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They tell us about daily life in Alfonso&#39;s time&#44; in particular revealing how disease&#44; with its causes and treatments&#44; was perceived&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Cantigas</span> were written in the context of a popular mass movement venerating the Mother of God that spread across Christendom after the first millennium&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Maternal figures had been venerated in many of the religions of antiquity&#8212;one example is the ancient Egyptian cult of Ast &#40;Isis&#41;&#46; The goddess was typically depicted breastfeeding her son Horus&#44; an image analogous to those of the Virgin and Child &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The cult of Mary as goddess&#44; which managed to divert attention even from the figure of Jesus&#44; came late in the history of Christianity&#58; Marian veneration began to take shape after the Council of Ephesus and became fervent during the 12th to 14th centuries&#46; The Marian cult was especially popular in the kingdoms of the Iberian Peninsula and was spread by pilgrims along the Way of St James&#46; King Alfonso&#44; who described himself as the Virgin&#39;s troubadour in his prologue to the <span class="elsevierStyleItalic">Cantigas</span>&#44; very probably wrote some of the poems himself&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The songs are a rich source of information concerning medieval life&#46; They contain rich descriptions of places&#44; historical events&#44; and more or less imagined scenarios&#46; Along with the illustrations that accompany each poem&#44; these songs help us grasp what court life was like&#46; We learn of the musical instruments that were played&#44; the dress and customs of courtiers&#44; the food they ate&#44; and of course the ailments they suffered&#46; We must remember that many of the cantigas tell of people who ask Mary to intercede on their behalf because they seek a cure&#46; Thus&#44; we are given accounts of a large number of diseases of the time&#44; although as we shall see&#44; the stories are subject to multiple interpretations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For this paper&#44; we have selected some of the songs that describe dermatologic conditions and will attempt to analyze them from a medical and historical point of view&#46; We have not transcribed each cantiga in full&#59; rather&#44; we present excerpts for commentary&#46; Readers wishing to see the original texts are recommended to visit the website of Andrew Casson&#58; <span class="elsevierStyleItalic">Cantigas de Santa Maria for Singers</span> &#40;<a href="http://www.cantigasdesantamaria.com/">http&#58;&#47;&#47;www&#46;cantigasdesantamaria&#46;com&#47;</a>&#41;&#46; The information there is valuable for anyone who would like to delve more deeply into this monumental work&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Cantiga 54&#44; &#8220;Toda sa&#250;de da santa Reinna&#8221; &#40;All Health Comes From the Holy Queen&#41;&#58; A Foul-Smelling Affliction of the Face Is Cured by the Virgin&#39;s Milk</span><p id="par0035" class="elsevierStylePara elsevierViewall">Cantiga 54 tells the story of a monk with an ailment of the throat that spreads to his face&#44; causing extensive tumors and pain &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and preventing him from swallowing&#46; The odor that develops is described as &#8220;worse than that of a corpse&#44;&#8221; Thinking him dead&#44; his fellow monks administer the last rites&#46; At this point the Virgin appears and washes his face &#8220;with a towel she carried&#46;&#8221; Then&#44; &#8220;taking out her breast&#44; she sent milk into his mouth and onto his face&#44; which became so clear that he seemed completely changed&#44; as a swallow that renews its feathers&#46;&#8221;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">We cannot diagnose the disease based on this description&#44; but it strongly suggests an infection of the craniofacial structures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The 93rd cantiga&#44; about a man with leprosy&#44; offers another example of the medicinal use of milk&#46; In fact&#44; Alfonso&#39;s Marian repertory contains several songs praising the milk that fed the Savior&#44; a concept that serves the purpose of illustrating that the nature of Jesus was human as well as divine&#46; The curative power of the Virgin&#39;s milk was a familiar concept to the medieval mind&#46; Even today&#44; the cathedral in Murcia keeps a small vial with drops of milk for veneration as the Virgin&#39;s own&#44; and a Bethlehem tradition designates a local site as the Milk Grotto&#44; where Jesus was nursed by Mary&#46; Many artists have depicted the Virgin sending a spray of her milk into the mouth of St&#46; Bernard of Clairvaux&#46; The event took place when as a young monk