heat and cold, were both human and cosmic qualities. If women, for example, were generally cold and humid in temperament, they were akin to water also in other aspects, such as their malleability (Singer 1928; Engbring 1940). Societal and scientific perceptions were intimately tied with religious ideas. When Christianity came to connect body, pain, and salvation, it resorted to
7 See, for example, the description of Marcolf the peasant: "Short and fat of stature. His head was big; forehead very wide, red and wrinkled; ears hairy and hanging to the middle of his jaws; eyes protuberant and runny; lower lip resembling a horse's; beard dirty and bristly like a goat's; hands truncated; fingers short and fat; feet round; nose thick and twisted; lips big and fat; face asinine" (Croce 1978, 170).

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knowledge culled from other fields. The most remarkable example of this is an eighth-century Irish table of commutations, prescribing "for saving a soul out of hell. . . 365 paternosters and 365 genuflexions and 365 blows with a scourge on every day to the end of a year . . . this commutation for redeeming the soul that deserves torments in the body [my italics] has been made according to the number of joints and sinews that are in a man's body."(McNeill and Gamer [1938] 1990, 142). At the same time illness with its associated pain was a disruption of universal harmony. During the early Middle Ages indeed illness and pain were viewed as manifestations of sinfulness, one theologian going so far as to identify different diseases with corresponding sins: leprosy and heresy were one (Hrabanus Maurus 1844-64, bk. 18, chap. 5, "De medicina," 111:501-2). In theological terms, the human body was thus anything but the dead clay and unmitigated pollution described by some dualist religions. It was God's creation and thus an expression of divine will. That God's son should have assumed the human form was an excellent reason to see in it a representation of perfection. Its sensations were therefore an ideal vehicle for the divine plan of human destiny. Philopassianism was thus predicated on a perception allowing for no dichotomy of body and soul. The body and its sensations could serve as a tool for higher means only if the boundaries of the self were coterminous with the physical entity as well as the abstract concept. Perceptions of the human body were thus tied with notions of both physical and metaphysical reality. But even within this framework one could view pain in two opposite manners: either as the wages of sin, to be patiently born, or as a vehicle of grace, to be ardently sought. During the thirteenth century, Christianity turned from the first perception of pain to the second.

Pain and Salvation Pain came into the Christian world view via the story of Creation, thus being associated with women and with punishment for sin. Nowhere in this story is there any hint that Eve or her descendants might benefit from the pangs of childbirth, either in this world or in the next. Pain had simply become part of human destiny. Rather than an individual experience, it became a factor of cosmic proportions. The Pauline and Augustinian interpretations of the Fall added to the original penalty two more corollaries: the weakening of man's ability to withstand the temptations of evil and his subjection to death. Pain was thus identified with punishment, sin, and death. All human suffering, claimed theologians, was ordained by God: "All that we suffer in this mortal flesh through the infirmity of nature [i.e., the Fall] is ordained by the just judgment of God as a result of sin"(Letter of Pope Gregory the Great to Augustine of Canterbury, in Beda Venerabilis 1968,78; see also Wood 1981,714). Pleasure might be sinful, but pain was a penalty and thus blameless. The practical consequence of this approach was that Christians were enjoined to accept pain as

