Download PDF | (Medicine in the Medieval Mediterranean, 9) Costas Tsiamis - Plague in Byzantine Times_ A Historical and Medical Study-De Gruyter (2023).
260 Pages
Foreword Ancient Epidemics The Necessity of a Multidisciplinary Approach
In this well-researched, insightful monograph Plague in Byzantine Times: A Medicohistorical Study, Costas Tsiamis accepts the challenge of a topic that has long rightfully been considered a vexata quaestio in the history of both medical practice and pathology: ancient epidemics. To this date it has proved particularly complicated for scholars to determine the exact aetiology of infectious diseases that caused epidemico-pandemic manifestations, as well as their epidemiology, clinical presentations, and disappearance. A classic example of this, also aptly discussed in this study, is the Plague of Athens that devastated the ancient Attic polis in the 5" century B.C. In combination with the Peloponnesian War, plague provoked the decline of Athens and represented its farewell to its long-held imperial ambitions.
Despite undeniable advances in the research methodologies and the biomedical techniques that have opened a new era for medico-historical discoveries, ancient epidemics and pandemics are still more of a conundrum than a terra cognita to be crossed at ease. Questions and doubts are more numerous than answers. This is especially true if one considers not only the antiquity of diseases, but also their evolutionary history. One may be too hastily tempted to believe that the clinical presentation of diseases has indeed always been the same throughout the centuries, whereas it cannot be excluded that their semiology may have changed owing to pathomorphosis, which could reflect genetic mutations in the pathogens and their interaction with their hosts. This is something that ought not to be neglected and should be considered when examining ancient literary accounts of epidemics.
Moreover, as it emerges from Tsiamis’ pages, the ancient literary sources should be approached with extreme caution as they may use a language and knowledge that predate, sometimes by many a century, the discoveries of contemporary medicine. The very terms used to describe the clinical manifestations of nosological conditions should be carefully analyzed before any conclusions, either aiming to be definitive or being preliminary, can be drawn and put forward, and multiple sources should be scrutinized in the search for evidence. Such evidence could be made of data extracted not only from literary accounts, but also from archaeological excavations, numismatics, and ancient human remains, among others.
In addition, possible interpretative confusions and the inherent limitations of the matter subjected to the study of scholars devoting their academic activity to these topics, are not only an issue for the assessment of the past of infectious diseases, but also for the present, as the COVID-19 pandemic has recently demonstrated. This is particularly true when one reflects on the general despair encountered in both world leadership and populations facing a new, so-called “invisible enemy”, which may appear a novel phenomenon at first glance, whereas, at closer look and availing oneself of the tools of historico-medical research, it can be shown to have always existed and have characterised humankind’s response to such epochal manifestations of unexplained forces, alternatively interpreted as the results of divine wrath or some conspiracy ascribed to certain ethnic or religious minorities plotting against constituted authority. Furthermore, in general, it can be stated that epidemics mark epoch transitions or even end up accelerating them, something that makes their study of peculiar transdisciplinary interest.
Examining Justinian’s interaction with the political and religious institutions in a time of epidemics in the Byzantine Empire is relevant to the understanding of the complex socio-cultural dynamics taking place in the current pandemic times. Let us consider, for instance, the law Justinian issued on March 23, 543 A. D. decreeing that God’s teaching (i.e., the punishment of Humankind through the plague) was over. That decision had social and economic reasons, in spite of the fact that the plague would still continue to exist in the Empire and would continue to kill a high number of its subjects: this can be catalogued as a form of an ante litteram manipulation of the epidemiological reality, something that many a government worldwide attempted to implement in recent times when protests against restrictions of social interactions or economic hardships emerged in the COVID-19 pandemic.
Distancing himself from those approaches that value one method over the other, Costas Tsiamis rightly chooses to look at the complex matter lying before his eyes, adopting a multidisciplinary methodology that combines historical, archaeological, anthropological, and palaeopathological approaches in a very appropriate blend.
While much is still to be written about the nature and presentations of ancient epidemics, including those from the Byzantine Empire that Costas Tsiamis dwells a great deal upon in his research, Plague in Byzantine Times shows how the past of a disease can be fully understood only if methods are combined and knowledge is shared between scholars from various fields of research, never forgetting that Science is one, while its interpreters and disciples may be multiple.