Bernard was told by his abbot to go and preach&#46; Fearing he would disappoint&#44; the saint prayed to the Virgin until he fell asleep&#46; Mary appeared in a dream and bestowed the gift of eloquence by giving him milk from her breast&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The curative power of breast milk is a clear&#44; consistent motif in Marian hagiography&#44; one that has fascinated the faithful since the early days of the cult of the Virgin&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Cantiga 91&#44; &#8220;A Virgin nos d&#225; sa&#250;de e t&#243;lle mal&#8221; &#40;The Virgin Gives Us Health and Takes Away Our Pain&#41;&#58; On the Dreaded Ergotism&#44; or St&#46; Martial&#39;s Fire</span><p id="par0055" class="elsevierStylePara elsevierViewall">The story told in the 91st song takes place in France at the sanctuary of Soissons&#46; The central event is mass poisoning by ergot&#44; a fungus of the rye plant&#46; The condition is called ergotism today but was then called St&#46; Martial&#39;s fire&#46; The cantiga says&#44; &#8220;For the sins they had committed&#44; God sent St&#46; Martial&#39;s fire to punish and confound them&#8230;and as I have heard&#44; it was the nature of that affliction to first make them cold and then burn them worse than fire&#8230;Because their parts fell away&#44; nor could they eat or sleep&#44; nor stand on their own feet&#44; they preferred death to suffering such monstrous pain&#8230;&#46;&#8221; The Virgin appears&#44; bathed in light&#44; and miraculously cures them &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">This text gives an impeccable description of poisoning by ergot &#40;<span class="elsevierStyleItalic">Claviceps purpurea</span>&#41;<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> Epidemics of ergotism&#44; which have been well documented in many sources&#44; devastated the medieval world for centuries&#44; particularly in times of famine&#46; Also known as St&#46; Anthony&#39;s fire&#44; the holy fire&#44; or hell&#39;s fire&#44; ergot poisoning was a common occurrence because rye was an important food staple at a time when white bread was only available to those in the upper strata of society&#46; After the rye grain had been milled&#44; its dark flour was easily masked the red powder of ergot mixed with it&#46; Symptoms of ergotism included intense pain and cold in the extremities&#44; due to vasoconstriction&#44; followed by intense burning sensations&#44; pain&#44; distal necrosis&#44; hallucinations&#44; and convulsions&#46; Occasional survivors were usually left severely deformed by loss of limb&#46; Medicinal uses of ergot were known in the traditional Chinese pharmacopoeia&#44; and in the 17th century ergot was employed to suppress puerperal hemorrhages&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">St&#46; Martial&#44; who evangelized the Limousin region of France&#44; has been revered in the area around Limoges since the early years of Christianity&#46; His renown as a healer grew when the population of Aquitaine was decimated by ergotism in the 10th century&#46; When the faithful turned to this saint to intercede on their behalf&#44; the epidemic ended miraculously&#46; In his life of St&#46; Martial&#44; Ad&#233;mar of Chabannes &#40;983&#8211;1043&#41; went so far as to call him the 13th apostle who was present at the Last Supper and the crucifixion&#44; claims that are reflected in the local iconography&#46; Places associated with St&#46; Martial even competed with Santiago de Compostela as pilgrimage destinations among the local population&#46; In 1854&#44; the bishop of Limoges petitioned Pope Pius IX to declare the saint a direct disciple of Christ&#44; but the appeal was denied&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The cantigas were powerful promotional texts for Marian devotion&#44; crediting Mary with miracles of such great impact that they exceeded those of St&#46; Martial&#46; The accounts sought to firmly establish that her ability to intercede in healing the sick outstripped that of any other in heaven&#44; even the earlier healer of ergotism&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Several other cantigas provide descriptions of ergotism&#46; The events in Cantiga 134 take place in Paris and include the miraculous regeneration of an extremity lost to the disease&#46; Cantiga 19 tells of a condition referred to as &#8220;fire from heaven&#46;&#8221; Cantiga 53 mentions a &#8220;wild fire&#8221; and also mentions leprosy&#44; another scourge of the Middle Ages and one that could sometimes be confused with other diseases of the skin&#46; Cantiga 105 clearly distinguishes between the two&#46; In Cantiga 81&#44; St&#46; Martial&#39;s fire is said to &#8220;consume the flesh&#8221; of an afflicted woman&#44; who hides her disfigured face behind a veil&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The treatment of ergotism was based on plants