Kings, Knights & Lepers

Charles Savona-Ventura MD, DScMed
Department of Obstetrics & Gynaecology
Faculty of Medicine & Surgery
University of Malta Medical School, Malta

George G. Buttigieg MD, FRCOG
Department of Obstetrics & Gynaecology
Faculty of Medicine & Surgery
University of Malta Medical School, Malta

 

ABSTRACT
Throughout the Medieval Period, sufferers from Hansen’s Disease were often shunned by the community they lived in to be relegated to the lower strata of the social ladder. They often lost all their social rights being declared legally dead. This attitude was not universal, and a number of members of the royalty from various countries were apparently afflicted by the micro-organism but continued to rule their dominions. The evidence for the presence of Hansen’s Disease in a number individuals belonging to royal families is outlined.

 

INTRODUCTION
Leprosy had long been rampant in the Eastern Mediterranean lands and apparently reached Europe during the Roman campaigns of the first century A.D. During the Medieval period, leprosy sufferers were often ostracized from society and condemned to living in seclusion without recourse to social contact with the community. They were declared legally dead and their goods were confiscated. Their spouse was however expected to honor the sacramental bond and serve the leper until his/her death. Once identified as a leper, a “Mass of Separation” (13th century) was performed by the priest at the site of the leper’s hut. The whole parish accompanied a newly identified leper to his/her new home as the priest performed the mass. A list of garments and utensils were given to the leper, each being blessed before the leper received it - very much like was done at clerical ordinations. During the Mass of Separation, The priest then stated the admonition: “I forbid you to ever enter a church, a monastery, a fair, a mill, a market or an assembly of people. I forbid you to leave your house unless dressed in your recognizable garb and also shod. I forbid you to wash your hands or to launder anything or to drink at any stream or fountain, unless using your own barrel or dipper. I forbid you to touch anything you buy or barter for, until it becomes your own. I forbid you to enter any tavern; and if you wish for wine, whether you buy it or it is given to you, have it funneled into your keg. I forbid you to share house with any woman but your wife. I command you, if accosted by anyone while traveling on a road, to set yourself down-wind of them before you answer. I forbid you to enter any narrow passage, lest a passerby bump into you. I forbid you, wherever you go, to touch the rim or the rope of a well without donning your gloves. I forbid you to touch any child or give them anything. I forbid you to drink or eat from any vessel but your own”. (4)

The majority of those afflicted with leprosy were individuals belonging to the lower social classes. However, the disease transgressed all social borders and is known to have afflicted royalty. Two leper kings were to achieve notoriety and have recently featured in two epic films released by Twentieth Century Fox: “Braveheart” and “Kingdom of Heaven”. Other members of the royal families afflicted with the disease are less known.

Robert I, King of the Scots (1306-1329)
The film Braveheart released in 1995 featured the story of the Scottish warrior hero William Wallace who spearheaded the Scottish resistance to English dominion and defeated the English king Edward I at the Battle of Stirling in 1297. However, the following year was to see the defeat of Wallace at the battle of Falkirk, leading to his eventual capture and execution. Wallace’s capture is, in the film, attributed to betrayal instigated by Robert Bruce the sixth Lord of Annandale [died 1304]. Robert [portrayed by actor Ian Banner] is in the film presented as a leper living in seclusion, but still retaining control over political events around him and promoting the Bruce Family interests in their claim to the Scottish throne. While there is no documentary proof that the 6th Lord Annandale suffered from leprosy, his son Robert I [portrayed by actor Angus McFadyen] is believed to have developed leprosy in later adulthood. Robert I the Bruce [born 1274; died 1329], was crowned King of the Scots in 1306.

The first mention of the possibility that Robert I might have suffered from leprosy appears in the Chronicon de Lanercost, a general history of England and Scotland from 1210 to 1346 which has been attributed to an unknown Franciscan friar at Carlisle. This states that Bruce deputed the command of the army during the Weardale campaign in 1327 because he had developed leprosy - "Dominus autem Robertus de Brus, quia factus fuerat leprosus, ilia vice cum eis Angliam non intravit". (10) However, in spite of this contemporary assertion, there has always been some doubt as to whether Bruce, who died in 1329, did suffer from leprosy. It has suggested that his condition could have resulted from "sporadic syphilis", which in the Middle Ages was commonly confused with leprosy.

