Walking Corpses: Leprosy in Byzantium and the Medieval West

By Timothy S. Miller and John W. Nesbitt

In Walking Corpses, Timothy S. Miller and John W. Nesbitt contextualize reactions to leprosy in medieval Western Europe by tracing its history in Late Antique Byzantium, which had been confronting leprosy and its effects for centuries.

Integrating developments in both the Latin West and the Greek East, Walking Corpses challenges a number of misperceptions about attitudes toward the disease, including that theologians branded leprosy as punishment for sin (rather, it was seen as a mark of God's favor); that Christian teaching encouraged bans on the afflicted from society (in actuality, it was Germanic customary law); or that leprosariums were prisons (instead, they were centers of care, many of them self-governing). Informed by extensive archival research and recent bioarchaeology, Walking Corpses also includes new translations of three Greek texts regarding leprosy, while a new preface to the paperback edition updates the historiography on medieval perceptions and treatments of leprosy.

• Language: English
• Publisher: Cornell University Press
• Release date: May 15, 2023
• ISBN: 9781501770852

Book preview

Cover: Walking Corpses, Leprosy in Byzantium and the Medieval West by Timothy S. Miller and John W. Nesbitt

WALKING CORPSES

Leprosy in Byzantium and the Medieval West

TIMOTHY S. MILLER AND JOHN W. NESBITT

CORNELL UNIVERSITY PRESS

ITHACA AND LONDON

For Vicki and Carla

CONTENTS

Preface to the Paperback Edition

List of Illustrations

Preface and Acknowledgments

Introduction

1. The Ancient World

2. Leprosy in the Byzantine Empire

3. Byzantine Medicine

4. Byzantine Leprosariums

5. Leprosy in the Latin West

6. Leprosariums in the Latin West

7. The Knights of Lazarus

Conclusion

Appendixes

1. Aretaios of Cappadocia, On Acute and Chronic Diseases (Books IV.13 and VIII.13)

2. Gregory of Nyssa’s Oration, Regarding the Words As much as you have done for one of these, you have done for me (Matt. 25:40)

3. Selection from The Funeral Oration in Praise of Saint John Chrysostom (Chapters 60.17 to 67.1)

List of Abbreviations

Notes

Bibliography

Index

PREFACE TO THE PAPERBACK EDITION

When Walking Corpses first appeared in 2014, the Library of Congress cataloguers designated it as RC 153.5—Internal Medicine: infectious and parasitic diseases. As a study on ancient and medieval medicine, it did, in fact, discuss a particular infectious disease, an illness the ancient Greek physicians and their Byzantine heirs called elephant disease or elephantiasis and medical experts of the Latin West labeled lepra (leprosy), what modern physicians call Hansen’s disease. Medical history, however, by its very nature transcends the world of diseases and their therapies to address political, social, economic, and religious aspects of the human environment as well.

In writing The Private Science of Louis Pasteur, for example, Gerald L. Grison not only followed the progress of Pasteur’s meticulous experiments, but also placed the famous scientist’s labors in the context of Louis Napoleon’s French nationalism and the bitter intellectual confrontations between Catholics and secularists in nineteenth-century France.¹ Historians like Grison enjoy a unique vantage point in that they are able to view both the theory and practice of medicine within the wider context of a given place and time of the human experience.

In the case of Walking Corpses, its most significant contribution to our understanding of medieval society did not deal with infectious leprosy but with the leprosariums, the group homes supported by Christian bishops, monastic leaders, and generous lay people from the mid-fourth century until the beginnings of the Renaissance. These institutions provided victims of Hansen’s disease with a place to live, to share meals together, to pray, and to receive some palliative care for their illness. What Walking Corpses demonstrated for the first time was that the leprous residents of most leprosariums, both men and women, governed their institutions through their right to assemble at least once a week in chapter meetings and to approve all major decisions affecting their group homes. Moreover, they often enjoyed exclusive control over the financial resources of these leprosariums. Only two reviewers of Walking Corpses commented on these extraordinary rights of self-government.²

