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Plague, Empire, and the Birth of Europeby William Rosen

From Chapter Nine:

This disease always took its start from the coast, and then went up to the interior.”

Procopius, History of the Wars, II, xxii, 8

It began, as it always began, at the docks. From there, it climbed inexorably, week after week, a rising tide visiting the judgment of God on His people. Though Procopius could not, of course, know this, the plague was borne not by miasmic air (or by the supernatural creatures that he reported some victims saw before becoming ill) but by the rats that carried their fleas into every neighborhood. The geography of the city conspired with them; one reason that the Emperor Constantine was inspired to name his capital New Rome was that, like the original model, it had seven hills. The base of each one was stricken by the demon first, giving those who lived on the hilltops the same useless warning as the occupants of the top deck of a sinking ship.

In retrospect, the demon’s targets had all the evidence required to identify its carriers. They knew, as modern zoologists know, that rats are never found more than a few hundred yards from a human habitation. And they knew that the plague, like the rats, always spread outward from the harbors and the granaries.

The best evidence is that the peak of the first wave of the epidemic lasted only four months, after which both rat and human populations had crashed so fast that Y. pestis could no longer spread. But for one hundred days, Constantinople was a window onto Hell. Every day, one, two, sometimes five thousand of the city’s residents – one in one hundred of the pre-Plague population – would become infected. A day’s moderate fever would be followed by a week of delirium. Buboes would appear under the arms, in the groin, behind the ears, and grow to the size of melons. Edemas – of blood – infiltrated the nerve endings of the swollen lymphatic glands, causing massive pain. Sometimes the buboes would burst in a shower of the foul-smelling leukocytes called pus. Sometimes the plague would become what a modern epidemiologist would describe as “septicemic” ; those victims would die vomiting blood from internal hemorrhages that formed even more rapidly than the buboes. Those who contracted septicemic plague might have been the fortunate ones; though they all died (bubonic plague kills “only” four to seven out of ten victims, septicemic plague is virtually 100% deadly) they at least died fast. They weren’t tortured with pain for a week or more, nor did they go insane, as thousands of citizens of Constantinople did, leaping into the sea in the hope of ending their suffering.

As a dying body becomes incapable of replacing deoxygenated with oxygenated blood, the muscles surrounding the human voice box become more acid. They go into spasm, and make a characteristic dry, shaking sound. The normal hum of life in Constantine’s city had been overtaken by the sound of a thousand death rattles a day.

* * *

If the first line of defense for a single organism facing attack from the bacterium was the Innate immune system, society’s first responders, then and now, were the city’s doctors.

By Justinian’s day, the profession of medicine was as stratified as the Catholic Church. At the very highest rank were the empire’s court physicians, themselves almost always aristocrats – comites, or counts. Below them on the ladder were the empire’s public doctors, those who were paid by their respective cities for their services, among whom the highest ranking, dating from the early 5th century, were the public physicians of Rome (commanded by law to “honestly attend the poor, rather than basely …serve the rich.” ). Lowest in both status and income were the private practitioners of medicine.

Almost as important as a physician’s position was his educational credential. What Berytus/Beirut was for lawyers, Alexandria was for physicians. There, a four-year course of study was offered by professional teachers of medicine – the iastrophists, who were not merely scholars but indispensable consultants for any complicated case. That the same city should be the port of embarkation for both disease and doctor has an element of irony.

The training that Constantinople’s physicians secured, whether in Alexandria or elsewhere, was largely an immersion in the work of the the 2nd century philosopher-physician Galen, the Mediterranean world’s dominant medical authority for more than a millennium. Galen’s humoral theory of disease was little help in coping with any infectious disease, much less one as virulent as plague, but his disciples were not without resource in caring for the sick. During the 6th century, the greatest physicians of the known world, including Aetius of Amida and Alexander of Tralles (brother of the great architect Anthemius) resided in Justinian’s empire, though not always in his capital (Alexander eventually settled in Rome). Alexander’s pharmacopoeia, and those of his contemporaries, were heavily weighted toward spells, folk remedies, and charms, including the use of gladiator’s blood to treat epilepsy. Cold water treatments had been a popular cure since the founding of the empire – Augustus, particularly, is said to have favored it – and one of the most famous physicians during the reign of Leo, Jacobus, earned his use-name “Psychristus” for his enthusiasm for the treatment as a sovereign remedy. Another clinical tactic much in demand was the treatment of disease by the application of material that had been blessed by a saint, preferably a hermit. These literal “blessings” or eulogia, were frequently no more than dust or red clay that had been touched by a holy ascetic. Others included magical amulets and rings (frequently carrying the image of the biblical King Solomon)