like mandrake or other analgesics&#44; even though they could intensify the hallucinations caused by the disease&#46; Treating physicians protected themselves with sponges soaked in vinegar and wore a mask like a bird&#39;s beak impregnated with aromatic substances to guard against contagion&#46; Prayer and divine intercession remained the principal therapies&#44; however&#44; and it was considered important for a region to have relics of saints on hand or else nearby tombs where relics could be obtained&#46; The Hospital Order of St&#46; Anthony&#44; which used the letter tau in blue as their symbol&#44; were charged with caring for patients with ergot poisoning&#46; Medieval spirituality embraced all these practices and beliefs&#44; and it is likely that some patients improved with care&#44; hygiene&#44; and relief from the monotony of a diet based on rye bread made from the contaminated flour that was causing their misfortune&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Cantiga 93&#44; &#8220;Nulla enfermidade non &#233; de Saar&#8221; &#40;No Disease Is Impossible to Cure&#41;&#58; The Magical Healing of a Leper by Means of the Virgin&#39;s Milk</span><p id="par0085" class="elsevierStylePara elsevierViewall">For the sin of lust&#44; the protagonist of Cantiga 93 is punished with fulminant leprosy &#40;<span class="elsevierStyleItalic">gafeen</span>&#41; that covers his body with lesions&#44; paradoxically causing ungovernable sexual desire&#46; &#40;In fact&#44; lepers were widely believed at the time to be lustful&#46;&#41; Repentant&#44; the patient withdraws to a hermit&#39;s hut&#8212;probably banished because of his condition&#8212;and prays a thousand Hail Marys to please the Mother of God&#46; He is delivered from disease when Mary appears and decides to heal him with milk from her breast&#58; &#8220;She took out her breast and anointed him with her holy milk&#46;&#8221;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The illustration that accompanies the cantiga &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; shows a man in bed prostrated by disease yet joyful in his expression&#46; His skin shows signs of scaling or crusting&#44; but his extremities have none of the ulcers or deformities typical of leprosy&#46; We believe this case actually involves some other highly noticeable skin disease&#8212;perhaps scabies&#44; psoriasis or eczema&#44; but not the mere changes in pigmentation that come with such diseases as vitiligo or indeterminate leprosy&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Leprosy is one of the most often mentioned diseases in the <span class="elsevierStyleItalic">Cantigas of Holy Mary</span>&#46; However&#44; just as we exercise caution when interpreting other medieval texts&#44; we should not rush to assume that the individuals described as lepers in these poems in fact had Hansen disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#8211;6</span></a> Many conditions referred to as leprosy are in fact other diseases that manifest with a great variety of skin signs&#44; such as psoriasis&#44; scabies&#44; or fungal infections&#44; to mention only a few&#46; The word <span class="elsevierStyleItalic">gafo</span>&#44; however&#44; is the medieval Galician-Portuguese term for a person with leprosy&#44; and when it appears again and again in the <span class="elsevierStyleItalic">Cantigas</span> it does seem to refer to Hansen disease&#46; The word also denotes a claw- or hook-shaped tool used to draw the string of a crossbow back to the nut&#44; where it is fixed before the shot&#46; This tool&#39;s shape resembles the clawlike deformities sometimes caused by peripheral neuropathy in tuberculoid leprosy&#46; The conventional meaning of the Spanish word <span class="elsevierStyleItalic">gafe</span> to refer to a person who attracts bad luck may have been derived from <span class="elsevierStyleItalic">gafo</span>&#46; Finally&#44; the name of the river running through the Galician city of Pontevedra&#8212;R&#237;o dos Gafos&#8212;is a reference to an old lazaretto that housed lepers in the Campolongo neighborhood&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Leprosy is estimated to have afflicted 4&#37; of the population in the Middle Ages&#44; and there seems to have been a well-documented rapid spread of the disease in the 12th and 13th centuries&#46; Lepers struck their fellow citizens with terror&#58; the marks left by their disease&#44; the deforming protuberances it left&#44; the neurological impairment of arms and legs that obliged lepers to use crutches&#44; and the numbness that developed did nothing to calm the widespread fears&#46; The notion that lepers carried a moral burden came from the Book of Leviticus&#44; where the afflicted are considered impure&#44; sinners chastened by God&#46; Paradoxically&#44; however&#44; the disease named in the Old Testament &#40;<span class="elsevierStyleItalic">tsar&#225;¿t</span>&#41; may not have been leprosy at all&#44; but rather psoriasis&#44; vitiligo or some other condition that causes the skin to scale&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The most common treatments for leprosy were bloodletting and the eating of snake meat&#8212;the latter grounded in the principle that one poison expels another&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Cantiga 54&#44; &#8220;Toda sa&#250;de da santa Reinna&#8221; &#40;All Health Comes From the Holy Queen&#41;&#58; A Foul-Smelling Affliction of the Face Is Cured by the Virgin&#39;s Milk"
