Reminiscence

Did Justinian the Great (527–565 CE) suffer from syphilis?

John Lascaratos, MD, PhD, and Effie Poulakou-Rebelakou, MD

From the Department of the History ofMedicine, University of Athens,Greece

CorrespondenceJohn Lascaratos, MD, PhD

Hippocratous 164b str.Athens 11471Greece

Introduction The ‘‘syphilis’’ of Justinian

Justinian the Great (527–565 CE, Fig. 1) was one of the The silence of the sources concerning the cause of the

most cultured and learned emperors of his era, with a wide Emperor’s death gave rise to Korbler’s theory which main-

range of political aims. The restoration of a universal tained that he died from syphilis.5 The writer inclines to

Roman Empire, a constant dream of Byzantium, was the opinion of those who believed that syphilis was arealized during his reign. After successful battles, Justinian disease which had first appeared in antiquity as an endemicoccupied the kingdoms of the Vandals and Ostrogoths in entity, continuing into the medieval period. In the caseAfrica and Italy respectively, and the lands of the Visigoths of Justinian, Korbler5 believes that the Emperor’s wifein Spain. After his campaigns, the Mediterranean was once Theodora contracted syphilis from her activities over manymore a Roman lake, because the greater part of north years in brothels (lupinaria) in different cities of the east,Africa, part of Spain, Italy, and the Mediterranean islands before she had met Justinian. It is known that Theodora’swere brought under the scepter of the Roman Emperor of father, Acacius, was a tamer of wild beasts at the circusConstantinople. In the east, a peace treaty was signed with and forced two of his daughters, Comito and Theodora,the Persian king, Chosroes I. Despite his occupation with into begging and prostitution. Theodora, especially, carriedwar, Justinian devoted time to matters of internal adminis-

out theatrical presentations similar to tableaux vivants.tration, to ensure domestic peace, crushing the fearsome

The historian Procopius,6 in his ‘‘Secret History,’’ gives‘‘revolt of Nika’’ which broke out against him in

scandalous details about Theodora’s life before she marriedConstantinople in 532. At the same time he expanded

Justinian, revealing that frequent feasts comprising all-trade, especially in silk, with the far eastern states of China

night orgies with ten or more young men were held toand India and introduced and developed the silk industry

satisfy her lust, the result being that she was constantlyin his empire. Concurrently, he codified the Roman law,

pregnant and endeavored to terminate these pregnanciesthe most notable achievement of his reign. From his epoch

by various means. The same historian6 discloses that, whendated the famous Codex Justinianus, the Pantects, and the

she could not terminate one pregnancy with abortion, sheInstitutes, collections of laws comprising the famous Corpuswas obliged to give birth to a boy, named John, whoseJuris Civilis Justinianis which, until very recently, was onewhereabouts became unknown after she became Empressof the main elements in the codes of all European countries.(the historian suggests that she was behind his disappear-On his death (14 November 565), after a reign of 39 years,ance). Korbler,5 in the light of these accounts, maintainshe left his successors a great empire with expanded frontiers,that Justinian, a short time after his acquaintance withbut economically and financially exhausted, due to con-Theodora, whom he had met in a brothel, contractedtinuous wars.1

a venereal disease from his future wife, most probablyThe cause of his death is not known and different

gonorrhea and/or syphilis, from which both later died.Byzantinologists simply refer to the fact that he died at a

This theory is based upon the symptoms which weregreat age, 83 years old,2–4 which obviously is most unusual

for that epoch. presented in a hagiographic text (which is not indexed in

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788 Report Did Justinian the Great suffer from syphilis? Lascaratos and Poulakou-Rebelakou