Francesco M. Galassi Flinders University June 2022
Acknowledgments
The present book is a revision of my doctoral thesis Historical and Epidemiological Approach of Plague during the Byzantine Times (330-1453 A.D.), which I wrote between 2005 and 2010 at the Department of Hygiene, Epidemiology and Medical Statistics of the Medical School of the National and Kapodistrian University of Athens. I would like to express my sincere gratitude to those who guided and trusted me in that time, namely my tutors Professor Eleni Petridou (Epidemiology), Professor Effie Poulakou-Rebelakou (History of Medicine), and Professor Aristotelis Efthychiades (History of Medicine). While delving into the historical sources over many years, I was constantly accompanied by Professor Dionysios Stathakopoulos (Department of History and Archaeology, University of Cyprus) and Dr. Ioannis Telelis (Academy of Athens, Research Center for Greek and Latin Literature), to whom I am most grateful for offering their specialized knowledge whenever I needed it.
The molecular study of the plague pathogen rapidly developed after I completed my doctoral thesis, making it necessary to correct my work, to add new elements, and to update data. In the past years I have had the great privilege to do research at the Department of Microbiology of the Medical School of the National and Kapodistrian University of Athens, where I found myself right at the heart of the laboratory diagnosis of infectious diseases and became accustomed with the most modern diagnostic methods. I wish to thank the Director of the Department of Microbiology, Professor Athanassios Tsakris, as well as Professor Georgia Vrioni, for the knowledge they shared with me and the help they provided to penetrate the secrets of the microcosm and approach Yersinia pestis.
The epidemiological approach to an infectious disease comprises two basic parameters: space and time. On these matters, I wish to thank Professor Dimitrios Anoyatis-Pelé (School of History, Ionian University, Corfu) for his help on issues related to Historical Demography and Geography, and Alexandros Aidonidis from the Historical Demography Postgraduate Program of the Ionian University, who edited the plague maps that frame and illustrate the history of the disease.
Paraphrasing Captain Cook, my childhood hero who considered the first navigation clock to be his ‘most faithful guide that shows the right path’, my friend and long-term colleague and translator Aggelos Zikos, constantly showed me the right path in the uncharted waters of my endeavour over the past years. I deeply thank him for the translations and his technical skills that helped me to make my writing more understandable.
The publication of this book would not have been possible without the assistance, advice and trust placed in me by the Senior Editor of the series Medicine in the Medieval Mediterranean, Dr. Alain Touwaide (Scientific Director, Institute for the Preservation of Medical Traditions, Washington, D.C., USA), to whom I am deeply grateful. I also wish to warmly thank the other members of the editorial board: Vivian Nutton (Emeritus Professor of History of Medicine at University College London), Marie Héléne Congourdeau (Honorary Researcher at the Centre National de la Recherche Scientifique, Paris-France) and Dimitri Gutas (Professor of Arabic and Graeco-Arabic Studies at Yale University).
Also, I wish to thank Dssa Emanuela Appetiti (President, Institute for the Preservation of Medical Traditions, Washington, D.C., USA) for her enthusiastic support and her detailed proofreading of the final version of my manuscript. In this final phase Marie Héléne Congourdeau, Niki Papavramidou and Witold Witakowski have been helpful in checking documents difficult to trace in a time when library are still close because of the pandemic. As usual all mistakes remain mine.
Finally, I warmly thank De Gruyter Senior Editor for Classical Studies, Dr Serena Pirrotta, and her team, especially Marco Acquafredda and Dr Carlo Vessella, as well as all De Gruyter dedicated staff for their collaboration and patience, professionalism, and assistance with technical issues.
Costas Tsiamis Athens, June 2022
Introduction
Let us take a brief moment to consider whether the human brain—given the amount of information and knowledge it stores—is able to establish a spontaneously logical link upon hearing the following words: Lake Victoria, Damascus, hibernation. An instinctive and probably the sole, reasonable answer would be that no connection exists between them. When the brain visualizes these words, it might automatically visualize three different pictures, and three distinctive and distant geographical environments and ecosystems: savanna, desert, and steppe, respectively. What if these images, however, were not only related to space but also to time? Of course, the concept of time is ‘flexible’ and may refer to the alternation of seasons during the calendar year, the alternation of aeons in the desert, or to a given point in time in the steppe. What would happen though, when the projections of events that took place at different times and places start to intersect at a specific point in time?