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inevitable. Though its origins were overshadowed by sin, it had become an unavoidable part of life and thus innocent of either personal choice or blame. The sufferings of Christ introduced a different note. Christ too had suffered and died because of man's transgression; but the fault was not his, and his death wiped out mankind's original sin. For the first time, pain was associated with a voluntary choice leading to salvation. So crucial was the suffering of Christ to orthodox Christianity that by the fifth century the leaders of the church were prepared to face a major schism for the cause of Christ's humanity and passibility. The redemption of the entire human race from eternal death hinged on pain. Nevertheless, Christ of the early and high Middle Ages was not the sufferer on the cross. Once the theological point had been established, it failed to capture the imagination and sensibilities of those articulating contemporary beliefs.8 The Christ most often portrayed in the sixth century is Christos Pantocrator, ruler of the world, seated on his throne like any Byzantine monarch, hieratic and impassive. Two centuries later in the West, Carolingian illuminations and bookbindings show the same tendency. Christ treading upon beasts, Christ blessing the world, Christ seated in glory and majesty, his feet resting on the imperial orb. Even the crucifixions, rare as they are, fail to convey any sense of suffering or show physical evidence of wounds and pain (Schiller 1983, 2:110-29). Poetry sounded the same theme. Theodulf of Orldans, one of the leaders of the Carolingian revival, voiced the aristocratic views of his circle by repeatedly using in his hymns the term "king," stressing Christ's royal lineage (Raby 1966, 109).9 For the intellectuals who conceived the theological structure of Charlemagne's sacral majesty it was inconceivable that Christ should be seen as anything but a powerful ruler. Others, less politically-minded, translated this might into a source of protection. Gottschalk, perhaps the most individual of all Carolingian poets, prayed to Christ "light of my darknesses," whom he addressed much in the manner of a client appealing to a contemporary potens, calling him once more a fearful, great king (ibid., 120). Indeed, most churches and monasteries dedicated to Christ during the early Middle Ages were dedicated to Christus Salvator. High medieval art and literature changed very little in this view. Barring the new emphasis on the Virgin and Child motif, the humanity and passibility of Christ did not become central to Christian piety until the later Middle Ages. It was only then that sculptors, painters, poets, and playwrights began centering their best efforts on showing the Man of Sorrows in all the details of his agony. Christ's birth, life, and ministry became secondary to his passion, paling in the shadow of the cross.
8 The one notable exception is the seventh-century legend of Saint Gregory's mass, in which the host was miraculously transformed into a bleeding finger in order to convince a doubter. Significantly, the finger was transformed by the later Middle Ages into the image of the Man of Sorrows, surrounded by all the instruments of his torture. See Rubin 1991, 121-22, 308-10. 9 The theme goes back to late antiquity. An anonymous fourth-century poetic life of Christ refers to him as "Christ the king," devotes a great deal of attention and detail to his conception, birth and ministry, and mentions the crucifixion in one line: "The death of the flesh which he undertook vanquished everyone's death" (Raby 1966, 6).

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Two preconditions were necessary for this transformation to come about. First, Christ had to be perceived as human and passible, pitiful and poignant rather than lordly and intimidating. Second, the connection between guilt and pain, so blatantly unimportant in the early and high Middle Ages, had to be reaffirmed. The perception that Christ's suffering atoned for the guilt of humanity was an essential prerequisite for the development of philopassianism. As Christ had suffered, those who believed in him wished to suffer. The ideal of Imitatio Christi, fervently preached throughout the period to clerics and laymen alike, insisted that in order to follow in Christ's footsteps one must carry his cross and feel his pain (see, for example, The Imitation of Christ [attributed to Thomas a Kempis], bk. 2, chap. 12, "Of the king's high way of the holy cross" [Imitatio Christi 1982]). In order to identify and empathize with the experience of the cross, contemporary saints deliberately inflicted a variety of punishments on themselves. They rolled in nettles, whipped themselves, stuck nails and thorns in their flesh, and wore various abrasive or restrictive garments that effectively prevented all possibility of rest (Bynum 1987, 209-11; Vauchez 1981, 174-83). But all these practices were in reality necessary only for tyros. Expert philopassians could duplicate Christ's agony by means of meditation alone. Many mystics testified to feeling Christ's pains on the cross simply by praying to be granted the experience or by meditating on it (Bynum 1987,211-12; Kieckhefer 1984, 94). In extreme cases the saints exhibited psychically induced physical symptoms. The most common of these was stigmatization, or the appearance of wounds akin to Christ's on the saint's hands and feet. Saint Francis was the first and the best-known but certainly not the only one to suffer thus (Bynum 1987, passim). Other physical symptoms were less common. The experience of Saint Colette was by no means unique: . . . On the holy day of Good Friday, from Matins till the sisters returned from Chapter, she was so immersed in meditation concerning the terrible pains which Christ suffered in his body, that she bore such a severe torment that the sisters, upon coming out of Chapter and meeting her, saw a miracle take place in her. It could be seen that her precious face was violently altered, as though skin and bones were broken and crushed, with the nose twisted and folded. Indeed, while the sisters watched, the image of her face returned gradually, and the nose straightened out, until it was returned to its original state. (AASS March 1:561). Though the most extreme manifestations of philopassianism belong to a small circle of dedicated mystics, both male and female, the phenomenon was clearly grounded in a widespread popular form of piety. Almost every saint and theologian of the period testified to his parents' extreme emotional preoccupation with the sufferings of Christ (Huizinga 1949, 230; AASS March 1:540; Kieckhefer 1984, 93). While the offspring of such an upbringing ended up spending their lives in religion, their parents were neither clerics nor mystics. They were merely devout