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          "titulo" => "Cantiga 91&#44; &#8220;A Virgin nos d&#225; sa&#250;de e t&#243;lle mal&#8221; &#40;The Virgin Gives Us Health and Takes Away Our Pain&#41;&#58; On the Dreaded Ergotism&#44; or St&#46; Martial&#39;s Fire"
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          "titulo" => "Cantiga 93&#44; &#8220;Nulla enfermidade non &#233; de Saar&#8221; &#40;No Disease Is Impossible to Cure&#41;&#58; The Magical Healing of a Leper by Means of the Virgin&#39;s Milk"
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          "titulo" => "Acknowledgments"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The images of Isis and Horus and the Virgen and Child &#40;Figure 1&#41; are in the public domain&#46; They were obtained from <span class="elsevierStyleInterRef" id="intr0005" href="http://www.es.mitologia.wikia.com/wiki/isis">http&#58;&#47;&#47;www&#46;es&#46;mitologia&#46;wikia&#46;com&#47;wiki&#47;isis</span>&#46; The images in Figures 2 and 3 have been reproduced with the permission of the library of the Monastery of El Escorial&#46; They come from the library&#39;s C&#243;dice Rico &#40;Rich Codex&#41; of the <span class="elsevierStyleItalic">Cantigas of Holy Mary</span> of Alfonso X the Learned&#46; &#169; Patrimonio Nacional&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Roman&#237; J&#44; Sierra X&#44; Casson A&#46; An&#225;lisis de la enfermedad dermatol&#243;gica en 8 <span class="elsevierStyleItalic">Cantigas</span> de Santa Mar&#237;a del Rey Alfonso X el Sabio&#46; Parte <span class="elsevierStyleSmallCaps">I</span>&#58; introducci&#243;n&#44; el monje resucitado &#171;lac virginis&#187;&#44; el ergotismo y la lepra&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;572&#8211;576&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">On the left&#44; Isis nursing Horus in a third-century Coptic depiction&#46; On the right&#44; an image of the Virgin and Child carved on a fifth-century Egyptian tomb&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scenes illustrating Cantiga 54&#46; On the left&#44; the monk afflicted with a disease that causes tumors on his face lies wrapped in a shroud&#46; On the right&#44; the monk is awake&#44; restored to health after the miracle&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Persons with ergotism&#44; or St&#46; Martial&#39;s fire&#44; in Cantiga 91&#46; Note the loss of distal extremities&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The man described in Cantiga 93 suffered from a disease that caused skin lesions&#46; Note how they are depicted as generalized plaques or crusts that might correspond to psoriasis or eczema&#46; The Virgin uncovers her breast and sprays her milk onto the patient&#39;s skin&#46;</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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              "referencia" => array:1 [
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                          ]
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                  "host" => array:1 [
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                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "2"
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                0 => array:1 [
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            2 => array:3 [
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            3 => array:3 [
              "identificador" => "bib0050"
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              "referencia" => array:1 [
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                  "comentario" => "ISBN&#58; 84-88865-1994"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Historia de la Dermatolog&#237;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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History and Humanities in Dermatology
Dermatologic Diseases in 8 of the Cantigas of Holy Mary of Alfonso X the Learned−Part 1: Introduction, the Monk Revived by the Virgin's Milk, Ergotism, and Leprosy
Análisis de la enfermedad dermatológica en 8 Cantigas de Santa María del Rey Alfonso X el Sabio. Parte I: introducción, el monje resucitado «lac virginis», el ergotismo y la lepra
J. Romanía,
Autor para correspondencia
jromani@tauli.cat

Corresponding author.