This study attempts to broaden the way we think and approach the biological phenomenon of epidemics. This is the first inherent obstacle to this effort. The exchange of information between different scientific fields is given. What kind of information is needed, however, and by whom? Diffusion and access to information is easy nowadays. How easy is it for a researcher, however, to understand the findings of another scientific field that is different from his/her own? Modern scientific collaborations lead to interesting and useful conclusions which are easily disseminated and exchanged. Supposing that a researcher has access to a plentiful amount of data, what would the key-element allowing him/her to ‘unlock’ the sequence of events be? It is easy for the reader to understand the difficulties stemming from the approach to the same issue by two distinct sciences, from a different starting point. It is understood that when we examine this issue retrospectively over the course of centuries, its solution becomes exponentially more difficult, the more so when it comes to health-related issues and especially to epidemics.
Studying the epidemics of the distant past poses a particular challenge and, regardless of how theoretical our approach is, such studies present certain scenarios which are more or less likely to be closer to the facts. Research is not one-sided, but rather multidimensional, as it draws data from various sources. This effort can be likened to the pieces of a puzzle. Before fitting the pieces, we need to separate and group them together by colour or contour. Even this is not always enough to find a solution, however. Epidemics are multifactorial systems that entail subtle and often long-term interactions. Each process and factor represents a distinct piece of the broader picture. The aim of this study is to present as many pieces of this historical puzzle as possible. The theories put forward herein are based on this very method. The distinct pieces of the same system that started to come together as a result of historical events, biological processes or even randomly, are all laid out right before us. What remains is to reconstruct the full picture which, as already men-tioned, shall always comprise an element of probability rather than absolute certainty. The reader must nevertheless not forget that the study of epidemics moves along two axes: space and time.
This study aims at collecting, presenting and processing historical and medical data on the plague epidemics that struck the Byzantine Empire. It will present the two plague pandemics, that is, the Plague of Justinian and the Black Death, which ravaged the Byzantine Empire. Our approach, namely the combination of historical data and contemporary medical knowledge, highlights the importance of interdisciplinary cooperation in the field of Historical Epidemiology, History of Public Health, and the History of Medicine in general. The range of scientific fields involved in this study is wide, thus providing for the use of data from several disciplines such as Epidemiology, Microbiology, History, Historical Demography and Geography, as well as Archaeology.
Nosologically, plague exists until today and every year a few countries report plague cases to the World Health Organization (WHO), which by no means present the intensity and extent that characterized the disease some centuries ago. The medical interest in plague remains high and it is indicative that the keyword plague came up in more than 12,000 publications on the MedLine database, which cover the period 1960 - 2021. After 2001, plague resurfaced along with smallpox and anthrax, in the context of bio-terrorism after the attacks of September 11 in New York, given that Yersinia pestis is listed as a Class A biological weapon. Beyond this politico-military dimension, however, the study of plague continues in the context of analyzing the genome of Yersinia pestis, in order to prepare effective vaccines and to predict, prevent, detect, and control the natural foci of the disease all over the world by the WHO and the national health services.
This study will cover the whole spectrum of plague epidemics that occurred in the Byzantine Empire, from the year of its foundation until its fall, that is, from 330 to 1453 A.D. The time of occurrence of the two pandemics coincides with two particular periods of Byzantine history. The first period (541-750) relates to the acme of the Empire, whereas the second period (1347-1453) coincides with the struggle of a state entity that was discredited on the political scene of the fourteenth and fifteenth centuries, and was tormented by civil wars, corruption, government decay, and decadence until its final fall. The epidemics of the first pandemic are presented in the context of a ‘Byzantine ecumene’, whereas subsequent pandemic comprise the epidemics that occurred in territories under foreign occupation, located mainly in the regions of Greece, thus spatially delimiting a wider geographical area perceived as ‘Byzantine space’.