In 1817, the Magistrates of the Burgh of Dunfermline resolved to rebuild a new church on the site of the nave of the ruined ancient Cathedral Church of Dunfermline. During the clearance of the site, workmen accidentally came across what appeared to be a royal tomb located at the very centre of the ancient cathedral in front of where the high altar had formerly stood. This was protected by two large stones, a headstone and a much larger stone (six feet in length) into which six iron rings had been fixed by lead. When these stones were removed, they found the complete skeletal remains of an individual entirely enclosed in two layers of lead, with what remained of an embroidered linen cloth shroud over it, the fine linen material being interwoven with threads of gold. Over the head of the individual, the lead was formed into the shape of a crude crown. The find was reported to their Lordships, who directed the Sheriff to secure the tomb. The skeleton, formally exhumed in 1819, was attributed to Robert I on the basis of the sawn sternum; a procedure carried out after death to remove his heart in accordance to Robert’s wish to have it carried by Sir James Douglas during a Crusade against Saracens. Douglas obeyed his king’s wishes but died during the Crusade. The heart was returned to Scotland and was buried at Melrose Abbey, the most important Cistercian house in Scotland. The exhumed skeleton was studied by a number of medical specialists including Dr Alexander Monro tertius, Professor of Anatomy at Edinburgh University. An accurate Plaster-of-Paris cast was made of the skull and mandible by W. Scoular.

All available evidence suggests that the original copy of the cast is now located in the Anatomy Museum of the University of Edinburgh. Copies of this cast have been used to produce the portrait head of Robert I that was displayed in the Royal Scottish Academy in 1958; and more recently the reconstruction of the facial features by George Buchanan and computer-aided reconstruction prepared by Professor Vanesis of the Forensic Medicine Department of the University of Glasgow. The cast confirms that Robert I suffered the loss of his upper incisors and associated alveolar maxillary bone. These features have been interpreted by V. Moller-Christiansen and R.G. Inkster, authorities on the osteological appearance of leprosy, as typical of facies leprosa, and not those of calvaria syphilitica (syphylitic osteitis). According to the latter authors, the cast displays "antemortem loss of the central and right lateral incisors, and possibly the left lateral incisor". The authors continue: “There are no signs of loss of teeth caused by trauma in vivo. But the most important component of the facies leprosa, the inflammatory changes in the hard palate, cannot be verified in this case because the plaster cast does not show the hard palate, and so does not allow investigation. ….. The plaster cast of Robert the Bruce shows clear signs of facies leprosa, but to be one hundred percent sure of the diagnosis of leprosy, we would have to unearth his skeleton once more and make a proper examination.” (7)

Baldwin IV, King of Jerusalem (1174-1182)
The film Kingdom of Heaven released in 2005 featured the story of Bailen of Ibelin and the loss of Jerusalem. In the story, Baldwin IV the Leper King of Jerusalem is featured as a successful diplomat who maintains good peaceful relationships with Sultan Salah al-Din. All political negotiations fail with the death of the king, plunging the Kingdom of Jerusalem into turmoil and conflict leading to the disaster at the Battle of Hattin and the Fall of Jerusalem in October 1187. First mention of Balwin developing leprosy was made in the chronicle written by his tutor William of Tyre who observed the youth’s insensitivity to pain caused by the disease.

William of Tyre in his book Historia rerum in partibus transmarinis gestarum wrote that “It so happened that once when he was playing with some other noble boys who were with him, they began pinching one another with their fingernails on the hands and arms, as playful boys will do. The others evinced their pain with yells, but, although his playmates did not spare him, Baldwin bore the pain altogether too patiently, as if he did not feel it. When this had happened several times, it was reported to me. At first I thought that this happened because of his endurance, not because of insensitivity. Then I called him and began to ask what was happening. At last I discovered that about half of his right hand and arm were numb, so that he did not feel pinches or even bites there. I began to have doubts, as I recalled the words of the wise man: ‘It is certain that an insensate member is far from healthy and that he who does not feel sick is in danger’. I reported all this to his father. Physicians were consulted and prescribed repeated fomentations, anointings, and even poisonous drugs to improve his condition, but in vain. For, as we later understood more fully as time passed, and as we made more comprehensive observations, this was the beginning of an incurable disease. I cannot keep my eyes dry while speaking of it. For as he began to reach the age of puberty it became apparent that he was suffering from that most terrible disease, leprosy. Each day he grew more ill. The extremities and the face were most affected, so that the hearts of his faithful men were touched by compassion when they looked at him”. (1)