, X. Sierrab, A. Cassonc
a Servicio de Dermatología, Hospital Parc Taulí, Universidad Autónoma de Barcelona, Sabadell, Barcelona, Spain
b Dermatología, Práctica Privada, Terrassa, Barcelona, Spain
c Software Engineer, York, United Kingdom
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science and law as well as many literary works&#44; bringing together a remarkable contingent of Latin&#44; Jewish and Islamic musicians and intellectuals&#46; He promoted the use of Castilian for prose&#44; but for lyrical expression he favored Galician-Portuguese&#44; the educated vernacular language of the court at that time&#46; The king was tormented by family infighting and health problems&#44; which have engendered lively debate&#46; Alfonso&#39;s great aspiration to be crowned Holy Roman Emperor was never realized&#44; but his intense&#44; productive life speaks of a restless&#44; intelligent and sensitive man who also had to cope with disease and hardship&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Cantigas of Holy Mary</span> are certainly Alfonso&#39;s greatest artistic legacy&#46; This immense corpus of music&#44; poetry&#44; and illustration is the largest repository of songs surviving in a vernacular European language with the musical notation intact&#46; They tell us about daily life in Alfonso&#39;s time&#44; in particular revealing how disease&#44; with its causes and treatments&#44; was perceived&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Cantigas</span> were written in the context of a popular mass movement venerating the Mother of God that spread across Christendom after the first millennium&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Maternal figures had been venerated in many of the religions of antiquity&#8212;one example is the ancient Egyptian cult of Ast &#40;Isis&#41;&#46; The goddess was typically depicted breastfeeding her son Horus&#44; an image analogous to those of the Virgin and Child &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The cult of Mary as goddess&#44; which managed to divert attention even from the figure of Jesus&#44; came late in the history of Christianity&#58; Marian veneration began to take shape after the Council of Ephesus and became fervent during the 12th to 14th centuries&#46; The Marian cult was especially popular in the kingdoms of the Iberian Peninsula and was spread by pilgrims along the Way of St James&#46; King Alfonso&#44; who described himself as the Virgin&#39;s troubadour in his prologue to the <span class="elsevierStyleItalic">Cantigas</span>&#44; very probably wrote some of the poems himself&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The songs are a rich source of information concerning medieval life&#46; They contain rich descriptions of places&#44; historical events&#44; and more or less imagined scenarios&#46; Along with the illustrations that accompany each poem&#44; these songs help us grasp what court life was like&#46; We learn of the musical instruments that were played&#44; the dress and customs of courtiers&#44; the food they ate&#44; and of course the ailments they suffered&#46; We must remember that many of the cantigas tell of people who ask Mary to intercede on their behalf because they seek a cure&#46; Thus&#44; we are given accounts of a large number of diseases of the time&#44; although as we shall see&#44; the stories are subject to multiple interpretations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">For this paper&#44; we have selected some of the songs that describe dermatologic conditions and will attempt to analyze them from a medical and historical point of view&#46; We have not transcribed each cantiga in full&#59; rather&#44; we present excerpts for commentary&#46; Readers wishing to see the original texts are recommended to visit the website of Andrew Casson&#58; <span class="elsevierStyleItalic">Cantigas de Santa Maria for Singers</span> &#40;<a href="http://www.cantigasdesantamaria.com/">http&#58;&#47;&#47;www&#46;cantigasdesantamaria&#46;com&#47;</a>&#41;&#46; The information there is valuable for anyone who would like to delve more deeply into this monumental work&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Cantiga 54&#44; &#8220;Toda sa&#250;de da santa Reinna&#8221; &#40;All Health Comes From the Holy Queen&#41;&#58; A Foul-Smelling Affliction of the Face Is Cured by the Virgin&#39;s Milk</span><p id="par0035" class="elsevierStylePara elsevierViewall">Cantiga 54 tells the story of a monk with an ailment of the throat that spreads to his face&#44; causing extensive tumors and pain &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and preventing him from swallowing&#46; The odor that develops is described as &#8220;worse than that of a corpse&#44;&#8221; Thinking him dead&#44; his fellow monks administer the last rites&#46; At this point the Virgin appears and washes his face &#8220;with a towel she carried&#46;&#8221; Then&#44; &#8220;taking out her breast&#44; she sent milk into his mouth and onto his face&#44; which became so clear that he seemed completely changed&#44; as a swallow that renews its feathers&#46;&#8221;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">We cannot diagnose the disease based on this description&#44; but it strongly suggests an infection of the craniofacial structures&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The 