Figure 1 Justinian among members of his court (mosaic of

St. Vitalius, Ravenna, 547 CE)

his bibliography). The text writes that, ‘‘a severe disease

afflicted Justinian in his genital organs and presented an

incurable ulcer in the bladder.’’ At that time, many physi-

cians were summoned to cure the patient’s condition but

could offer no solution and the disease was treated by a

miracle of St. Sampson. Korbler5 supposes that this disease

was gonorrheal or saprophytic urethritis, which was

obviously cured without any treatment. Furthermore, the

writer5 maintains that, ‘‘in the 23rd or 24th year of

Justinian’s reign he suffered from a disease of his legs,

perhaps an oedema or gummas accompanied with dysuric

problems,’’ and propounds the theory that these symptoms Figure 2 Empress Theodora (detail of a mosaic ofwere due to syphilis which the Emperor had been infected St. Vitalius, Ravenna, 547 CE)

with by the Empress, who meanwhile had died. The disease

of the legs, according to Korbler,5 was supposed to have

been treated with the help of Saints Cosmas and Damien known that Procopius, to whom all this information is

attributed, was prejudiced against her, for unknownand the dysuria with the drinking of water from the spring

of the Monastery of Zoodochus Pege. Finally, the problems reasons.4,7 Therefore, he does not recognize in his work

that the life of Theodora was morally irreproachable afterof senility and mental incapacity which are referred to by

Nicolaus Alemannus, the first editor of the ‘‘Secret History’’ her marriage.8 Procopius did not dare to write anything

against the Imperial pair in his official works, except inof Procopius (1623), are ascribed by Korbler5 to neuro-

syphilis. Further, the death of Theodora (548 CE) was also the ‘‘Secret History’’ for private circulation rather than

publication,4 which circulated much later, after the deathattributed to a syphilitic attack of the glands of the breast

and to a further attack of her body of rupial syphilid type.5 of both the Emperor and its writer. There are such differ-

ences of opinion concerning Justinian and Theodora in his

official work and in the ‘‘Secret History’’ that historiansReassessment of Korbler’s theory

for a long period of time after the discovery of the latter

manuscript did not believe that this was the work ofA new evaluation of the historical sourcesIt is well known that Theodora’s life was immoral before Procopius.7 Independently of this, the fact remains that

Justinian married a prostitute and the theory of Korblerher marriage and she had indeed performed in the theater

of the hippodrome and then worked in the brothels of the should be examined in the light of a new evaluation of the

historical sources.east,6 especially in Alexandria. Further, it is known that,

when she was going to marry the Imperial heir Justinian

(523 CE) the Emperor Justin I abolished the law which The diseases of the Empress TheodoraProcopius,6 describing the Empress’ appearance during herprohibited marriage between members of the senatorial

(ruling) class and prostitutes. On the other hand, it is also last years, wrote that the earlier beautiful and cheerful face

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Lascaratos and Poulakou-Rebelakou Did Justinian the Great suffer from syphilis? Report 789

of Theodora showed paleness; furthermore, an expression

of fatigue and melancholy was apparent in her contempor-

ary portrayals, such as in the famous mosaic in the Church

of St. Vitalius in Ravenna (Fig. 2).9 The same historian6

implied that Theodora had a serious fatal chronic disease,

when he wrote, some years before her death, that the

imminence of death did not result in the improvement of

Theodora’s character, as she never lost her fury against her

fellow men.

The African Bishop Victor Tonnennensis,10 contempor-

ary of the Empress, confirms in his ‘‘Chronicle’’ that

Theodora died of breast cancer which had metastasized all

through her body: ‘‘Theodora Augusta Calchedonensis

Synodi inimica canceris plaga corpore toto perfusa vitam

prodigiose finivit.’’

This opinion is today widely accepted2,11,12 as it is

apparent that the condition was known to the Byzantine

physicians and was difficult to confuse with other illnesses.