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laymen, and not particularly educated ones at that. Though deeply impressing their children with their extreme devotion, they were neither exceptional nor unique in their environment. The spiritual climate of late medieval Europe was steeped in the experience of the cross, down to its most minute particulars. Books like Henry Suso's The Passion of Eternal Wisdom detailed every step, every blow, every humiliation and every wound that Christ suffered. They also dwelt extensively and imaginatively on the specific way by which each of Christ's five senses was made to suffer on the cross (Suso 1943, 24; Ruysbroeck 1552a, 308). By the fourteenth century sanctity and suffering had become one. Sanctity was achieved by imitating Christ, and the imitation of Christ was the imitation of his passion, not of his life. Within the span of one century philopassianism became the hallmark of all religious experience. It was Henry Suso, one among many, who summed up the theme in his prayers: "Grant your servant, my king, that I may follow you in your passion and carry my sufferings in such a way that I should be crucified with you in order to rule eternally with you" (Suso 1943,48). In striking contrast to the early medieval figure of Christ, late medieval iconography saw a new emphasis, that on Christ as the man of suffering, whose depiction clearly included a minute description of the stigmata and other wounds, the blood and the scourging marks. Crucifixions andpietas became the most popular way of showing Christ, and the new vernacular poetry followed suit. The impassive countenance of the early medieval Christ gave way to a patently anguished expression (Schiller 1983, 2:198-243; Marrow 1979; Barasch 1976; Dronke 1978, 58-63). But the extreme manifestations of the fourteenth and fifteenth centuries were no more than the popularization of themes considered already by twelfth-century scholastics. Some of these themes indeed concerned directly Christ's example of redeeming pain. Saint Anselm's highly influential treatise Cur Deus homo (Why God became a man) revived the concept of Christ's suffering and death as the means of human salvation. Other contemporaries were more interested in the salvation of humans through their own pain. The concept of purgatory, or the place where people suffered physical pain in order eventually to reach heaven, crystallized roughly at the same time that Anselm wrote his work (Le Goff 1984). The contemporary growth of the two concepts was no coincidence. The perception of Christ's suffering humanity affected the entire view of the human race, inevitably elevating to a higher level those beings who shared the part of Christ's nature that was becoming his most prominent trait. But with this newly found valuation of humanity came a more individual form of piety and a perception of individual responsibility. The early Middle Ages had recognized the value of vicarious responsibility and sacrifice; parents could donate children to a monastery as oblates for their own souls' salvation. By the twelfth century leaders of monasticism were insisting on the monk's individual choice. Individual consent and responsibility began affecting all the choices of life also outside religion. It was at the same time that the theology of marriage began insisting quite unequivocally that no marriage was valid without the free and adult agreement of all the parties

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involved. Similarly, punishment for transgressions, borne in the early Middle Ages by the criminal's entire kindred, became increasingly a matter of individual retribution. The value of vicarious pain was of a similar order. By the twelfth century, theologians were no longer satisfied with redemption only by virtue of Christ's suffering. His death exonerated the human race, but not individual people. These had to bear individually the pain of punishment in purgatory in order to reach heaven. More so, they had to choose voluntarily to bear that pain. The discovery of the individual in the twelfth century bore consequences in many areas of life. The attitude toward pain was only one of them. All twelfth- and thirteenth-century theologians discussing purgatory agreed on certain points. They did not know where it was or whether there was actually such a place. But they were in no doubt as to the reality and nature of purgation. First, sinners suffered physically, from a physical, corporeal fire. The fire "corporeally and really tortures the souls' bodies."10 Second, it was possible to begin purgation on earth. Whatever one suffered during one's lifetime was remitted from time in purgatory." Finally, the pains of purgatory were infinitely worse than anything even martyrs might suffer on earth. This belief was not confined to theological speculations but vividly illustrated in sermons (e.g., Lecoy de la Marche 1877, 31-33). Purgatory and hell assumed for laymen a terrifying immediacy during the later Middle Ages. Vernacular treatises describing the sufferings of hell and purgatory, graphically illustrated with detailed woodcuts, were popular among the earliest printed books {Legrant kalendrier n.d.; Traictie despaines d'enferet depurgatoire 1492; La complainte de I'ame dannee n.d.). Thus even those who had no wish to embrace Christ's sufferings as their own were forced to acknowledge that pain on this earth was not only salutary but the sole means of avoiding a much worse agony later on. By the end of the Middle Ages, the love of Christ's passion and the search for individual purification through pain merged in a perception of the human body as the one and only medium for salvation and identification with Christ. It was not just that Christ had once had a body. His body was present every time a mass was celebrated, in the form of the host; meditations on the eucharist and its corporeal nature go back to the twelfth century (William of Saint-Thierry 1844-64). The feast and cult of Corpus Christi grew from mid-thirteenth century onward to become the central event of late medieval Christianity (Rubin 1991). But even more so, Christ was still being crucified every day by evildoers, just as he had been
10 "Ut ignis . . . corporaliter et vere torqueat corpora animarum" (William of Auvergne, late 12th century, quoted in Le Goff 1984, 245). " See Honorius of Autun: "Some undergo purgation in this life; it may come in the form of physical pain brought by various ills, or physical trials laid down by fasting, vigils, or other activities, or the loss of loved ones or treasured belongings, or pains or illness, or a want of food or clothing, or, finally, a cruel death. But after death purgation takes the form of excessive heat or excessive cold or any other kind of trial, but the least of these trials is greater than the greatest that one can imagine in this life" (quoted in Le Goff 1984, 136-37).