93rd cantiga&#44; about a man with leprosy&#44; offers another example of the medicinal use of milk&#46; In fact&#44; Alfonso&#39;s Marian repertory contains several songs praising the milk that fed the Savior&#44; a concept that serves the purpose of illustrating that the nature of Jesus was human as well as divine&#46; The curative power of the Virgin&#39;s milk was a familiar concept to the medieval mind&#46; Even today&#44; the cathedral in Murcia keeps a small vial with drops of milk for veneration as the Virgin&#39;s own&#44; and a Bethlehem tradition designates a local site as the Milk Grotto&#44; where Jesus was nursed by Mary&#46; Many artists have depicted the Virgin sending a spray of her milk into the mouth of St&#46; Bernard of Clairvaux&#46; The event took place when as a young monk Bernard was told by his abbot to go and preach&#46; Fearing he would disappoint&#44; the saint prayed to the Virgin until he fell asleep&#46; Mary appeared in a dream and bestowed the gift of eloquence by giving him milk from her breast&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The curative power of breast milk is a clear&#44; consistent motif in Marian hagiography&#44; one that has fascinated the faithful since the early days of the cult of the Virgin&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Cantiga 91&#44; &#8220;A Virgin nos d&#225; sa&#250;de e t&#243;lle mal&#8221; &#40;The Virgin Gives Us Health and Takes Away Our Pain&#41;&#58; On the Dreaded Ergotism&#44; or St&#46; Martial&#39;s Fire</span><p id="par0055" class="elsevierStylePara elsevierViewall">The story told in the 91st song takes place in France at the sanctuary of Soissons&#46; The central event is mass poisoning by ergot&#44; a fungus of the rye plant&#46; The condition is called ergotism today but was then called St&#46; Martial&#39;s fire&#46; The cantiga says&#44; &#8220;For the sins they had committed&#44; God sent St&#46; Martial&#39;s fire to punish and confound them&#8230;and as I have heard&#44; it was the nature of that affliction to first make them cold and then burn them worse than fire&#8230;Because their parts fell away&#44; nor could they eat or sleep&#44; nor stand on their own feet&#44; they preferred death to suffering such monstrous pain&#8230;&#46;&#8221; The Virgin appears&#44; bathed in light&#44; and miraculously cures them &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">This text gives an impeccable description of poisoning by ergot &#40;<span class="elsevierStyleItalic">Claviceps purpurea</span>&#41;<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> Epidemics of ergotism&#44; which have been well documented in many sources&#44; devastated the medieval world for centuries&#44; particularly in times of famine&#46; Also known as St&#46; Anthony&#39;s fire&#44; the holy fire&#44; or hell&#39;s fire&#44; ergot poisoning was a common occurrence because rye was an important food staple at a time when white bread was only available to those in the upper strata of society&#46; After the rye grain had been milled&#44; its dark flour was easily masked the red powder of ergot mixed with it&#46; Symptoms of ergotism included intense pain and cold in the extremities&#44; due to vasoconstriction&#44; followed by intense burning sensations&#44; pain&#44; distal necrosis&#44; hallucinations&#44; and convulsions&#46; Occasional survivors were usually left severely deformed by loss of limb&#46; Medicinal uses of ergot were known in the traditional Chinese pharmacopoeia&#44; and in the 17th century ergot was employed to suppress puerperal hemorrhages&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">St&#46; Martial&#44; who evangelized the Limousin region of France&#44; has been revered in the area around Limoges since the early years of Christianity&#46; His renown as a healer grew when the population of Aquitaine was decimated by ergotism in the 10th century&#46; When the faithful turned to this saint to intercede on their behalf&#44; the epidemic ended miraculously&#46; In his life of St&#46; Martial&#44; Ad&#233;mar of Chabannes &#40;983&#8211;1043&#41; went so far as to call him the 13th apostle who was present at the Last Supper and the crucifixion&#44; claims that are reflected in the local iconography&#46; Places associated with St&#46; Martial even competed with Santiago de Compostela as pilgrimage destinations among the local population&#46; In 1854&#44; the bishop of Limoges petitioned Pope Pius IX to declare the saint a direct disciple of Christ&#44; but the appeal was denied&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The cantigas were powerful promotional texts for Marian devotion&#44; crediting Mary with miracles of such great impact that they exceeded those of St&#46; Martial&#46; The accounts sought to firmly establish that her ability to intercede in healing the sick outstripped that of any other in heaven&#44; even the earlier healer of ergotism&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Several other cantigas provide descriptions of ergotism&#46; The events in Cantiga 134 take place in Paris and include the miraculous regeneration of an extremity lost to the disease&#46; Cantiga 19 tells of a condition referred to as &#8220;fire from heaven&#46;&#8221; Cantiga 53 mentions a &#8220;wild fire&#8221; and also mentions