Cold water, saint’s relics, and magic amulets offered only the relief found in placebos, but – like placebos – they were also generally harmless. The same cannot be said of drugs that were known to the physicians of late antiquity, who spent much of their training in their use … though the training was not without its magical components. Galen’s drug categories were based on a mild sort of sympathetic magic; the 7th century physician Isidore of Seville described the theory behind it so: “every cure is brought about either by the use of contraries or by the use of similars. By contraries, [we mean that] a chilling disease is treated with heat or a dry one with moisture…” . But the contraries and similars were frequently powerful alkaloids like the atropine found in mandrake and belladonna, purgatives like copper oxyacetate (verdigris) or the “juice of the opium poppy” all of which were in wide use in 6th century Constantinople. The 7th century Alexandrian physician Paul of Aegina, in contrast, did far less damage, and probably an equal amount of good, with his belief that a homely substance like butter was useful for reducing the swelling caused by the plague’s distinctive buboes.

Clearly, the 6th century pharmacopoeia was of negligible use in treating plague (or in fact, most any infectious disease) though a modern reader must guard against a smugness about primitive medical practices. Physician and author Lewis Thomas, remembering his own medical education in the first half of the 20th century (Dr. Thomas graduated medical school in 1933, and practiced almost until his death sixty years later) writes movingly of the limited therapeutic lessons of the medicine of the day: A doctor’s job, in 1933, was to “diagnose, enlist the best possible nursing care, explain things to the patient and family, and stand by.” In this, he was far closer to the practice of medicine described by Alexander in his 12-volume Therapeutika than to that employed by the time of the Second World War. A modern physician appalled by the use of charms and folk remedies would nonetheless find Alexander’s approach to medicine familiar, particularly his respect for peira, the experience of a clinician willing to try anything that might alleviate the discomfort of his patients…even if sometimes that means using magic charms to treat pain for a patient unwilling to take medicine orally or rectally.

The limitations of the physicians of late antiquity would be shared by their successors well into the twentieth century, for until the discovery of broad-spectrum antibiotics the only weapons available to combat deadly infections were those of the body’s own immune system*. One in three victims – those with a combination of good fortune, strong underlying health, and an uncompromised immune system – survived an infection of bubonic plague during those horrific months. One of them was the emperor himself.

Justinian’s exposure and survival is evidence of both the egalitarian character of the disease’s vector, and the vigorous nature of his body’s defenses. The specific progress of Justinian’s illness is undocumented, but he seems to have escaped the worst of the uncontrollable inflammatory response caused by the disease’s endotoxins. As a result, though he spent weeks on the brink of death (during which time Theodora was effectively ruling the entire empire) and his demise was regularly rumored, he survived, both the disease, and the problematic ministrations of his physicians.

The tools available to those physicians attempting to treat the disease clinically were only slightly less effective than their ability to control its spread. Attempts to treat infectious disease by traditional public health tactics, including quarantine, were in wide use by the 6th century, though problematic in effect; When Bishop Nicholas of Sion banned farmers from entering his town on market days in order to limit the poorly-understood spread of the disease, he was nearly arrested by the municipal authorities who believed he was manufacturing a famine in order to drive up prices. More effective, because more widely available, was the one great medical innovation of late antiquity: the hospital, which evolved from the Christian xenodochia, combinations of treatment centers, hospices, and poorhouses, which spread from their original locations in Judaea during the late 4th Century; to Rome, Ephesus, and (largest of all) the hospitals built and staffed by St. John Chrysostom during his tenure as Bishop of Constantinople.