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in the past.12 The religious context of pain was immediate and all-embracing. Crucifixion, purgatory, and salvation were all overwhelmingly present to the senses. And none of these cosmic forces and events could have any meaning unless people possessed bodies capable of suffering. The merging of the concrete and the evanescent was the unique pathway to the abstract truth of the soul. Pain, Guilt, and Innocence The matter-of-fact acceptance of pain as an integral part of life in early medieval religiosity permeated all spheres of human consciousness. When Gregory the Great stated that individual pain did not stem from individual guilt, but related only to the universal blame of all humanity, he was speaking also for the laity of his time, voicing attitudes expressed in legal systems as well. Early medieval law codes completely dissociated pain from guilt and punishment. Though the Germanic codes consist largely of compensation lists for various damages ranging from homicide to simple injuries the law did not consider inflicting pain as a legitimate cause for claiming indemnity. Damages were always defined by functional considerations: breaking a man's arm will incapacitate him for life, but causing him pain will not. The former thus entitled the injured party to compensation, the latter did not. In addition, corporal punishment was applied to lay free people only on very rare occasions. Whipping, a penalty associated with disgrace as well as pain, applied among the free only to defaulting debtors and prostitutes (Boretius and Krause 1883,1:298,335). Only two human categories suffered corporal punishment as a matter of course: serfs and clergymen (Boretius and Krause 1883,1:6,281,284; Werminghoff 1906-1908, 4, 166, 411). While corporal punishment within the monastic and clerical world stemmed from a longstanding autonomous tradition, it is notable that in the eyes of contemporary laity both groups formed no part of the economy of honor and status dictating one's place in society. Again, the aristocratic point of view associating physical pain with degradation shaped societal attitudes. Thus any layman forced to undergo a ritual of public penitence was debarred for life from bearing arms and filling public office. The shame of public penitence was much akin to the shame of corporal punishment (De Jong 1992, 33-34). The religious establishment reacted differently. Since pain was neither culpable nor degrading but merely the lot of humans, there was no reason not to imitate God's methods by using it as punishment. Applied at first only within the monastic enclave to disobedient monks (Benedict of Nursia 1977, 28, 30, 70), it spread eventually to penalties prescribed for lay people breaking religious laws. Early medieval penitentials resorted more often to fasts and prayers than to whippings,
12 "Sic hodie in mundo agitur: Homines peccatis dediti, suis sceleribus crucifigunt dominum, sicut olim Iudaei & pagani manibus" (Ruysbroeck 1552b, 485).