leprosy&#44; another scourge of the Middle Ages and one that could sometimes be confused with other diseases of the skin&#46; Cantiga 105 clearly distinguishes between the two&#46; In Cantiga 81&#44; St&#46; Martial&#39;s fire is said to &#8220;consume the flesh&#8221; of an afflicted woman&#44; who hides her disfigured face behind a veil&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The treatment of ergotism was based on plants like mandrake or other analgesics&#44; even though they could intensify the hallucinations caused by the disease&#46; Treating physicians protected themselves with sponges soaked in vinegar and wore a mask like a bird&#39;s beak impregnated with aromatic substances to guard against contagion&#46; Prayer and divine intercession remained the principal therapies&#44; however&#44; and it was considered important for a region to have relics of saints on hand or else nearby tombs where relics could be obtained&#46; The Hospital Order of St&#46; Anthony&#44; which used the letter tau in blue as their symbol&#44; were charged with caring for patients with ergot poisoning&#46; Medieval spirituality embraced all these practices and beliefs&#44; and it is likely that some patients improved with care&#44; hygiene&#44; and relief from the monotony of a diet based on rye bread made from the contaminated flour that was causing their misfortune&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Cantiga 93&#44; &#8220;Nulla enfermidade non &#233; de Saar&#8221; &#40;No Disease Is Impossible to Cure&#41;&#58; The Magical Healing of a Leper by Means of the Virgin&#39;s Milk</span><p id="par0085" class="elsevierStylePara elsevierViewall">For the sin of lust&#44; the protagonist of Cantiga 93 is punished with fulminant leprosy &#40;<span class="elsevierStyleItalic">gafeen</span>&#41; that covers his body with lesions&#44; paradoxically causing ungovernable sexual desire&#46; &#40;In fact&#44; lepers were widely believed at the time to be lustful&#46;&#41; Repentant&#44; the patient withdraws to a hermit&#39;s hut&#8212;probably banished because of his condition&#8212;and prays a thousand Hail Marys to please the Mother of God&#46; He is delivered from disease when Mary appears and decides to heal him with milk from her breast&#58; &#8220;She took out her breast and anointed him with her holy milk&#46;&#8221;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The illustration that accompanies the cantiga &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; shows a man in bed prostrated by disease yet joyful in his expression&#46; His skin shows signs of scaling or crusting&#44; but his extremities have none of the ulcers or deformities typical of leprosy&#46; We believe this case actually involves some other highly noticeable skin disease&#8212;perhaps scabies&#44; psoriasis or eczema&#44; but not the mere changes in pigmentation that come with such diseases as vitiligo or indeterminate leprosy&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Leprosy is one of the most often mentioned diseases in the <span class="elsevierStyleItalic">Cantigas of Holy Mary</span>&#46; However&#44; just as we exercise caution when interpreting other medieval texts&#44; we should not rush to assume that the individuals described as lepers in these poems in fact had Hansen disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#8211;6</span></a> Many conditions referred to as leprosy are in fact other diseases that manifest with a great variety of skin signs&#44; such as psoriasis&#44; scabies&#44; or fungal infections&#44; to mention only a few&#46; The word <span class="elsevierStyleItalic">gafo</span>&#44; however&#44; is the medieval Galician-Portuguese term for a person with leprosy&#44; and when it appears again and again in the <span class="elsevierStyleItalic">Cantigas</span> it does seem to refer to Hansen disease&#46; The word also denotes a claw- or hook-shaped tool used to draw the string of a crossbow back to the nut&#44; where it is fixed before the shot&#46; This tool&#39;s shape resembles the clawlike deformities sometimes caused by peripheral neuropathy in tuberculoid leprosy&#46; The conventional meaning of the Spanish word <span class="elsevierStyleItalic">gafe</span> to refer to a person who attracts bad luck may have been derived from <span class="elsevierStyleItalic">gafo</span>&#46; Finally&#44; the name of the river running through the Galician city of Pontevedra&#8212;R&#237;o dos Gafos&#8212;is a reference to an old lazaretto that housed lepers in the Campolongo neighborhood&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Leprosy is estimated to have afflicted 4&#37; of the population in the Middle Ages&#44; and there seems to have been a well-documented rapid spread of the disease in the 12th and 13th centuries&#46; Lepers struck their fellow citizens with terror&#58; the marks left by their disease&#44; the deforming protuberances it left&#44; the neurological impairment of arms and legs that obliged lepers to use crutches&#44; and the numbness that developed did nothing to calm the widespread fears&#46; The notion that lepers carried a moral burden came from the Book of Leviticus&#44; where the afflicted are considered impure&#44; sinners chastened by God&#46; Paradoxically&#44; however&#44; the disease named in the Old Testament &#40;<span class="elsevierStyleItalic">tsar&#225;¿t</span>&#41; may not have been leprosy at all&#44; but rather psoriasis&#44; vitiligo or some other condition that causes the skin to scale&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The most common treatments for leprosy were bloodletting and the eating of snake meat&#8212;the latter grounded in the principle that one poison expels another&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Cantiga 54&#44; &#8220;Toda sa&#250;de da santa Reinna&#8221; &#40;All Health Comes From the Holy Queen&#41;&#58; A Foul-Smelling Affliction of the Face Is Cured by the Virgin&#39;s Milk"