Baldwin IV was born in the early summer of 1161, the son of Amalric and Agnes of Courtenay. He contracted leprosy in childhood, possibly from a member of the Royal household affected with a mild form of the infection, and developed the initial symptom of skin anaesthesia just prior to his puberty (circa 9-13 years of age). There was no mention of any other obvious skin lesions at this stage suggesting a polyneurotic form of the disease. This advanced to a lepromatous form during the pubertal years, so that by his early twenties, the nerve damage had led to severe muscle weakness requiring him to be carried in a litter. Weakness of the facial muscles probably led to corneal ulceration causing eventual blindness. In addition the bacteria had multiplied in the skin of the limbs and face to form disfiguring plaques and nodules, and destroyed the nose. He died prematurely in 1185 at the age of twenty-three years. The general approach to treatment of leprosy during the medieval period included modifications in the diet and bloodletting to restore the body humours; bathing in sulphurous hot springs; and the use of drugs including herbal syrups, enemas, and topical applications of fatty-based ointments based on quicksilver and herbs. Public health measures included forced avoidance of sexual activity and segregation in leprosaria. In spite of his debilitating affliction and premature death, King Baldwin IV was throughout his reign constantly engaged in warfare against his Islamic foes. In 1180, he obtained a two-year truce during the latter part of his reign, which truce was lost after he relinquished his kingdom to regents because of failing health. (6)

Henry VII of Sicily and Germany (1212-1242)
Henry VII, born in 1211 in Sicily, was the eldest son of Emperor Frederick II and Constance of Aragon. When Frederick sought the crown of Germany, he had his son crowned King of Sicily in February 1212 by Pope Innocent III, since an agreement between Frederick and the Pope stated that the kingdoms of Germany and Sicily should not be united under one ruler. However, after the death of the Pope in 1216, Frederick called his son Henry to Germany and entrusted him with the Duchy of Swabia. After the end of the Zähringen line in 1219 Henry also received the title of Rector of Burgundy, though that title disappeared again when Henry was elected king of Germany in 1220. In 1229, he came into conflict with Frederick II in support of the German aristocracy and the claims of the Lombard Communes. Having headed a revolt in 1235, he was defeated and was confined in various fortresses of southern Italy. He died at Martirano on 10th February 1242, at the age of 31 years, falling into a precipice, perhaps committing suicide. His father had him buried with royal honours in the Cathedral of Cosenza, in an antique Roman sarcophagus.

In 1998, a team of Italian palaeopathologists explored the tomb of Henry VII in the Cathedral of Cosenza. Bone consolidation and restoration made it possible to perform an accurate anthropological and palaeopathological study. The skeletal remains belonged to a male individual aged 30-35 years of a robust stature with a height of around 1.66 centimeters. The skeletal remains also showed abnormalities the spine and the knee, possibly a result of traumas and/or excessive overloads during adolescence, probably due to the practice of horse riding. The latter lesion would have seriously compromised the subject’s pace; a fact agreeing with the historical data since Henry VII had been assigned the nickname “the lame”.

The skeletal study also revealed signs of advanced leprosy. The facial bones revealed all the pathognomonic stigmata of a rhinomaxillary syndrome known as facies leprosa caused by severe mucus-purulent chronic rhinitis typical of lepromatous leprosy. The peripheral skeleton also showed features consistent with the end result of leprosy of the extremities, and in particular of the feet. These features included extensive wide diaphyseal periostitis of the femurs, with bilateral diaphyseal remodelling and thinning, with subtotal resorption of the epiphyses, of the fourth metatarsals and proximal phalanxes. The palaeopathological study confirms that the Henry VII suffered from lepromatous leprosy in quite advanced stage of development. The infection and clinical overture certainly started some years before the death and the disfiguring conditions of Henry VII must have obliged him to forced isolation, until his dramatic suicide. (2)

Afonso II, King of Portugal (1212-1223)
Afonso II known as the Fat was born in Coimbra on the 23rd April 1185. He was the second but eldest surviving son of Sancho I of Portugal and Dulce of Barcelona, Princess of Aragon. Afonso succeeded his father in 1212 to become the third king of Portugal. As king, Afonso II pursued a different approach to government choosing a political management in contrast to the military one adopted by his father and grandfather before him. By avoiding the pursing of territory enlargement policies, Afonso managed to insure peace with Castile during his reign. He centralized administrative power onto himself and designed the first set of Portuguese written laws. These were mainly concerned with private property, civil justice, and minting. Afonso also established political and commercial links with other European kingdoms outside the Iberian Peninsula.