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but they did recognize a variety of physical penalties, all culled from the behavior patterns of monastic asceticism. Pronouncing a prescribed number of prayers while standing with outspread arms (cross vigil) and sleeping in nettles, on nutshells, in cold water, or in graves all appear together with the occasional blows as penalties for religious transgressions (McNeill and Gamer [1938] 1990, 32-33, 142, 144, and passim). There was a certain logical consistency between the avoidance of painful punishments in the secular sphere and their adoption in religion. All religious punishment hinged on penitence and an avowal of guilt. These were expressed essentially in self-abasement, which is also a form of degradation. But secular law took no interest in guilt or repentance. It was interested in keeping the peace through a system of compensations carefully graded according to status. Degradation and defamation were reserved for those unable to pay the proper compensation, who were consequently expelled from normative society. Secular laws therefore consistently avoided corporal punishment throughout the early Middle Ages. Significantly, pain appears in the one domain where legal and religious authorities cooperated the ascertaining of truth when no direct evidence was available. In those cases, truth was discovered by means of an ordeal to which either suspect or plaintiff could be subjected. Most tests were autonomic, based on the involuntary reactions of the human body to usually painful situations. The body was the scroll on which the evidence of guilt or innocence was written. It was not the ability to carry a hot iron unflinching or to plunge an arm into boiling water for the prescribed time that decided the issue. It was the condition of the scorched limb three days later that stood proof to the veracity of the person undertaking the ordeal. The basic assumption behind the ritual, of course, was that justice was immanent in nature and in the human body. Given the proper sanctifying rituals water, iron, salt, even bread and cheese would reveal the truth by working on the human body. The body was the locus of truth. Foucault wrongly identified the ordeal with judicial torture as two manners of extorting truth by means of pain (Foucault 1977, 40-41). The ordeal carried no association of degradation despite its often painful nature. It was not a standard mode of proof but rather a dramatic mechanism used only when all other proof was lacking. Plaintiffs unable to substantiate their accusations often volunteered to undergo an ordeal instead (Lea 1973, 60-63; Bartlett 1988, 15). Legends maintained that the innocent remained unscathed and unhurt by the experience (Lea 1973, passim; Bartlett 1988,80), a claim repeated in judicial formulae: "If you are innocent of this charge . . . you may confidently receive this iron in your hand and the Lord, the just judge, will free you" (Zeumer 1886, 696-97). Furthermore, the truth inhered in the ritual and in the human body in general, not specifically in the body of any given plaintiff or defendant. Any participant could openly name a champion to take his or her place. Once the champion had ritually offered his body as the vehicle for truth, the ordeal was expected to work. The validity of vicariousness stood at the basis of ordeal rituals, coming under

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criticism together with the whole system during the twelfth century. Again, individual responsibility loomed large also in a field completely unrelated to theology. Efficacy was the central issue in all the arguments raging for and against ordeals. Did ordeals indeed reveal the truth? Neither supporters nor detractors criticized the ordeal for inflicting unnecessary pain on people (Browe 1933; Radding 1979; Bartlett 1988, 70-90; Brown 1975). The one evidence we possess of the physical reaction is a twelfth-century German manuscript illustration, showing a man about to take the hot iron. He is supported from behind by his wife, his pose and bared teeth showing his apprehension (Codex Lambacensis 73, fol. 72, reproduced in Zeumer 1886, following p. 672). One might therefore argue that ordeals were in no way related to the economy of corporal pain. But still the overwhelming majority of ordeals used the human body in a manner that tested also its pain endurance. In addition, they were most commonly used when the accusation concerned the sins of the body, or sexual misconduct (Bartlett 1988,16-20). Finally, though it was possible to decide many issues by holding ordeals between books or objects (Lea 1973, 131-37; Cohen 1993, 56), in reality courts usually relied on sentient human bodies as witnesses to the truth. Ordeals were thus an inquiry into truth by means of the human body's pain. The rise of judicial torture is roughly contemporary with the first appearances of the imitation of Christ in the early thirteenth century. Once the church forbade the participation of the clergy in ordeals (1215), they quickly fell into desuetude. The process has been ascribed both to the discrediting of ordeals as a mode of proof and to the growing influence of Roman law. Once ordeals were no longer considered proof, the only valid mode remaining, according to Roman law, was either confession or the testimony of two full witnesses (Langbein 1977, 4-5; Ullmann 1944, 129-30). Since criminal acts rarely left any but circumstantial evidence insufficient by Roman standards judges had no choice but to fall back on the criminal's confession, usually extorted by means of torture. Torture used pain in a manner different from the ordeal. The entire practice was based on the consciously inflicted effects of agony on the human frame. In sharp contrast to the exuberant, unrestrained embracing of pain as part of a religious experience, judicial pain was meticulously and exactingly measured in degrees and duration. It was also employed with great circumspection and awareness of its intrinsically punitive character. Aware that a man under unrestrained torture would probably confess to anything, law codes forbade the use of leading questions precisely in order to protect the innocent from falsely confessing under duress. Torture was meant to extract information that no innocent person could know. Furthermore, torture was to be employed only in cases of capital crimes (i.e., crimes to be punished by execution or mutilation), because in any more trivial case the pain of torture would have exceeded the presumed penalty (Langbein 1977,5; Peters 1985, 50; Ullmann 1944, 127). The body was once more the locus of truth, but of a different kind. While in the ordeal the body served as a witness of guilt or