The Byzantine physicians Aetius13 (sixth century) and Paul

of Aegina14 (seventh century) knew well the existence of

breast cancer and considered it to be the most usual form

of cancer, together with that of the womb. They also

describe techniques of removing this kind of tumor (local

and total removal of the breast). The first eminent Byzantine

physician, Oribasius15 (fourth century), recommended only

conservative treatment. Thus, in the era under considera-

tion, it must be regarded as certain that the physicians of

the palace knew the condition well and were able to

recommend surgical treatment. The lack of relevant evid-

ence in the historical sources indicates that Theodora’s Figure 3 Justinian in advanced age (a mosaic ofcancer belonged to the inoperable type which her contem- St. Apollinarius, Ravenna, sixth century)

porary, Aetius,13 sets out clearly in his text (tight attachment

of the tumor to the thorax; thus making removal of

the diseased breast from the healthy area a dangerous means of endoscopy, the ulcer of the bladder could only be

supposed from the symptomatology. The eminent Byzantineoperation).

physician, Leo21 (ninth century) makes clear that ‘‘ulcers

appear in the bladder when patients have dysuria (urinateThe diseases of JustinianThe first disease of Justinian was, in Korbler’s5 opinion, with pain).’’ The symptom of dysuria obviously coincided

with the undisclosed disease of the genitals referred to ingonorrheal or saprophytic urethritis. These diseases,

according to Grmek,16 are ancient. Brondy17 believes that the previous text.

Another text, however, unknown to Korbler, reveals ingonorrhea was mentioned in the Bible and described by

Hippocrates (fifth century CE), Celsus (first century CE), detail the disease of Justinian and its therapy. It is written

by the great ecclesiastical writer Nicephorus Callistusand Galen (second century CE), but other historians18 do

not agree with him, because instances of urethritis and Xanthopoulos (fourteenth century),22 who undoubtedly

obtained his information from earlier sources. Nicephorusvulvovaginitis produced by the gonococcus can also be

produced by other germs. Other writers recognized in states that the disease of Justinian was ‘‘a lithiasis of

the bladder due to his unhealthy diet and fatigue.’’ Thethe Hippocratic treatises parasitic, mycotic, or bacterial

leukorrhea.16 Urethritis was an ancient disease, independ- condition, according to the writer, ‘‘caused dysuria, that

is, difficulty in urinating and pain, and the Emperor’sent of its exact etiologic agent.16 In spite of this, the first

disease of Justinian does not seem to be urethritis. The physicians could not cure his unbearable pains’’ (obvious

colics). Nicephorus adds that Justinian saw the Holybiography of St. Sampson,19,20 on which Korbler’s theory

is based, refers to an ulcer of the bladder and an undisclosed Mother in his sleep and she advised him to drink large

quantities of water from the spring of her monasterydisease of the genitals. As the Byzantine physicians had no

© 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 787–791

790 Report Did Justinian the Great suffer from syphilis? Lascaratos and Poulakou-Rebelakou

(Zoodochus Pege). Indeed, this therapy brought about the works.26 The condition troubled Justinian and frequently

break-up and dissolution of the stone which was excreted he had recourse to the assistance of the Saints.26 The two

with urine and the Emperor was cured.22 This text leaves conditions, gout and lithiasis of the urinary tract, coexist

no doubt that Justinian’s condition was lithiasis of the in between 25% and 50% of cases, according to differing

bladder which was treated with systematic hydroposia. statistics.27

The second disease of Justinian, that of ‘‘his lower leg The information that Justinian had symptoms of senility

edema or nodes and further dysuric problems,’’ Korbler5 is not evidenced by contemporary historians but is referred

ascribes to syphilis. The question of the origin of European to much later (1623). There is no remarkable information

syphilis is not new, but it continues to interest and divide about the state of the Emperor in his last days (Fig. 3).

medical historians.16 Thus, while in earlier days scholars Stein2 remarks on his general feebleness accompanied by

seemed to accept the belief of those who held that syphilis headaches after 560. Rubin28 also observed that he showed

was imported into Europe by Columbus’ sailors as late as curious behavior near the end of his life and Browning4

the last decade of the fifteenth century, no eminent special- maintains that ‘‘without any signs of illness, Justinian

ists are proposing biological arguments in favor of historical suddenly died.’’ Finally, only Korbler,5 without evidence,

speculations that the disease was distributed throughout writes that he had such symptoms of senility during his

the world at a very early date. In Hudson’s23 opinion, the last years that his wife Theodora for some time undertook

disease had started in Paleolithic times as an endemic form his duties. Thus, even if we accept Korbler’s hypothesis that

and had been transformed to venereal syphilis in many the 83-year-old Emperor presented symptoms of senility at

places at various times whenever rural life became urban- the end of his life, it would be excessive to believe that these

ized. Endemic and venereal forms must have coexisted in alone were indications of parenchymatous neurosyphilis