With Portugal’s position as a country established, he set out to consolidate the royal patrimony, much of which had been willed away by his father to the Catholic Church. The king appointed a number of royal commissions authorized to investigate land ownership. These commissions concluded that the Catholic Church in Portugal had expropriated a significant proportion of royal property. Angered by the activities of these commissions, the Archbishop of Braga excommunicated Afonso II in 1219. The king responded by seizing church property and forced the archbishop to flee Portugal for Rome. In 1220 Pope Honorius III confirmed the king's excommunication and relieved him of his oath of fealty to the Holy See. In response, Afonso promised to make amends to the church, but in March 1223 he died prematurely of leprosy at the age of thirty-six years after a 12-year reign before making any serious attempts to do resolve the issue. To enable an ecclesiastical burial, his chancellor arranged for the return of the seized church property and the promise that future inquiries would respect canon law. (8)

Henry IV of Bolingbroke, King of England (1399-1413)
Henry IV was born at Bolingbroke in 1367 to John of Gaunt and Blanche of Lancaster. Henry had a tremulous relationship with his cousin, Richard II of England. Henry was created Duke of Hereford in 1397 but in 1398, the increasingly suspicious Richard banished him for ten years while he further confiscated the Lancastrian estates pertaining to Henry after his father’s death in 1399. Henry invaded England while Richard was on campaign in Ireland, usurping the throne from King Richard imprisoning King Richard (who died in prison under mysterious circumstances). He was crowned King of England on the 13th October 1399. The very nature of Henry's usurpation dictated the circumstances of his reign - incessant rebellion by Richard's supporters became the order of the day. Two political blunders in the latter years of his reign diminished Henry's support. The first blunder was his marriage in 1402 to his second wife Joan of Navarre who was eventually convicted of witchcraft in 1419. His second political mistake was the execution of Richard Scrope, Archbishop of York in 1405 after he proclaimed his opposition to the Lancastrian claim. Crushing the myriad of rebellions was costly, which involved calling Parliament to fund such activities. The House of Commons used the opportunity to expand its powers in 1401, securing recognition of freedom of debate and freedom from arrest for dissenting opinions.

The later years of Henry's reign were marked by serious health problems. He had some sort of disfiguring skin disease, and more seriously suffered acute attacks of some grave illness in June 1405, April 1406, June 1408, during the winter of 1408–09, December 1412, and then finally a fatal bout in March 1413. This aliment persuaded many that God was punishing the king for executing an archbishop. Medical historians have long debated the nature of this affliction or afflictions. The skin disease might have been leprosy, but other contender diagnoses include psoriasis, syphilis, or some other disease. The recorded acute attacks have been given a wide range of explanations, from epilepsy to some form of cardiovascular disease. Henry, incapacitated by disease, watched as Prince Henry controlled the government for the last two years of his reign. In 1413, Henry died in the Jerusalem Chamber of Westminster Abbey. Unlikely as it may seem (due to the amount of rebellion in his reign), Henry left his eldest son an undisputed succession. He was buried at Canterbury Cathedral and given an alabaster effigy. His body was well embalmed, as established a Victorian exhumation some centuries later. (5)

Constance of Brittany, Duchess (1186-1196)
Constance, born in c.1161 in Bretagne, France, was the daughter of Conan IV "le Petit", Duke of Brittany and Earl of Richmond and Margaret of Scotland (granddaughter of King David I). In 1181, Constance married Geoffrey Plantagenet, the fourth son of Henry II of England and Eleanor of Aquitaine, and had two children by him. Geoffrey therafter assumed the title of Duke of Brittany, but he died in 1186, stamped by a horse during a tournament. Constance then became ruler of Brittany until 1196, when she abdicated in favour of her son Arthur. Constance was in 1188 married off by King Henry to Ranulph de Meschines, 4th Earl of Chester. This marriage was however not successful in her being imprisoned by her husband in 1196. On her release in 1198, she had her marriage to annulled and remarried Guy of Thouars. Constance lived out the last few years of her life quite peacefully and died of leprosy in 1201. She was buried at the Villeneuve Abbey Church in France. (3)