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innocence, under torture it was used to extract the facts of the case in the form of confession. Torture was never prescribed arbitrarily, unless there was already a corpus of evidence (indicia) in existence against the suspect. A great deal of discussion was devoted to the quality and amount of evidence necessary for a judge to order a suspect's torture. The differences between Roman and medieval judicial torture clearly reflect contemporary influences, particularly religious ones, on legal practice. Roman law allowed torture only against slaves and in cases of treason. At the same time it was perfectly permissible to torture not only a suspect but also a potential witness in order to extract the facts of the case. Guilt and innocence had nothing to do with it (Mommsen et al. 1922, Digesta 48:14). But such an attitude was inconceivable in a Christian context, which invariably tied pain, confession, guilt, punishment, and salvation in one cohesive scheme. Late medieval courts could torture any person, regardless of status, against whom there was enough evidence to warrant such a procedure. At the same time only a suspect could be tortured, because the "queen of proofs", as jurists called it, was a personal confession.13 The importance attached to this act undoubtedly stemmed from the centrality of confession and contrition in the religious scheme of salvation. The religious element was also clearly visible in the last form of judicial pain, that of punishment. Semantic changes witness the connection between the two. While late antique Latin used the term dolor for usual pain and passio for the sufferings of Christ and his martyrs, during the later Middle Ages a new term emerged:poena, with its French, German, and English derivatives, denoting both pain and retribution. The usage was common in religious literature, plays, and sermons, as well as in juridic texts. Though the connection between punishment and pain is always almost universal, it was fairly rare in the early and high Middle Ages. But in late medieval Europe pain and punishment gained the added dimension of salvation. Causing a malefactor to suffer was not a matter of retribution. It was meant to ease his way to salvation by subjecting him on earth t o some of the sufferings he would otherwise have to bear in purgatory. As Jan Ruysbroeck remarked, Christ had chosen to die between two thieves in order to show that penitence and suffering could redeem the most hardened criminal (Ruysbroeck 1552b, 508). Corporal punishment in itself or prior to capital execution was therefore part of the same perceptual scheme that tied suffering, truth, and salvation together.14 This perception found expression in the growing tendency to identify condemned criminals with the dying Christ. By the fifteenth century theologians stressed that crucifixion was a criminal execution, and one reserved for slaves at that. In the
So central was the analogy to religious confessions that courts jealously guarded the fiction of "spontaneous" confession. Before confessing the suspect was released from torture and allowed to recover for a while, then brought to court to give his voluntary confession. 14 Notably, medieval executions were remarkably free of torture, which only became common in the early modern era. See Foucault 1977, chap. 1.
13

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central Middle Ages condemned criminals were denied the eucharist because presumably it stayed inside the body for three days after ingestion, and "it would be a scandal if Christ, who is believed still to be in the gullet, should be delivered to the gallows." Theologians then refused to admit that Christ too had died on the gallows. And yet by the end of the fifteenth century similarly condemned criminals were indeed receiving the eucharist (Alain de Lille 1965, 2:141-42; Cohen 1993, 198-201). By then the connection had been made, and it was fitting for Christ's body to be inside the dead criminal, on the gallows.

Pain and Healing Surgeons and physicians do not exist in a perceptual void. They are, and always were, very much the product of their times. The furniture of their minds is a composite of contemporary reality and culture with acquired, traditional learning. All fourteenth-century physicians absorbed from early childhood the stories of passion and martyrdom, and watched the ubiquitous Corpus Christi processions, public whippings and executions. Together with the writings of Constantine the African and Avicenna, they read or heard all the Lenten sermons explaining the purpose of Christ's agony and death. Presumably, these views would affect also their practice of medicine. One thing at least is certain. While late medieval medicine stood helpless in the face of the plague and other causes of mortality, some means of relieving pain were at hand, and had been known from antiquity. Even semipopular encyclopedic works, such as Vincent of Beauvais' Speculum naturalis and Bartholomaeus Anglicus' De rerumproprietatibus gave detailed instructions concerning the analgesic uses of various plants (Bartholomaeus Anglicus [1601] 1964, 227-365; Vincent of Beauvais 1624, 624). Their sources were the orthodox sources of thirteenth-century medicine namely, classical and Arab medicine. There is no question that late medieval physicians knew how t o relieve pain, albeit not very effectively. The questions remain as to the extent to which killing pain was practiced and the circumstances in which it was either applied or avoided. The greatest stumbling block in the way of answering this question is the nature of late medieval medical writing. Here an analogy with the growth of law is illuminating. Like jurists, late medieval physicians legitimized their knowledge by relying on ancient wisdom. Where a jurist quoted (often wrongly) the Code of Justinian, a physician cited Galen, Dioscorides, Constantine the African, and Avicenna. How much of this repetitive theoretical knowledge found its way into practice is open to question. Even practically trained surgeons of no academic background tended to cite ancient authorities. In both law and medicine the gap between theory and practice was apparently growing during the later Middle Ages (Riddle 1974; for law, see Cohen 1993,28-39, 71-73). But while legal practice, as opposed to theory, was carefully recorded in court protocols, medicine has be-