Justinian himself terminated the state subsidy paid directly to physicians and transferred them to the hospitals, which were by then functioning very like modern medical centers. The largest of them, St. Pantalaimon, had been built on the site of the house occupied by Theodora upon her return to Constantinople and modesty – the place where she spent her last days before meeting Justinian, famously, if legendarily, spinning wool,. But large as Constantinople’s hospitals were, they were overwhelmed within weeks by victims of the demon, for whom they could do little except house them until they were ready for burial.

* * *

On the first hill of the city, at the south end of the Bosporus where Constantinople’s peninsula curls like the bottom of a letter C, stands the Hippodrome, Hagia Sophia, and the Emperor’s palace. From that hill, Justinian and his ministers watched the destruction of their capital. A city the size of Constantinople has a “normal” death rate estimated at thirty a day. Increasing that by two orders of magnitude put a crushing burden on the business of easing the departed on their way to heaven. Fifty years later, Bishop Gregory of Tours would write about the pestilence,

“Since soon no coffins or biers were left, six and even more persons were buried together in the same grave. One Sunday, three hundred corpses were counted in Saint Peter’s basilica [in Clermont] alone.”

This was nothing compared to the problem facing Justinian. In very short order, the existing burial grounds were filled, then every square foot of new ground; gigantic new cemeteries were built across the Golden Horn at Sycae. At the same time, the population that was filling up the graves rapidly overtook the population that could dig them – those who were still healthy, and not spending every waking hour caring for victims. Though burial had always been a family responsibility, Justinian could not ignore the problem, and detailed a minister named Theodorus to find a solution. A Christian city could not contemplate cremation. Instead, Theodorus looked to the walls.

Eighty years after Constantine’s death, when Alaric’s Goths sacked Rome itself, the ministers of the eastern Emperor Theodosius began construction of an immense series of walls that would surround and protect the imperial city from a similar fate. The Walls of Theodosius ran roughly north to south guarding the eastern portion of the city’s peninsula from landward attack, were nowhere less than twenty, and more frequently thirty feet high. Every 180 feet, a square tower sixty feet high was built from which Constantinople’s bowmen could save the city from any barbarian attack. The cemeteries at Sycae were likewise surrounded by such towers, which evidently inspired Theodorus with another idea of salvation. At his direction, Justinian’s troops removed the tops of dozens of the towers, and filled them with the bodies of the dead. “As a result,” Procopius writes, “an evil stench pervaded the city and distressed the inhabitants still more, especially when the wind blew fresh from that quarter.”

The internment of the dead was practically the only occupation that drew the city’s population out into the streets, which were otherwise desolate; as a consequence, the ovens of the city’s bakeries remained unlit. Justinian had constructed dozens of granaries and cisterns as insurance against another Nika Riot, but without bakers to turn wheat and water into bread, his prudence went unrewarded. “Indeed, in a city which was simply abounding in all good things, starvation almost absolute was running riot…” In an epidemic with a direct path of contagion, the lack of human-to-human contact might have exhausted the demon in days. Human starvation, however, did nothing for the rats and fleas except provide them with a huge new source of food.

* * *

As with so many of the events of Justinian’s reign, the most vivid chronicle of the plague’s arrival is that of Procopius, whose greatest talent as a historian may have been the good fortune to be present at the most significant events of his time. This is not to diminish his other abilities, including devotion to accuracy and a clear prose style, consciously modeled on that of Thucydides (despite a pronounced taste for Homeric excess). Nor is it to grant him any sort of consistent impartiality, which is one virtue he failed to exhibit in either his sycophantic record of Justinian’s architectural achievements – On Buildings – or his extraordinarily splenetic catalog of the moral failings of emperor, empress and everyone else, the Anekdota, or The Secret History, which remains the source of most of the stories of Theodora’s salacious past, Antonina’s scandalous lovers, and Justinian’s supernatural wickedness.