In this preface we will review what we discovered about leprosarium governance and administration as well as introduce new information on the origins of this spirit of self-governance. Surprisingly, the origins of leper democracy come not from the High Middle ages, the period from which we have the most extraordinary examples of political organization on the part of lepers who resided in Latin Europe’s many leprosariums, but from the very beginnings of Christian concern for victims of elephant disease, fourth-century Asia Minor. This precocious spirit of democracy was strengthened by the force of law when first the emperor Anastasios (491–518) and subsequently the Emperor Justinian (526–565) issued two imperial decrees that were included in the Corpus juris civilis, laws regulating legal acts performed by leprosariums and other philanthropic institutions.³

We first noticed the remarkably democratic nature of leprosarium government in analyzing the statutes or rules of the leprosarium of Brives in south-central France. The version of these statutes drafted in 1259 guaranteed the lepers the right to elect their superior, to approve all legal actions regarding the property of their institution, and to review yearly financial statements that the superior was required to provide to the leper residents every June 25. The lepers could even remove the superior by a simple vote (pp. 132–33).

At Verona in northern Italy, the lepers of Santa Croce confronted both this leprosarium’s superior and the bishop of the city in 1145 and asserted their right to control all the property God and men have given them.⁴ At the leprosarium of Saint Lazarus in Genoa, the lepers also controlled their property, but in addition they claimed the right to elect their superior. When the archbishop of Genoa tried to usurp that right, the lepers as a corporation appealed to the pope and, after a forty-year battle, succeeded in convincing Pope Nicholas V (1447–1455) to confirm their right of election (p. 133).

In the Byzantine Empire, however, we found no such evidence of leper residents’ governing their group homes. From Antioch, Alexandria, and smaller provincial cities only brief descriptions survive. We found that lepers were housed in special facilities outside city walls, that these leprosariums accepted both male and female victims of elephant disease, and that bathing was an important palliative treatment for their condition (pp. 79–85, 189).

In the case of the large leprosarium of Saint Zotikos in Constantinople, however, far more information has come down to us. This large institution was governed by a superior called the epitropos who was under the supervision of the city’s orphanotrophos, the director of the Great Orphanage of Constantinople and several other philanthropic institutions in the city, including the Zotikos leprosarium. The orphanotrophos, in turn, was appointed by the patriarch of Constantinople until the early ninth century when the emperor himself began selecting the orphanotrophos. In a centralized state such as the Byzantine Empire one would expect such a top-down administrative model for the Zotikos leprosarium.⁵

There survives, however, one piece of evidence that the leper residents of the Zotikos leprosarium exercised some legal rights independent of those belonging to the Zotikos institution—a mysterious lead seal from the collection in the Dumbarton Oaks museum in Washington, DC. This seal bears the inscription Seal of the Brothers of Saint Zotikos. While we were writing Walking Corpses, it was not clear why the lepers as a group possessed this seal. Some scholars suggested that the seal belonged to a monastic community associated with the Zotikos leprosarium as was the case at the leprosarium of Basil outside Caesarea (pp. 134, 215n87). The laws of Emperors Anastasios and Justinian, however, reveal why the lepers as a distinct corporation needed their own seal, as we will explain in what follows.

In writing Walking Corpses, therefore, the origins of this spirit of self-government eluded us. In 2018, however, Daniel Caner published an article in Dumbarton Oaks Papers that provided the key to resolving this puzzle. Caner based his argument on a reassessment of what the Greek words ptochotropheion and ptochos meant in the early Byzantine period (323–642). Before we can understand the imperial decrees of Anastasios and Justinian, we must summarize Caner’s arguments concerning what ptochotropheion and ptochos meant in the early Byzantine Empire.