Previous studies have highlighted specific questions which have not yet been dealt with, even more so at a time when epidemiological data are inconsistent with prevailing views. According to one view, for example, the biblical Plague of the Philistines, the Plague of Athens, the Antonine Plague or the Plague of Cyprian constitute cases of plague epidemics. On the other hand, despite the indication that these epidemics affected immunologically ‘virgin’ populations, there is no factual evidence that the disease existed before the fifth century A.D. This view, however, which is often reproduced in medical textbooks of microbiology and epidemiology as part of their introduction to plague, illustrates the tradition of obsolete theories. The questions are not exhausted here, though. The present study attempts to clarify such questions arising from reading the sources. As far as the first pandemic is concerned (the so-called Plague of Justinian), the question of the gateway of the disease into Europe and the origin of the first pandemic remains. In an effort to identify the origin of plague, the phenomenon of research orientation (or disorientation) towards identifying epidemics before 541 instead of monitoring the course of the microbe is presented. The present study aspires to combine existing views, taking into account not only historical data, but also particular phylogenetic and evolutionary elements of Yersinia pestis strains. In this context, it is deemed necessary to redefine the grouping of epidemic outbreaks. Studies have so far been linking the disease with trade, wars and movements of populations, disregarding the possible existence of enzootic foci.
Similarly, the Second Pandemic (or Black Death) displays particular elements that need clarification. The medico-historical study is entrapped into the narrative of Gabriele de’ Mussi, which covers the events of the terrible siege of the Genoese colony of Kaffa in Crimea by the Mongols in 1346, wherefrom plague spread to Europe, after affecting Constantinople in 1347. The incubation period, the nature of the disease, the time of the siege and particular Byzantine sources, all prompt us to think of other possible routes that plague followed from Crimea to Constantinople. Our study attempts to present the epidemiological and historical data of the period from a different perspective, that is, in conjunction with the findings of the first pandemic, instead of examining only the period in question. In addition, it has been deemed appropriate to compare the clinical forms of epidemics of the two pandemics, given that the medical and medico-historical literature has revealed controversies over the true nature of the Second Pandemic. Finally, in the case of Black Death epidemics, the grouping of epidemic waves and outbreaks is considered equally necessary.
This study takes into account a large number of works carried out to date. It rests on two fundamental elements defined by the modern medical community: the clinical picture of plague, and its epidemiological cycle. These two elements constitute our interpretive and comparative tool for describing the Byzantine disease. They are essentially critical of primary sources and, by extension, secondary literature since—as already mentioned—it is a well known fact that positions and opinions ultimately need to be revised.
Unfortunately, the era of the two pandemics has been misinterpreted and the general public does not usually grasp that these centuries are crucial to the shaping of the European culture and modern European states. To some extent, the readers’ preconception, which is often the result of the study of epidemics of this period, should be attributed to the term ‘Middle Ages’ which, by association and insufficient knowledge, suggests a dark period. In the context of the misunderstood significance of this period, which supposedly slowed down the progress of Europe, epidemics are construed as an expected result of superstition and ignorance of contemporary people, while the social behaviors that emerged seem strange and bizarre nowadays. However, when we examine the epidemics of that period from a purely epidemiological perspective, we may conclude that infectious diseases have diachronically been governed by fixed epidemiological cycles and models and that, as such, they can emerge anytime and anywhere on the planet.
The number of years that separates us from that era is minimal in relation to the actual presence of the Homo sapiens on earth for tens of thousands of years. Beyond any cultural differences, modern humans appear to share psychological traits with the people living in the Middle Ages. Collective fears and emotional reactions were, are and will remain, a human characteristic. Moreover, despite the sophisticated diagnostic and therapeutic arsenal of modern Medicine, nobody could guarantee that, in the case of a modern pandemic of any deadly disease, no similar individual and collective social behavior would emerge. A behavior may once again go to extremes, from fleeing and abandonment to pogroms against social, national or religious groups. Therefore, if ignorance was the curse of people of the Middle Ages and epidemics their anticipated punishment, sciolism is the curse of modern humans.