Mesopotamia and Egypt starting between 4000 and (paresis). No other symptom (grandiose ideas, megalo-

6000 BC, and in Greece at about 900 or 800 BC. Endemic mania, delusions, and hallucinations),24,29 consistent with

syphilis, according to this theory, spread into Western this kind of neurosyphilis, is evidence by any historical

Europe during the Roman period and was present there source, nor any symptom of any other type of neurosyphilis.

throughout the Middle Ages. This hypothesis, based on

biological and sociocultural criteria, is not confirmed by

osteoarcheologic finds; no trace of syphilis has been found Conclusionson the ancient bones exhumed in Greece and its vicinity.16

The Byzantine Emperor Justinian the Great, according toThus, Grmek16 believes with certainty that syphilis did notthe theory of Korbler, suffered from venereal diseases andexist in the ancient Greek world, in contrast with leprosyespecially from gonorrheal or saprophytic urethritis andand tuberculosis. In spite of this conclusion, however, thesyphilis having been infected by his wife, Theodora, whotwo opposing theories, that of an autochthonous origin ofhad been a prostitute; this latter disease was supposed toEuropean syphilis and that of an American origin, havebe the cause of the death of the Imperial couple. Analysistheir own supporters and arguments; thus, the theory ofof the existing Byzantine historical sources reveals that, inKorbler ought to be re-examined by a new estimation ofall probability, Theodora died from cancer of the breastthe Byzantine historical sources.and Justinian presented lithiasis of the urinary tract andFirstly, it must be noted that the later dysuric problems

gout which caused him dysuric problems and a number ofof Justinian could be attributed to the new formation of

crises of pain in one knee, all conditions well known tostones in his urinary tract, as there had been a precedent.

contemporary Byzantine physicians and widespread inThe ‘‘disease of the legs’’ was not correlated by Byzantine

Byzantium.historians with edema or nodes which Korbler5 supposed

to be syphilitic gummas. In addition to the fact that

gummas, typical of tertiary syphilis, usually occur 3–5

years after the infection24 (and not more than 28 years Referenceslater, as Korbler supposed in Justinian’s case) Procopius25

1 Ostrogorsky G. History of the Byzantine State. London:states clearly that the Emperor suffered from repeated

Blackwell, 1986: 69–78.crises of pain which were located in his knee. He notes the

2 Stein E. Histoire du Bas-Empire, Vol. II. Paris: J-Rsingle arthritic location of the disease in one knee and the

Palanque, 1949: 589, 777–780.strict diet (water and wild grasses) which was given by the 3 Grierson P. The tombs and obits of the ByzantineEmperor’s physicians, including avoidance of wine,25 which Emperors (337–1042). Dumbarton Oaks Papers 1962;Byzantine doctors recommended for patients suffering from 16: 46.

gout.26 This disease was widespread in Byzantium and thus 4 Browning R. Justinian and Theodora. London: Thames

and Hudson, 1987: 165–178.well known to physicians who describe it in detail in their

International Journal of Dermatology 1999, 38, 787–791 © 1999 Blackwell Science Ltd

Lascaratos and Poulakou-Rebelakou Did Justinian the Great suffer from syphilis? Report 791

5 Korbler J. Die Krebserkrankung der byzantinischen 18 Vertue HSH. Inquiry into venereal disease in Greece and

Rome. Guy’s Hosp Rep 1983; 102: 277–302.Kaiserin Theodora (Ein Beitrag zur Geschichte der

Syphilis). Janus 1974; 61: 15–22. 19 Anonymous. Vita S. Sampsonis. In: Migne JP, ed.