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queathed few equivalent sources to juxtapose with the prescriptive text, and case histories rarely found their way into medical texts, only as consilia. It is therefore possible only to delineate the dimensions of the problem. First, one must distinguish between the writings of physicians and of surgeons. It was not merely a question of a different training but also the fact that surgeons often knowingly and deliberately inflicted pain in their procedures. Already Augustine of Hippo noted that "sometimes physicians ministering to the health of the body perform things there which are gruesome to see," and that "the cures and remedies are themselves torture." Since this statement prefaced the description of a surgical procedure, his words could well apply to the work of medieval surgeons (Augustinus 1899,1.18, VIII.22). Second, one must distinguish also between the treatment of disease-associated pain, wound-related pain, and pain resulting from the treatment itself. The difference in approach to each type of pain might provide some indications as to accepted contemporary norms. A random survey of some contemporary medical writings, though, only underlines the complexity of attitudes. There was no generalized policy among professional healers regarding any of the three categories. On the one hand Arnaldus of Villanova claimed that people hardened to pain could better withstand drastic treatment, and Jacques $espars spoke disapprovingly of a man who drank himself to death rather than suffer pain (Arnald of Villanova [1922] 1968, 19; Jacquart 1980,60). On the other hand there is no dearth of recipes and prescriptions to ease headaches, toothaches and various other illness-induced forms of suffering. Indeed, Ambroise Pare's most detailed treatment of pain appears in the context of medication (Arnald of Villanova [1922] 1968, 57; Hieatt and Jones 1990; Aldobrandino da Siena [1911] 1978:, 33,41; Pare [1840-41] 1970, 3:547-51). The tenth-century treatise Quomodo visitare debes infirmum, still popular at the end of the Middle Ages, insists that the physician's first duty on visiting the sick is to assess the type and amount of pain, though primarily as a diagnostic device (Sigerist 1941). Nor was pain resulting from wounds invariably sedated. Mondeville clearly distinguished between tolerable and intolerable pain, an indication of his awareness of the problem. Guy de Chauliac warned that pain in wounds of nerves and tendons could be severe enough to cause damage, insisting that sedation must precede any further treatment for fear of spasms. Two centuries later, Ambroise Pare prescribed sedation for all wounds not in order to ease the patient but because pain was a source of inflammation (Gui de Chauliac 1979,2:84-88; Par6 [1840-41] 1970, 1:442). The evidence concerning surgical anesthesia is equally contradictory. Some medical historians have noted that "from the fourteenth century onwards, there is an increasing amount of criticism of the use of preoperative sleeping draughts by prominent surgeons" (De Moulin 1974,559), while others described "the increasing use in the late middle ages of alcohol-based anesthetics in surgery, as well as soporific sponges, sedative drinks, ointments and opium" (Gottfried 1986,237).l5
15

Unfortunately, the author provides no references for this assertion.

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There is no mention of sedation as part of surgery in Henri de Mondeville's work. He openly discouraged the use of painkillers, arguing that they were dangerous in surgery. At the same time, though, he "bitterly complained that most of his contemporaries had made pain into the necessary indicator of therapeutic efficacy in surgical matters." Pare too recommended only a tight ligature around the member to be amputated in order to desensitize it, rather than drugs, and a careful and quick procedure to minimize the pain (Pouchelle 1983, 127-28; Pouchelle 1979; Pare [1840-41] 1970,2:222, 3:549). Even Pare, though, stated categorically that in cases of very great pain nothing in his pharmacopoeia could help, and that in those cases one had to resort to painful procedures, such as cauterization or phlebotomy, so that "dolor sit medicina doloris."(Pare [1840-41] 1970,2:114-15, 3:549). The overall impression is that surgeons were indeed aware of the pain caused by their procedures but were equally conscious of the dangers inherent in the use of the available analgesic means, as well as of their limited usefulness. There is a plethora of prescriptions for deadening pain, primarily by means of soporific sponges soaked in alcohol-based anesthetics and placed under the patient's nose during the operation (Daems 1970). The fact that patients were tied down prior to surgery as late as the eighteenth century indicates that even if used, these anesthetics did little to alleviate the pain of surgery (Siraisi 1990 171-72; Gottfried 1986).16 The inefficiency of anesthetics is probably the reason why surgeons avoided discussing the problem of surgical pain in their treatises. Even according to the evidence of medical or surgical textbooks it is thus impossible to generalize about the attitude of late medieval medicine to pain. Surgeons did acknowledge its existence and dangers, but usually recommended alleviating measures only in cases where pain might cause damage. Just as often, they saw it as a useful indicator of illness, an inevitable side effect of drastic cures, and a toughening, salutary sensation. Did the laity share this view? The idea that late medieval and early modern people were less sensitive to pain than present sufferers has long been exploded (De Moulin 1974). Contemporary writers have made their views amply clear. Petrarch's statement that "pain is something unpleasant, cruel, horrible, bitter, sad, unnatural and offensive to the senses" is sufficiently eloquent (ibid. 1974, 560). Francis Bacon saw it as the healer's duty to alleviate pain not only as a corollary of the cure but as an end in itself (Bacon 1973, 114). Were they voicing a common attitude? One of the richest sources for lay views of the relationship between pain and healing lies in miracle collections. Since 90 percent of all miracles were thaumaturgic, these texts provide a great deal of information concerning pain. Healing was largely in the hands of God and his saints, whose help was in any case cheaper than
16 The composer Marin Marais, who was operated on in 1725 in order to extract his gall bladder, left a remarkable musical record of the sensations of a patient tied down and operated on with no anesthetics, called "Tableau sur Poperation"(K.iefer 1963). My thanks go to Myrna Herzog, violistda-gamba, who brought this piece to my attention.