In the eight volumes entitled The Wars, however, he approaches the level of his idol, Thucydides, earning a Gibbonesque encomium: “His facts are collected from the personal experience and free conversation of a soldier, a statesman, and a traveler; his style continually aspires, and often attains to the merit of strength and eloquence.” It is in The Wars that his account of the plague appears, beginning with the famous lines:

“During these times, there was a pestilence, by which the whole human race came near to being annihilated. Now in the case of all other scourges sent from heaven some explanation of a cause might be given by daring men, such as the many theories propounded by those who are clever in these matters, for they love to conjure up causes which are absolutely incomprehensible to man… But for this calamity, it is quite impossible either to express in words or to conceive in thought any explanation, except indeed to refer it to God.”

The description of the disease itself is a model of clinical description: Victims “had a sudden fever, [though] the body showed no change from its previous color, nor was it hot as might be expected, but of such a languid sort that neither the sick themselves nor a physician who touched them could afford any suspicion of danger…But on the same day in some cases, the next day in others, and in the rest not many days later, a bubonic swelling developed, and this took place not only in the groin, but also inside the armpits, and in some cases also beside the ears, and at different points on the thighs….There ensued with some a deep coma, with others a violent delirium…who suffered from insomnia and were victims of a distorted imagination. and in those cases where neither coma nor delirium came on, the bubonic swelling became mortified and the sufferer, no longer able to endure the pain, died.”

Compare this with an epidemiology textbook written fifteen centuries later:

“Onset is sudden with chills and rigors and rise of temperature to 102o or 103o …severe, splitting headache and often pain in the limbs, the back and the abdomen. He may curl away from the light, or, as the painful bubo develops, take up some attitude in bed that relieves the pressure on the painful swelling. He becomes confused, restless, irritable, or apathetic, his speech slurred as if drunken [Procopius: “the tongue did not remain unaffected…lisping or speaking incoherently and with difficulty”] he is unable to sleep, sometimes wild or maniacal. He may bleed into his skin, or internally into his stomach or intestine or from his kidney… Within a day or two he is prostrate with all the symptoms of shock. His temperature may come down and he appears better on the third day or so, but this is deceiving; he is worse the next day and dead soon after. Most patients died between the third and sixth day."

But all accounts of the plague are revealing. A lawyer-turned historian from the eastern shores of the Mediterranean, Evagrius Scholasticus, was only a boy in his native Syria when the plague arrived in Constantinople, but nonetheless produced a remarkable account of the demon’s spread during subsequent years, and speaks with the privileged position of one of its victims::

“[The plague] took its rise from Aethiopia, as is now reported, and made a circuit of the whole world in succession, leaving, as I suppose, no part of the human race unvisited by the disease. Some cities were so severely afflicted as to be altogether depopulated, though in other places the visitation was less violent. It neither commenced according to any fixed period, nor was the time of its cessation uniform; but it seized upon some places at the commencement of winter, others in the course of the spring, others during the summer, and in some cases, when the autumn was advanced…at the commencement of this calamity I was seized with what are termed buboes, while still a school-boy, and lost by its recurrence at different times several of my children, my wife, and many of my kin, as well of my domestic and country servants…”

Given the widespread devastation that he reports, to say nothing of the personal injury he suffered at the demon’s hands, one can only call Evagrius’ account remarkably sedate. Though orthodox in his Christianity, his faith’s taste for the apocalyptic perspective was still tempered by the restraint of its Hellenic forebears.

Not, however, everywhere. As early as the “plague” of 251-266, Bishop Cyprian of Carthage could cheer the disease decimating his city with a “Kill them all and let God sort them out” sermon: “How suitable, how necessary is this plague and pestilence…the just are called to refreshment, the unjust are carried off to torture.” By the time of the plague’s arrival in Constantinople and the eastern Mediterranean three hundred years later, one can read:

"In this last millennium, which is the seventh, during which the kingdom of the Persians will be extirpated, the Children of Ishmael will come out of the desert of Yathrib and all come and collect there at Gab ‘ot Ramta…While I beheld these four heads of punishments, Devastation and the Devastator, Destruction and the Destroyer, they cast lots over the land. The land of the Persians was given to Devastation for him to devastate it, sending its inhabitants to captivity, slaughter and devastation; Syria was given to the sword of Devastation, its inhabitants to captivity and to slaughter; Sicily was given to Destruction and the sword, and its inhabitants to captivity and to slaughter; the Roman empire was given to Devastation and its inhabitants to captivity and to slaughter…”