Caner began his argument by reviewing all the sources describing the philanthropic institution that Basil had constructed outside the walls of Caesarea, an institution Basil himself called a ptochotropheion. Caner demonstrated that all contemporary sources described this institution as caring for lepers. Moreover, sources from the fifth and sixth centuries concurred. There is, therefore, no evidence to believe that Basil’s ptochotropheion was an institution to feed poor people during famine, as some historians have suggested, nor was it a medical hospital to cure the sick as other researchers have maintained. Rather it functioned solely as a leprosarium.⁶

Basil’s ptochotropheion was part of a system of ptochotropheia that had opened across Asia Minor. The first of these institutions about which we have any information was founded by a monastic leader named Eustathios in the city of Sebasteia 180 kilometers north of Caesarea. This facility also served only lepers or people crippled by chronic diseases (pp. 73–74).

As we demonstrated in Walking Corpses, Eustathios’s ptochotropheion also served as the model for the large Zotikos leprosarium in Constantinople (pp. 75–79). Thus, it is not surprising that all sources until 1000 used either ptochotropheion or its synonym, ptocheion, whenever they referred to the Zotikos leprosarium. All versions of the Zotikos legend (the hagiographical tales surrounding the life and work of Saint Zotikos) describe the institution as either a ptochotropheion or a ptocheion and call the founder, Zotikos, a ptochotrophos. Even in the tenth century, the official list of saints’ commemorations in Constantinople referred to the Zotikos asylum as a ptocheion. Not until the twelfth century did a Byzantine writer select any other term such as lobokomeion (an institution for people disfigured by disease or injury) to indicate the Zotikos leprosarium even though extant sources clearly depict it as assisting only lepers (pp. 86–88).

Sources describing leprosariums, located in other regions of the empire, also used this terminology. In recounting the Empress Eudocia’s establishment of a large institution for four hundred lepers outside the walls of Jerusalem in 450, the historian Nikephoros Kallistos Xanthopoulos described it as a ptocheion.⁷ In his colorful account of the deeds of Egyptian ascetics, Palladios recorded how in the early fifth century a priest named Makarios used the jewels of a wealthy woman to support a ptocheion for lepers in Alexandria.⁸

Having established the meaning of ptochotropheion and ptocheion, Caner turned his attention to ptochos, defined in Liddell and Scott’s Greek-English Dictionary as a beggar. After studying fourth-century texts, especially Gregory of Nazianzos’s Oration XIV (On the Love of the Poor), Caner became convinced that in Christian Greek usage ptochos served as a euphemism in some contexts for a person with leprosy, almost a synonym for leper.⁹ Gregory’s Oration XIV was initially given as a sermon at a service probably held at the time Basil dedicated his recently constructed philanthropic institution. The sermon’s extraordinary length, however, suggests that Gregory later expanded the original sermon into a treatise.

Although Gregory of Nazianzos called his Oration XIV On the Love of the Poor (Peri philoptochia), its subject was not the hardships of the penniless, but the plight of lepers, the poor who had lost everything—family connections, friends, their polis citizenship, even their appearance by which people recognized them. They were forced to cling to one another for survival. Gregory never once used the word leprosy or elephantiasis to indicate their illness; rather he named it the Holy Disease (pp. 41–43). Basil’s brother, Gregory of Nyssa, described the leper residents at his brother’s ptochotropheion as the the poor in body, and compared them to the monks who assisted the ill, monks who were the poor in spirit. In fact, Gregory of Nyssa conceived of the ptochotropheion as a school where the monks learned from the lepers the meaning of suffering while the lepers learned from the monks the self-control and humility of asceticism.¹⁰

By the 420s, the Zotikos leprosarium in Constantinople had become such a respected Christian institution among the common people of the capital that, when Patriarch Attikos died, they demanded that its current supervisor, a priest named Sisinnios, be installed as the city’s new bishop. The fifth-century church historian, Sokrates, referred to the lepers in Sisinnios’s care as ptochoi.¹¹ Sozomenos, another historian who focused on church affairs, called Basil’s leprosarium outside the walls of Caesarea a shelter for ptochoi.¹² Finally, in the 380s John Chrysostom, future patriarch of Constantinople, described a leprosarium for both male and female ptochoi, located outside the Syrian metropolis of Antioch.¹³