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          "titulo" => "Cantiga 91&#44; &#8220;A Virgin nos d&#225; sa&#250;de e t&#243;lle mal&#8221; &#40;The Virgin Gives Us Health and Takes Away Our Pain&#41;&#58; On the Dreaded Ergotism&#44; or St&#46; Martial&#39;s Fire"
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          "titulo" => "Cantiga 93&#44; &#8220;Nulla enfermidade non &#233; de Saar&#8221; &#40;No Disease Is Impossible to Cure&#41;&#58; The Magical Healing of a Leper by Means of the Virgin&#39;s Milk"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The images of Isis and Horus and the Virgen and Child &#40;Figure 1&#41; are in the public domain&#46; They were obtained from <span class="elsevierStyleInterRef" id="intr0005" href="http://www.es.mitologia.wikia.com/wiki/isis">http&#58;&#47;&#47;www&#46;es&#46;mitologia&#46;wikia&#46;com&#47;wiki&#47;isis</span>&#46; The images in Figures 2 and 3 have been reproduced with the permission of the library of the Monastery of El Escorial&#46; They come from the library&#39;s C&#243;dice Rico &#40;Rich Codex&#41; of the <span class="elsevierStyleItalic">Cantigas of Holy Mary</span> of Alfonso X the Learned&#46; &#169; Patrimonio Nacional&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Roman&#237; J&#44; Sierra X&#44; Casson A&#46; An&#225;lisis de la enfermedad dermatol&#243;gica en 8 <span class="elsevierStyleItalic">Cantigas</span> de Santa Mar&#237;a del Rey Alfonso X el Sabio&#46; Parte <span class="elsevierStyleSmallCaps">I</span>&#58; introducci&#243;n&#44; el monje resucitado &#171;lac virginis&#187;&#44; el ergotismo y la lepra&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;572&#8211;576&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">On the left&#44; Isis nursing Horus in a third-century Coptic depiction&#46; On the right&#44; an image of the Virgin and Child carved on a fifth-century Egyptian tomb&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Scenes illustrating Cantiga 54&#46; On the left&#44; the monk afflicted with a disease that causes tumors on his face lies wrapped in a shroud&#46; On the right&#44; the monk is awake&#44; restored to health after the miracle&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Persons with ergotism&#44; or St&#46; Martial&#39;s fire&#44; in Cantiga 91&#46; Note the loss of distal extremities&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The man described in Cantiga 93 suffered from a disease that caused skin lesions&#46; Note how they are depicted as generalized plaques or crusts that might correspond to psoriasis or eczema&#46; The Virgin uncovers her breast and sprays her milk onto the patient&#39;s skin&#46;</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#169; by Patrimonio Nacional&#46;</p>"
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              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mary and the Fathers of the Church"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Gambero"
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1999"
                        "editorial" => "Ignatus Press"
                        "editorialLocalizacion" => "San Francisco"
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                  "referenciaCompleta" => "Salvador Mart&#237;nez H&#46; Alfonso X El Sabio&#58; una biograf&#237;a&#46; Polifemo&#44; 2003&#46; ISBN 9788486547660&#46;"
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              ]
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              "identificador" => "bib0045"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "El fuego de San Marcial y el fuego de San Ant&#243;n en el contexto del arte medieval"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "M&#46;L&#46; Mart&#237;n-As&#243;n"
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Anuario del Arte"
                        "fecha" => "2010"
                        "volumen" => "22"
                        "paginaInicial" => "9"
                        "paginaFinal" => "29"
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              "identificador" => "bib0050"
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                0 => array:3 [
                  "comentario" => "ISBN&#58; 84-88865-1994"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Historia de la Dermatolog&#237;a"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "X&#46; Sierra Valent&#237;"
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                        "fecha" => "1994"
                        "editorial" => "MRA Barcelona"
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ISSN: 15782190
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