Τreatment of rheumatic diseases in the Eastern Roman (‘Byzantine’) Empire

Many Byzantine doctors, who had been influenced by the authors of ancient Greece, have considered rheumatic diseases in their works. In almost all the centuries of Byzantine medicine you can find texts dealing with topics related to rheumatism. There are references already in the early days by Dioscorides Pedanius (1st century AD) and of Rufus of Ephesus (2nd century AD).

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During the first period of the Byzantine era, Oribasius (IV-V century AD) reports exhaustive and interesting observations on rheumatological issues, repeating at large, however, concepts already transmitted in previous centuries. In the 5th century AD also Iakovos Psychristos makes precise references of character rheumatology.

Moreover, important observations can be derived from the works of Alexander of Tralles (VI century AD), of Aëtius of Amida (VI century AD), by Paul of Aegina (7th century AD) and of Leon Iatrosofistes (IX century AD).

Further, the works of Theophanes Chrysobalantes have been recovered, better known as Theophanes Nonnus or Nonnos (10th century AD), of Simeon Seth and of Michael Psellus (XI century A.D.).

In the 12th century A.D. Theodore Prodromos complete a summary with all the notions reported up to that time on rheumatism. In 13th century A.D. interesting ideas are contained in the works of Nicolaos Myrepsos and Demetrios Pepagomenos, who was the personal doctor of the emperor Michael VIII Palaeologus (1261-1282) and wrote a fundamental text on gout. Towards the end of the 14th century A.D. the important comes to light by Johannes Zacharias Actuarius.

All authors so far cited followed the Hippocratic theory of the moods/humors (phlegm, black bile, yellow bile, blood), on which they base the pathogenesis of rheumatic diseases.

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Frequency of Rheumatics diseases in Byzantium 

In general, much importance was given to rheumatic pathologies, because it seems that the frequency of these in the Byzantine population was rather high. They were often called the “disease of the diplomats”, and this is because some of them used it as a pretentious cause of disability in case they were forced to move for their work or other reasons. An emblematic example is that of Phillocalis, an important Byzantine diplomat and son-in-law of the emperor Alexius V Ducas (13th century AD), who, in order to avoid a transfer, pretended to suffer from a debilitating form of arthritis.

Even in the peripheral regions of the Byzantine Empire numerous cases of gout are reported. The bishop of Alexandria Dionysius (III century AD) describes a case where a disabled person due to rheumatism was unable to appear at court to answer of the charges that had been made against him.

Byzantine literature reported 14 cases of emperors who suffered from rheumatic disorders.

Despite the lack of objective epidemiological data on the frequency of rheumatic diseases in Byzantium, the fact that 14 out of a total of 86 emperors (16%), who, despite not having any type of kinship between them, suffered from similar diseases – and this over a very long period of time (324-1453 AD) – shows that the high frequency of rheumatism in the population must have been an objective fact.

So much that the historian Ioannis Zonaras (XI century AD) defines this type of diseases as very frequent. Apart from the historical references on the emperors who suffered from rheumatic disorders and this testimony of Zonaras, there also exists an earlier one by the historian Theophylact of Simocatta (VI century AD), that refers to the in question inhabitants of Constantinople as “These poor and without future”, who often suffered from gotta. Nicephorus Callistus agrees on this.

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General theories on Pathogenesis of Rheumatic diseases

Over the centuries the theories proposed by Byzantine doctors on the pathogenesis of rheumatic diseases do not present any substantial variation, given that all authors agree that the main cause is the obstruction of circulation of phlegm or bile. Several then gave an importance to the chronology of appearance of the joint symptoms.

According to many, the most critical period would be the summer, the season that is accompanied by epidemics and fevers, and then spring and the autumn. Most authors are of the opinion that the intake of large quantities of wine and malnutrition can result to the onset of the disease. Almost all the Byzantine doctors emphasize on the role of inheritance. One of the fathers of the Byzantine church, John Chrysostomus, who often refers to several diseases in his works, claims that other causes of rheumatic diseases are the food excesses, the sedentary life, as well as intense sexual activity.

Leon Iatrosofistes attempted to group and classify the various types of arthritis then known, and supported that the disease presents itself “when the phlegm or bile builds up in the joints”. If the mood/humor thickens in all its joints the body has arthritis, if only in the lower extremities gout, if it accumulates only in the hip, sciatica occurs.

The Byzantine authors often refer to the theory of Hippocrates, that arthritic diseases are due to morbid substances found in the blood that, when concentrated, induce exacerbations.

Aëtius of Amida believes that the main cause is the presence of moods/humors that are not completely digested. Moreover, as possible causes, he reports inadequate nutrition, constipation, and the great quantity of humours. To these causes he adds also excessive sexual activity and sedentary life. Nicolaos Myrepsos introduces the inheritance hypothesis, as John Choumnos also claims. Oribasius considers these diseases such as acute inflammation of spontaneous origin, in the absence of cardiac symptoms (as precordial pain) and without apparent causes.