Patrologia Graeca, Vol. 115. Paris: Turnhaut, 1864:6 Wirth G, Haury J, eds. Anecdota (Historia Arcana). In:

Procopii Caesariensis Opera Omnia, Vol. III. Lipsiae: 283–284.

20 Halkin F. Saint Samson le xenodoque de ConstantinopleBG Teubner, 1963: 56–68, 107–108.

7 Hunger H. Byzantine Literature, Vol. 2. Athens: Cultural (VIe siecle). Rivista di Studi Bizantini e Neoellenici

1977–1978; 14–16: 5–17.Foundation of the National Bank, 1992: 81–82.

8 Mantellou P. The personal life of Theodora before her 21 Ermerins FZ, ed. Leonis Philosophi conspectus

medicinae. In: Anecdota Medica Graeca. Amsterdam: Amarriage with Justinian, according to Procopius’

Anecdota. Byzantine Studies 1990; 2: 330–339. Hakkert; 1963: 193.

22 Pamperis A, ed. Nicephori Callisti Xanthopouli about9 Galavaris G. Early Byzantine art. In: Christopoulos J, ed.

History of Hellenic Nation, Vol. 7. Athens: Ekdotike the Zoodochus Pege in Constantinople and its Miracles.

Constantinople: Pamperis, 1802: 14–15.Athenon, 1978: 390–391.

10 Mommsen T, ed. Victoris Tonnennensis episcopi 23 Hudson EH. Treponematosis and man’s social evolution.

Am Anthrop 1965; 67: 885–901.Chronica. In: Monumenta Germaniae Historica, Vol. II.

Berolini: Weidmann, 1894: 202. 24 Arnold HL Jr, Odon RB, James WD, eds. Andrews’

Diseases of the Skin. Clinical Dermatology, 8th edn.11 Diehl C. Figures Byzantines. Paris: A Colin, 1908:

51–52. Philadelphia: Saunders, 1990: 405–422.

25 Wirth G, Haury J, eds. De Aedificiis. In: Procopii12 Nicol D. A Biographical Dictionary of the Byzantine

Empire. Athens: Hellenic Euroekdotica, 1993: 124. Caesarensis Opera Omnia, Vol. IV. Lipsiae: BG Teubner,

1964: 32–33.13 Zervos S, ed. Aetii Sermo Sextidecimus et Ultimus.

Leipzig: A Mangkos, 1901: 60–68. 26 Lascaratos J. ‘‘Arthritis’’ in Byzantium (AD 324–1453):

unknown information from non-medical literary sources.14 Briau R. Chirurgie de Paul d’Egine. Paris: V Masson,

1855: 210–213. Ann Rheum Dis 1995; 54: 951–957.

27 Wyngaarden JB. Gout. In: Wyngaarden JB, Smith LH, Jr,15 Raeder I, ed. Oribasii Collectionum Medicorum

Reliquiae, Vol. IV. In: Corpus Medicorum Graecorum. Claude Bennett J, eds. Cecil Textbook of Medicine,

19th edn., Vol. I. Philadelphia: W Saunders, 1992:Lipsiae et Berolini: BG Teubner, 1933: 299–300.

16 Grmek MD. Diseases in the Ancient Greek World. 1107–1115.

28 Rubin B. Das Zeitalter Justinians, B.1. Berlin: W deBaltimore and London: The Johns Hopkins University

Press, 1989: 133–151. Gruyter, 1960: 93–98.

29 Rook A, Wilkinson DS, Ebling FJG, et al., eds. Rook,17 Brondy ML. The history of gonorrhea among the Greeks

and Romans. Trans Am Neisser Med Soc 1937; 3: Wilkinson, Ebling Textbook of Dermatology, 4th edn,

Vol. 1. Oxford: Blackwell, 1986: 839–859.92–106.

From the collection of Lawrence Charles

Parish, MD, Philadelphia, Pennsylvania.

© 1999 Blackwell Science Ltd International Journal of Dermatology 1999, 38, 787–791