In the course of this study, particular key problems emerged relating to the nature and uniqueness of Byzantine sources. The first problem concerns the reliability of sources, because of three factors: a) the absence of descriptions of plague in Byzantine medical texts, b) the lack of medical knowledge of writers who were no physicians themselves, and, c) the time of writing of the plague descriptions. Regarding the first factor, all kinds of information provided by the sources are the result of writings by the chroniclers and historians of the time and not by physicians. This phenomenon is particularly interesting, since the surviving texts of eminent Byzantine physicians from the sixth to fifteenth century contain no clinical picture of plague. As for the second factor, except for the few cases of writers who—in the broader context of contemporary—possessed basic medical knowledge, the vast majority of them captured a simplistic image of an epidemic on the margins of eschatology and divine wrath. This eschatological predisposition of contemporary writers highlights another problem: their descriptions are characterized by pessimism, uncertainty, and despair. The perpetuation of this literary standard gradually and inevitably led to an established model for describing the disease, which frequently perpetuated stereotyped phrases stemming from past epidemics and may ultimately have nothing to do with the epidemic under study.
As far as the time of writing is concerned, the sources fall into two subcategories: descriptions by eye-witnesses, and descriptions that were drawn up many years after the event. In the latter case, there is an underlying risk of incomplete description, either because the writer did not recall all the events, or because the writer did not experience past events in person, but relied on second-hand information. At this point, the subjectivity of the chronicler plays a catalytic role. It is particularly important to notice that the terms ‘pestilence’ and ‘plague’ were gradually assimilated into the nosological entity of plague, despite the fact that, semantically, they might have been associated with an epidemic by any infectious etiological factor.
Another problem lies in the description of plague symptomatology. In several cases the clinical picture is unclear or incomplete, and problematic points are also identified in the differential diagnosis. Nevertheless, whenever described in detail by the Byzantines, the clinical picture appears compatible with the familiar symptomatology. Byzantine writers convey the medical legacy of the ancient Greeks, but differential diagnosis based on the terms BouBwv (vouvén) ‘bubo’ and dvOpaé (anthrax) ‘carbon’ has proven rather complex. For example, the word ‘bubo’ itself predisposes the reader with regard to its etymology, thus leading our thought to bubonic plague. The term &v@pakac ‘carbon’ was not related to the modern concept of the infectious disease anthrax—instead, it was simply used to describe the general dermatological manifestation of various diseases—not necessarily infectious.
The difficulty of an ex post factum diagnosis has to be taken for granted. This particular difficulty lies in a set of problems that emerge in all cases of studying diseases of the past based on their clinical picture. Perhaps the Plague of Athens, known as the Thucydides syndrome in medical terms, is the most striking example. Many historians and physicians tried to unravel and identify the disease with the help of the detailed symptomatology offered by the contemporary Greek historian Thucydides. It is really impressive that, based on the reading and study of the symptomatology of the Plague of Athens, more than 25 different possible diseases have been proposed, among them bubonic plague, typhus, typhoid fever, smallpox, ergotism, influenza, Ebola virus disease, and many more. Of course, when referring to those times, our diagnostic capability is definitely determined by, and broadly entails, the factor of probability.
Another point of friction when examining a proposed diagnosis often stems from the argument that no disease of the past can be safely defined as plague, since it is not the same disease from the same microbe that we know of today, considering the rate and number of microbial mutations. Whether the human body will get infected, however, depends not solely on the aggression of a new mutant microbe, but also on the defense level of the body. Microorganisms evolve, but the same is not true for defense mechanisms. This simply implies that the defense mechanisms of humans have been invariant and fixed against the invasion of all microorganisms for millennia. At the molecular and cellular level, scientific data support the view of a slow biological evolution of Homo sapiens. We can legitimately assume that the reactions and defense of the Homo sapiens against pathogens have essentially remained unchanged in the past millennia. The most obvious proof thereof lies in the fact that the impressive decline in mortality due to infectious diseases did not occur earlier than the twentieth century, when antibiotics were discovered. Although the human genome has undergone numerous mutations over the course of millennia, these mutations have not been able to dramatically alter the way in which the body responds to external bacterial stimuli. Before the discovery of antibiotics, humans of the sixth or the early twentieth century became infected with Yersinia pestis—regardless of bacterial mutations—and ultimately died in exactly the same way. Mutated or not, microbes have been causing the same sequence of reactions, through the activation and involvement of the same organs (bone marrow, blood, thymus, lymph nodes, spleen) and the same cellular elements (B- and T-lymphocytes, mononuclear macrophages, Natural Killer Cells, and so on).