Having summarized Caner’s arguments concerning the Greek terms for leprosariums as well as he conclusions about how Christian writers often used the Classical Greek term for a poor person (ptochos), we return to the laws of Anastasios and Justinian in the Corpus juris civilis. Emperor Anastasios issued his law (exact date unknown) to prevent pious houses (a category that included churches, monasteries, and philanthropic institutions) from selling or mortgaging their immovable property irresponsibly. In the first section of his decree, Anastasios defined under what conditions sales or any other legal exchanges would be valid and in the second section the proper process for executing such legal actions.¹⁴

Regarding the legal process for sales, leases, and mortgages, Anastasios required: first, that the church, monastery, or philanthropic institution draft a memorandum before a magistrate, a document explaining why the sale or lease was necessary; second, that the steward of the church, the superior of the monastery, or the director of the philanthropic institution be present at the relevant magistrate’s court; third, that the resident clergy of the church, the monks of the monastery, or the staff of the philanthropic institution also be present with their leader; and finally, that a majority of all those present give their assent to the legal action, described in the memorandum.¹⁵

In his law, Anastasios dealt with one category of philanthropic institution separately, ptochotropheia, i.e., leprosariums. The emperor stipulated that, in the case of ptochotropheia, the approval of the memorandum be confirmed not only by the director of the institution and the serving staff but also by the ptochoi (i.e., the lepers).¹⁶ In effect, Anastasios gave the leper residents of leprosariums together with the staff members who served them the ability to control the resources of the leprosarium, provided the reasons given for the legal action conformed to those the emperor had outlined in section one of the decree. If the leprosarium had a large number of residents, this would mean that the lepers ultimately had the ability to control the institutions’ assets.

In 528, Emperor Justinian issued another law that strengthened the lepers’ rights as a corporate group. As the result of errors in form when private donors made bequests by testament or made inter vivos gifts, lawyers, acting in the interest of the donors’ heirs against the wishes of those very donors, had often been able to invalidate such grants to philanthropic institutions. To correct this abuse, Justinian declared that gifts worth under 500 gold solidi to a charitable institution would be valid no matter in what form the bequest or gift was framed. In listing the types of institutions covered by his new law, Justinian named the Great Church of Constantinople, xenodocheia (hostels for Christian travelers), nosokomeia (hospitals to treat the sick), orphanages, and ptochotropheia (leprosariums). Regarding leprosariums, however, Justinian specified two types of gifts: those to the ptochotropheia or those to the ptochoi themselves.¹⁷ In other words, benefactors were able to leave land, money, or valuables not only to the institution but also to the lepers as a separate group, recognized as a legal corporation distinct from the institution.

In the decree of 528, Justinian was confirming an already existing practice, that is, that some benefactors had been making gifts to the lepers as a corporation distinct from the leprosarium institution. Although Justinian’s decree was dealing with grants valued at less than 500 solidi, nothing in this law prevented donors of much more valuable gifts from designating the lepers themselves as the beneficiaries as long as these donors used the proper legal form to convey their property to the leper residents. Justinian’s edict of 528, in fact, gave legal force to what had developed as a common practice.

As early as the 370s, Gregory of Nazianzos provided evidence in his Oration XIV that lepers had developed some form of organization.

They remain together with one another, cruelly yoked together by their illness. Each one makes a different contribution of misfortune to elicit mercy. Each one adds something unique to their common misfortune. The lepers inspire mercy because of their illness, but even more mercy because of their affection one for another.¹⁸

Gregory was describing the lepers’ ability to orchestrate displays of begging, which he compared to Greek tragic plays, but in the decades that followed, leper leaders, a category that surely included members of the local polis governing councils as some passages in Gregory’s Oration XIV implied, apparently pursued methods of soliciting assistance more sophisticated than organized begging in the streets. They made direct appeals to wealthy Christians to donate substantial sums of money and even movable property to spontaneous leper organizations. Justinian’s law of 528 simply acknowledged a practice that had been developing for more than a century.