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that of physicians. Though living saints sought to sense pain, suffering laymen who despaired of medical aid invoked the help of dead miracle-working saints. The records of the original infirmities leading the patient to seek saintly help did not dwell so much on pain as on incapacity: wounds, blindness, lameness (Chennaf and Redon 1983, 53-86). The widespread fear of the pain inflicted by the surgeon's knife, prompting an appeal for saintly interference, is a recurrent motif. Numerous pilgrims turned to saints for help because they recoiled from the pain of surgery. And yet, when the saints healed, their methods often resembled those of surgeons. Many miracules reported that the cure was presaged by great pain. Sometimes the patient dreamt or saw a vision of the saint operating on him and, waking up from the pain, found himself healed. Others sensed the pain, in a state of full consciousness, as a very sharp pang immediately preceding a dramatic cure. As one shrinekeeper noted: "We saw many similarly tormented before the cure"(Finucane 1977,66,68,88-89; Jacquet 1983). Medicine was thus hardly another expression of philopassianism. First of all one must consider the age-old identification, shared by healers and sufferers alike, of illness with pain and health with its surcease. Even the most dedicated philopassian milieu could not entirely obliterate the instinctive human reaction to pain. No doubt both physicians and patients sought relief from pain, either as part of a cure or for its own sake. But at the same time the theological validation of suffering played a significant role. It made the pain of sickness more bearable and the pain of healing more acceptable. The dearth of effective physical painkillers was thus offset by a mental attitude that not only accepted pain as inevitable but also saw certain merits in it.

Conclusion Beyond the expressions manifested in high culture, philopassianism was an integral part of the common consciousness, an awareness so widespread and universal as to be considered axiomatic by contemporaries. It was not a theory or even an articulated belief. As pain was a fact of life, so was its positive, eager acceptance. But given the clear differences between religious, legal, and medical attitudes toward pain in the later Middle Ages, is one justified in viewing medicine within the contemporary cultural context? Clearly, the minds of physicians valued their scientific heritage and their professional calling just as much as if not more than the surrounding culture. And yet, there are certain elements that cannot be understood outside this cultural matrix. First and foremost among these is the idea that pain might be useful. It was a means to many ends: truth, guilt or innocence, bodily health, and spiritual salvation. This idea, shared by jurists and physicians alike, must have influenced medical practice as much as it influenced the legal process. Alone among all the

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fields of knowledge we have reviewed, only these two professions could manipulate pain, ease it or inflict it. Theologians might explain pain, art and poetry might depict it, but medicine and law had to make decisions concerning pain on a daily basis, and obviously during the later Middle Ages their decision was, more often than not, to inflict pain rather than soothe it. In other words, they deliberately chose to use it. Such a decision, inconceivable nowadays, made sense only within the philopassian cultural context. Perhaps the most important factor of all is the ubiquitousness of pain during the later Middle Ages. Pain was part of all conscious processes, religious and scientific ones included. Philopassianism, with its multifaceted cultural manifestations and its attendant professional developments, was the formulation and expression of these processes. It was a coherent, multivalent attitude toward physical pain that fitted both the perception and the reality of the time in which it grew.

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