As mentioned above, the descriptions offered by chroniclers are dominated by a spirit of pessimism, insecurity, and desperation. Phrases like ‘there were not enough people alive to bury the dead’ are to be found again and again over time—although in several cases they may depict reality, a potential lack of living people could be explained in simple terms by a massive exodus from a city. On the other hand, we cannot contest the exactness of this phrase when considering the high mortality rates of plague. Nevertheless, the lack of reliable demographic data for Byzantine cities raises questions as to the actual rate of diffusion and mortality of diseases. This essentially leads to the question of change in, and progress of, the nature of infectious diseases in that period. Moving from Antiquity to the early Middle Ages, the question arises as to whether a certain change in the susceptibility of the European population against infectious diseases is to be found. Susceptibility or resistance of a population against a particular infectious disease is termed by the collective immunity (or ‘herd immunity’ or ‘community immunity’). It is this resistance that decisively influences the epidemiological behavior of a particular infectious disease in a given population. After all, it is known that the level of immunity declines over the course of years, although at varying rates, while the composition of the population varies accordingly as a result of the addition of new individuals through population shifts. Furthermore, the determination of the ‘critical number’ of immune individuals, that is, the number of individuals who define the level of collective immunity that suffices to protect a population from the spread of an infectious agent, is of particular significance.
In the broader context of the aforementioned problems, the current study attempts—among others—to expand the way of approaching the primary sources examined in medico-historical literature. Upon reading the primary sources, we ought to consider both what is mentioned in the source and why it is mentioned. Apart from medical and historical parameters, we understand the way of thinking of the time, as well as the psychology of the writers, since they were both shaped by a set of contemporary social, political, and religious factors.
We have to remember that Historical Epidemiology is a field where numerous theories can be proposed, which have more (or less) probability of being close to the facts. The underlying purpose of this study is to present to non-specialists the basic medical and epidemiological parameters of the disease in the simplest, clearest, and most comprehensible way. An elementary code of communication will be established between scientific disciplines, allowing non-specialists to understand the way scientists with medical knowledge obtain data to build an interpretative historico-epidemiological theory on past epidemics. This method could help scholars to understand and evaluate the medical data related to infectious diseases contained in historical sources. Moreover, this simplified approach can shed light onto the general behavior of microbes, particularly onto the traditional relationships between the factors involved in the emergence of an epidemic. By learning about the evolution of microbes—in our case of Yersinia pestis—historians could better understand the possible relationship between this evolution and the historical periods and facts.
Non-specialists cannot be expected to become familiar with medical fields like Molecular Medicine. The core idea of this study is to make the reader aware of the perpetual process of evolution and replication of the epidemiological relationships between humans, environment, and the microcosm. Conversely, references to the historical context of plague epidemics could help specialists to gain a better understanding of historical sources and descriptions of which they may not be aware, whereas these sources may offer useful information for the medico-historical analysis. Readers will definitely be puzzled by the complexity of the relationship between the factors responsible for triggering an epidemic, considering that this is a structured and established relationship that emerges time and again.
Each scientific field draws different data from available historical sources, according to its areas of interest. Instead of bringing individual fields together, however, this anticipated phenomenon may eventually alienate them. It is clear that the purpose of medical research is different from that of historical study. Indeed, medical research on past epidemics has been carried out from the perspective of Molecular Medicine, a field that can hardly be understood without medical knowledge. In light of this obstacle, molecular concepts are presented within a broader framework that may appear trivial or over-simplified to a physician, but is crucial for other readers to be able to understand the basic elements of evolution, and how they relate to the evaluation and approach to historical sources from a medico-historical perspective.
It is also understood that the findings of molecular research offer Medicine significant knowledge of the development of microorganisms, which is not limited to the academia, but entails practical benefits in the treatment of, and protection against, infectious diseases. A well-dated historical source concerning an epidemic that affected a city, the potential archaeological findings of human skeletal remains from the same period and the same city, and a potential finding among these remains related to a pathogen using molecular methods, do not necessarily translate into de facto proof that the microbe mentioned in the molecular findings is responsible for the epidemic. Unfortunately, the more distant the past, the less likely it is to reach definitive conclusions backed by irrefutable evidence. This scenario, however, shows that the study of past epidemics, regardless of its starting point, can serve as a meeting point for distinct theories and scientific fields, bridging their differences and fostering cooperation.
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