Justinian’s decree of 527 also explains the use of the Dumbarton Oaks Seal of the brothers of Saint Zotikos. The leper residents of the Zotikos leprosarium appended this lead seal to documents that granted them money, valuable gifts, or landed estates, grants made directly to them as a corporation rather than to the leprosarium institution (pp. 134–35). In Walking Corpses, we provided examples of imperial gifts to the Zotikos leprosarium, but so far no documents have been found recording private benefactions (p. 36). From the Leprosarium of Saint Lazarus on Crete, however, six documents mention leper representatives of the institution’s sick residents who accepted private gifts on behalf of the leper corporation.¹⁹ We believe that practices at this Cretan leprosarium, which was designed primarily for lepers from the Greek community on the island, followed usages at the Zotikos asylum in Constantinople (p. 135).

Although the Corpus juris civilis did not significantly impact the legal systems in Western Europe until the twelfth century, regulations in Book One of the Codex, all dealing with ecclesiastical organizations, did shape Christian institutions in Gaul and Italy before 1100. Since the laws of Anastasios and Justinian were both found in Book One, it is not surprising to find in the early 700s corporations of lepers at Metz and Maastricht that took possession of property as legal persons in accordance with Emperor Justinian’s law of 528 (pp. 122–23).

As the Corpus juris civilis grew in importance in Western Europe, lepers were able to justify ever greater rights over leprosarium property. When the lepers of Santa Croce in Verona defied both the bishop and the superior he appointed in 1145 with their bold assertion that they alone controlled the property that God and men had given them, the civil law ultimately supported their claims (p. 135). By the thirteenth century, lepers had gained the right to elect their superiors and hold them accountable for administrative decisions as we saw in the case of the leprosarium of Brives (pp. 132–33).

Regarding leprosy as an infectious disease (according to the Library of Congress cataloguers, the main theme of Walking Corpses), several reviewers criticized our assumption that the frightening disease that swept through Latin Christendom from 1100 to 1300 was Hansen’s disease, the modern name for the disfiguring set of symptoms that occur in individuals not immune to Mycrobacterium leprae.²⁰ The Swedish physician, Gerhard A. Hansen, discovered this pathogen in 1873 (p. 7). In the 1960s paleopathologists, examining skeletons from the cemeteries of medieval leprosariums, identified the same lesions on the bones of the hands, legs, and feet as well as on parts of the skull around the nose and mouth as they found during autopsies on the bodies of modern patients who died with symptoms of Hansen’s disease (pp. 8–9).

As early as 1969, J. G. Andersen maintained that the analysis of skeletons from cemeteries of medieval Danish leprosariums demonstrated that the vast majority of the residents at these institutions had suffered from Hansen’s disease.²¹ In 2006, Jasper L Boldsen echoed Andersen’s findings.

It is among other things this relationship (between bones from medieval leprosarium burial sites and those of modern victims of Hansen’s disease) which makes it overwhelmingly likely that the people gathered in medieval leprosaria suffered from a condition which, if they had lived now, would have been designated as leprosy (i.e., Hansen’s disease).²²

Boldsen, in fact, is so confident that medieval leprosy (lepra in Latin) and Hansen’s disease are the same malady that he considers leprosy as a synonym for Hansen’s disease with no need of further qualification.