Royal Patronage of leprosaria
The care of the sick was during the Medieval Period viewed a Christian duty. This attitude encouraged the philanthropic establishment of infirmaries or centers to serve the sick and infirm of the society, including lepers. The Latin Kingdom and some European leprosaria were managed by a hospitaller chivalric Order dedicated to St. Lazarus set up in the Holy Land with the specific aim of caring for lepers. Various members of the European and Latin Kingdom Royalty acted as benefactors to the Order furnishing it with land and monetary donations to help it achieve its functions. In the Holy Land, King Fulk, Queen Melisende, Baldwin III, and King Amalric I acted as significant benefactors. Amalric I, father to the Leper King Baldwin IV, in 1164 promised the Order one slave from every ten Moslem captives and monetary grants amounting to 112 bezants per annum from the tolls and customs from Jerusalem and Acre. Other contemporary Latin Kingdom barons also furnished their support. In Europe, members of the royalty returning from the crusades also patronized the Order of St. Lazarus in their own lands. Emperor Frederick II in 1226 donated land holdings and a leprosarium in southern Italy at Capua; Queen Elizabeth of Hungary, widow of crusader King Louis IV, in 1227 founded a leprosarium at Gotha. In Scotland, David I, ancestor of Robert I, in 1153 gave the Order a church and significant land holdings in Edinburgh. In England, Henry II in 1157 also acted as patron to the “lepers of St Lazarus of Jerusalem”. Significant and continuous support was given by the French kings starting with the donations made by Louis VII in 1154. The strong French support continued even after the fall of Jerusalem in 1187 and the fall of the Latin Kingdom in 1291. The Order of St. Lazarus established its magistery in France and continued to receive French Royal patronage throughout the subsequent centuries until the fall of the French Royalty in the early 19th century. The Italian priory at Capua in 1573 was linked with the Royal House of Savoy, a link that persists to the present day in the Order of Sts. Lazarus and Maurice. The French branch of the Hospitaller and Military Order of St. Lazarus of Jerusalem in 1935 re-established the Royal patronage to the traditional House of Bourbon, albeit the Spanish branch, appointing H.R.H. Francisco de Paula de Borbón y de la Torre Duke of Seville and Grandee of Spain the 44th Grandmaster of the Order. The link with the House of Bourbon has been maintained to the present day. (9)

While shunned by society, those afflicted with leprosy throughout the centuries have received the direct and indirect patronage of various members of the Royal Houses of the Latin Kingdom and Europe. Much of this patronage came from the Crusader Kings who could at close quarters view the devastating effects of the disorder and the sterling work being carried out by the Order of St. Lazarus. A significant number of knights participating in the Crusades became affected with the disease and thus helped introduce the chronic infection in their households. The Royal patronage helped increase the resources of the dedicated Order of St. Lazarus whose main scope was to care for those afflicted with the dreaded disease and ensure that leprosaria services were established in the various European countries.

REFERENCES
1. BRUNDAGE J. [translator]. The Crusades: A Documentary History. Milwaukee: University Press (1962) 148-150

2. FORNACIARI G., MALLEGNI F., DE LEO P. The leprosy of Henry VII: incarceration or isolation? Lancet 353 (1999) 758

3. HENDERSON J.G. The Ancestry of Chamberlin and Grant. Baltimore: Gateway Press (2000) 242
4. MARTÉNE E. De antiquis Ecclesiæ ritibus. Antwerp: J. Baptistæ de la Bry (1736-1738)

5. McNIVEN P. The Problem of Henry IV's Health, 1405–1413. English Historical Review 100 (1985) 747–772

6. MICHELL P.D. An evaluation of the leprosy of King Baldwin IV of Jerusalem in the context of the medieval world. In: HAMILTON B. (editor): The Leper King and his Heirs. Baldwin IV and the Crusader Kingdom of Jerusalem. Cambridge: University Press (2000) 245-258

7. MOLLER-CHRISTIANSEN V., INKSTER R.G. Cases of leprosy and syphilis in the osteological collection of the Department of Anatomy, University of Edinburgh, with a note on the skull of King Robert the Bruce. Danish Medical Bulletin 12 (1965)11–18

8. O'CALLAGHAN J.F. A History of Medieval Spain. Ithaca: Cornell University Press (1975) 337

9. SAVONA-VENTURA C. The Hospitaller Knights of Saint Lazarus. Malta: Grand Priory – MHOSLJ (2006)

10. STEVENSON, J. [translator]. Chronicon de Lanercost M.CC.I.-MCCCXLVI: e codice cottoniano nunc primum typis mandatum. Edinburgh: Bannatyne Club (1839) 259

 

 

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First Published March 2009

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