On Rheumatisms

Most authors agree on the important and aggravating role that humidity and the various seasons have (summer, spring and autumn). Undergoing many baths is referred to as another aggravating cause. According to Nicolaos Myrepsos the pathology of humours is also very important. Alexander of Tralles blames it on a pathological metabolism mood/humor, with subsequent storage in the joints. Aëtius of Amida argues that rheumatism is a type of inflammation, and for this it uses the term “rheumatic inflammations”, which are aggravated with humidity, during the autumn and after the baths. He adds also the migrant character of joint diseases, describing that they move from the knees to the hip. In addition, he also provides summary indications of epidemiology, observing that some sufferers suffer from a severe form while others from a mild form.

On deformant chronic Arthritis

Aëtius of Amida describes the bad prognosis and evolution of the disease, reporting the migrating character of this type of arthritis and deformities of the fingers it causes.

On the Gotta

The term “gotta” is already used from Hippocrates (as ‘ποδάγρα’ – ‘podagra’). Demetrios Pepagomenos and Alexander of Tralles refer to it also as “podagra”. Aëtius of Amida states that when the disease affects the upper limbs is defined “Chiragra”. Johannes Zacharias Actuarius qualifies patients as”Podagrici”. Nicolaos Myrepsos reports the terms “ποδαγρικός” or “ποδαλγικός”, underlining that the critical phase of the disease corresponds to the beginning of exacerbation. The conceptions of Hippocrates related to the fact that morbid substances are humoral in nature and exacerbations occur during spring and autumn, are taken for granted in the works of the Byzantine authors. Theodore Prodromos believes that the disease is due to a bad diet that makes the phlegm more fluid and causes inflammation of the bile.

Alexander of Tralles attributes gout to accumulation of blood in the joint cavity, made that it would cause pain and a burning sensation. The same what would happen, according to Alexander of Tralles, for the accumulation of bile between the nerves and ligaments. The bile mood/humor is hot, and if present in quantity higher than normal, it causes intense pain. The author also highlights the difficulties in gout therapy.

Paul of Aegina considers the accumulation of pathological mood/humor in the joints, in nerves and ligaments as a cause of gout. This accumulation can be bilious in nature or sanguine. The color of the overlying skin of the affected joint can be whitish, yellowish or reddish, depending on the type of mood/humor that accumulates. According to the author, the way of living is very important not only for the prognosis of disease, but also for its diagnosis.

Aëtius of Amida suggests the presence of great amount of badly absorbed and metabolized humors as a cause of illness, and gives some special information on the migrant nature of the disease, that would move from one joint to another. As causes of gout, he reports heredity, way of living, especially sexual activity, a sedentary lifestyle and constipation.

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On the therapy of Rheumatisms

The goal of therapy was to move away pathological mood (rheumatic) from the joints, to relieve pain. In most of the cases phlebotomy was practiced, purification practices, physiotherapy, sun exposure, the appropriate diet, and substances were administered antirheumatic and antidotes. The drugs that were used to remove the rheumatic mood they had a diuretic effect.

On deforming Arthritis therapy

It includes diet, physiotherapy and drugs, such as in the case of joint rheumatism and gout.

On the therapy of Gotta

In general, the therapy would consist in trying to reduce excess mood/humor and increase its expulsion from the body, so the joint can be freed from inflammation and from ache. The expulsion of the mood could be practiced by various methods, such as bleeding.

Much importance was given to the diet both in terms of prevention and of therapy. Oribasius prohibits the meat, wine and grass pea. Aëtius of Amida, in turn, offers easily digestible foods, consumption of few liquids and a sputum-based poultice, soda, fennel, common firrastrina and myrrh. He does not recommend the consumption of foods that lead to production of harmful moods/humors, such as spleen, brain and other viscera, while proposing a diet based on legumes, vegetables, chicken, fish and fruit. Moreover, he suggests inducing vomiting before meals. Alexander of Tralles proposes a diet based on vegetables, chicken or pheasant, fish and legumes. Aëtius of Amida and Alexander of Tralles consider that certain forms of gymnastics (like the so-called “swing”) are useful in relieving pain, while John Choumnos adds “alternative” therapies to horse riding, walks and physical exercise.

Gastrointestinal therapy, based on colchic acid and other products, practiced by Byzantine doctors yielded remarkable results. According to these authors, with the treatment we had a rapid and important improvement of pain symptoms and inflammation, as well as increased mobility of the affected joint.

Conclusions

All the notions concerning rheumatic diseases, that had already been formulated since ancient Greece, have been taken and enriched by Byzantine doctors. The tendency is perceived in their works to explain the causes of the disease, and to inform the population on common themes (for example, on living and eating healthy), while focusing their therapeutic approaches having as a reference the Hippocratic theory of humors. From the works of Byzantine physicians it is noted that rheumatic diseases were widespread.

(Source: “Theories and cures of the rheumatic diseases during the byzantine period (330-1453 a.D.)”, by C. Tsiamis et al.)

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Research-Selection-Translation (original article in Italian) for NovoScriptorium: Anastasius Philoponus

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