Although paleopathological studies have demolished arguments such as those of Sheldon Watts that medieval leprosy was simply a tool of social control to imprison enemies of public order and right religious doctrine, medical historians are still hesitant to believe that physicians of medieval Catholic Europe were able to identify correctly a specific illness such as Hansen’s disease.²³ While it is true that ancient and medieval medical science, based on Galen’s concept of the proper balance or krasis (mixture) of humors (blood, phlegm, yellow bile, and black bile) in the body, did not have an adequate explanation of how infectious diseases operated, still their training made them excellent diagnosticians, experts capable of detecting subtle changes in skin color, reflexes, eye movements, pulse rates, and of course, urine samples.

In detecting changes in the living human body, medieval physicians were unquestionably better than modern medical experts who now depend almost entirely on specific tests for their diagnoses. It is, of course, to be expected that a few leprosarium residents did not have Hansen’s disease, but some other skin condition. Nevertheless, from osteopathic evidence we know that most of them did. The burden of proof now rests on those medical historians who would claim that medieval lepers were not suffering from Hansen’s disease.

Whether the leprosarium residents in fourth-century ptochotropheia in Asia Minor were also suffering from Hansen’s disease is, however, less certain because so far no burial site has been found that is connected to one of these Anatolian leprosariums. In fact, archaeologists have not yet identified the ruins of any single structure or complex of buildings that definitely functioned as a ptochotropheion.

As we explained in Walking Corpses, skeletal remains have proven that Hansen’s disease had infected Macedonian soldiers, stationed in third-century (BC) Egypt under the Ptolemys (p. 11). Moreover, evidence from Palestine during the fifth and sixth centuries (AD) has shown that some people buried in Christian monasteries of the Judean desert had suffered from Hansen’s disease.²⁴ At the Monastery of John the Baptist near the Jordan River, scholars have identified the skeletal remains of thirty-two individuals. According to Joseph Zias’s analysis, a considerable number of these bones display the marks made by Microbacterium leprae; Zias, however, did not determine exactly how many of the thirty-two people had died with symptoms of Hansen’s disease. Moreover, he was unable to link any of these monastic sites with documents that mentioned leprosariums associated with these communities.²⁵ There is, however, sufficient evidence that leprosariums were operating in Palestine during these centuries (pp. 84–85).

Analysis of skeletal remains, thus, demonstrates that Hansen’s disease infected people in the Eastern Mediterranean basin during the early Byzantine era and that this specific disease had most likely existed in these regions since early Hellenistic times. Until archaeologists locate a leprosarium with a separate burial ground reserved for leper patients as researchers have managed to do in Denmark, Cologne (Germany), and England, we cannot be absolutely certain that the residents of Basil’s ptochotropheion and of other such asylums in Asia Minor suffered from Hansen’s disease, but we believe that they did on the basis of the symptoms mentioned in the sources we have presented in Walking Corpses (pp. 8–9).

With regard to the opening of Christian leprosaria in the fourth century, we suggested that bishops like Basil and Eustathios were responding to an epidemic of leprosy, especially in Asia Minor and Constantinople. Indeed, in justifying his construction of a new leprosarium on the Asian shore of the Bosporos directly across from the capital, John Chrysostom claimed that the number of lepers along the roads in Bithynia was in the thousands (pp. 188–89). In her through review of Walking Corpses, however, Dorothy Abrahamse restated the opinion of some scholars that the establishment of leper asylums outside Caesarea in Cappadocia, Sebasteia, and Constantinople in the mid-fourth century did not necessarily indicate that cases of leprosy were increasing during those years. She suggested, instead, that founding these ptochotropheia might have been part of a campaign by Christian bishops to gain more political power within their cities as protectors of the poor, especially of those poor who had recently migrated into cities from the countryside and thus lacked citizen rights in their new communities.²⁶ In the view of Peter Brown, these bishops were becoming the patrons of a new urban plebs.²⁷

There is some evidence to support Abrahamse’s theory. In 425, the people of Constantinople insisted that Sisinnios, the director of the Zotikos leprosarium in Pera, fill the vacant episcopal throne of the capital. From the account of Sisinnios’s selection in the ecclesiastical history of Socrates, however, it is not clear whether he was popular with the city’s common people because of his personality and willingness to provide alms to those in need or because of his role as administrator of the leprosarium.²⁸