Perhaps the most revealing account of the plague is that of John of Ephesus, a Syrian-speaking member of a monastic order who was a professed Monophysite, and in consequence a frequent refugee from waves of persecution whenever orthodox leaders were in positions of authority in Constantinople. At other times, particularly during the ascendancy of Theodora whose favorite he was, he enjoyed very high status indeed, even rising to a bishopric at Ephesus in Asia Minor. By his own no doubt exaggerated accounting, he was personally responsible for baptizing more than 70,000 former pagans living on the Anatolian plateau, he has been not inaccurately described as “a writer whose zeal exceeds his elegance,”

His Ecclesiastical History, of which only fragments have survived, contains by far the longest, and most apocalyptic, of the contemporaneous account of the plague. Comparing John to Procopius is an object lesson in the relative importance of prophecy over fortune:

“Thus, over these things the prophet [In this case, the author of the Book of Lamentations] might weep and say, ‘Woe upon me not because of the destruction of the daughter of my people, but because of the desolation of the entire habitable earth of humanity, which has been corrupted by its sins; and because the world in its entirety has already been made desolate for some time and has become empty of its inhabitants.”

and the preemption of the natural by the supernatural

“When this plague was passing from one land to another, many people saw shapes of bronze boats and (figures) sitting in them resembling people with their heads cut off. Holding staves, also of bronze, they moved along on the sea and could be seen going whithersoever they headed. These figures were seen everywhere in a frightening fashion, especially at night. Like flashing bronze and like fire did they appear, black people without heads sitting in a glistening boat and traveling swiftly on the sea, so that this sight malmost caused the souls of the people who saw it to expire.”

John’s chronicle reads, to a modern, like an unlikely combination of clinical accuracy and apocalyptic imagery. To his contemporaries, however, the missionary’s willingness to describe suffering on its own terms, rather than as a way to salvation is a pure expression of Monophysitism. To John – to many Monophysites – the argument that no distinction could be made between the human and divine attributes of Jesus was more than just a bit of empty theologizing. It also demanded a respect for a pragmatic understanding of disease. The demon killed and disfigured, not as evidence of God’s displeasure, but because all of reality is embraced in the Monophysite world . Perhaps for that reason, one of the more distinctive tropes of John’s Chronicle is its strained attempt to discover a silver lining around the pestilential cloud:

“Although [the plague] was very frightening, grievous, and severe, it would not be right for us to call it not only a sign of threat and of wrath, but also a sign of grace and a call to repentance. For the scourge…by its silence sent as it were numerous messengers from one country to another, and from city to city and to very place, just as if somebody were to say, ‘Turn back and repent…for behold I am coming…

“As in the days of Noah, when that blessed man together with his family heard the message of the threat and of perdition, he grew afraid, and did not disregard it but took care to build the ark…So also in this time in like manner as did that blessed man, many people managed in a few days to build ships for themselves consisting of almsgiving, that these might transport them across that flood of flame.”

Whatever his perspective, John’s eye for the telling detail is very real, indeed: Once the plague arrived in Constantinople, “nobody,” he wrote, “would go out of doors without a tag upon which his name was written and which hung on his neck or his arm” …a means of identification in case he died suddenly. One can, perhaps, imagine the grotesquerie of a mass grave so full that the living needed to march on top of layers of the dead in order to press the corpses more efficiently into the available space. John wrote,

“How can anyone speak of or recount such a hideous sight, and who can watch this burial, even though his soul should remain in his body and not waste away from bitter lamentations over so much iniquity which would suffice to destroy the children of Adam? How and with what utterances, with what hymns, with what funeral laments and groanings should somebody mourn who has survived and witnessed this ‘wine-press of the fury of the wrath of God?*’”

(c)William Rosen, 2007