One should consider, however, that John Chrysostom was removed from his episcopal office, at least in part, because of the large leprosarium he began to build on the Asian shore of the Bosporos to care for the many lepers who were lining the roads of Bithynia. According to Pseudo-Martyrios, a cleric who wrote a long funeral oration in 407 to honor Chrysostom’s achievements, a group of landowners in Bithynia fiercely opposed the bishop’s plans for a leper asylum and complained to the empress Eirene who already disliked Chrysostom. As Pseudo-Martyrios described these events, the opposition to the bishop’s leprosarium project led directly to his deposition and exile to central Anatolia (pp. 189–91).

Bishop Basil of Caesarea also had met opposition to his famous leprosarium outside his city. In 372, shortly after becoming bishop, Basil wrote a letter to Elias, the governor of the province of Cappadocia at the time. Basil had discovered that a group of people, probably wealthy landowners, opposed his construction of this ptochotropheion and that they had complained directly to the governor. According to Basil, Elias should now be willing to hear Basil’s side of the story.

In this letter, Basil presented, in brief, his defense. He began by describing his charitable facility (he did not call it a ptochotropheion). This philanthropic institution included a magnificent church and an adjacent monastery there, a new residence for the bishop of Caesarea, facilities to house the governor and his staff when he visited Caesarea, a guesthouse for travelers, and some sort of facility for the sick with a nursing staff and people trained in medicine. Basil did not use the word for physician (iatroi), but mentioned only those who did the work of physicians (iatreuontes). In this letter, he never mentioned people with elephant disease—as the contemporary medical texts called leprosy—nor did he indicate that residents at his charitable complex suffered from the Holy Disease, the euphemism Gregory of Nazianzos used to identify lepers.²⁹

As Caner has shown, every other text describing Basil’s ptochotropheion mentions only leper residents there, no other patients suffering from different maladies.³⁰ That, in his letter to Elias, Basil failed to mention lepers in any way and in fact never mentioned that his charitable foundation outside Caesarea was known as a ptochotropheion (a synonym for leprosarium) indicates that Basil was afraid that the governor would agree with his critics. In effect, this letter 94 of Basil is deliberately deceptive. Whether it fooled Elias or not we do not know, but it surely misled modern historians. Timothy Miller, coauthor of Walking Corpses, claimed that Basil had opened a true hospital in Caesarea.³¹ More recently, Andrew Crislip was also led astray by Basil’s dissimulation and claimed that the leprosarium in Caesarea was the first true hospital in the Western world.³²

In view of the serious problems that both Basil and Chrysostom encountered in building leprosariums for their cities, it would seem to have been more effective for the bishops of Anatolia to have gained popular support by opening simple xenodocheia to house and feed the poor migrants from the countryside who began streaming into cities in the Eastern Roman Empire during the fourth century. Apparently, that was the approach of bishops in Syria and perhaps also in Egypt.³³ That Eustathios at Sebasteia, Basil at Caesarea, and a number of other bishops of central Anatolia chose, instead, to support controversial leprosariums suggests that they did so because they perceived a need. As Pseudo-Martyrios described the problem that faced Chrysostom, the roads leading to the coast of Bithynia were lined with walking corpses.³⁴

The strongest argument against a fourth-century leprosy epidemic are the two essays on elephant disease, one on its symptoms and the other on its treatments, written by Aretaios of Cappadocia. Several passages in these essays suggest that leprosy was a growing health problem at the time Aretaios was writing his On Acute and Chronic Diseases.³⁵ Modern historians, however, have no idea when he completed this treatise. In an article reviewing the state of this debate, Steven Oberhelman concluded that experts have presented plausible arguments to place Aretaios’s floruit any time from the mid-first century (AD) to the early fourth century.³⁶

In a recent article emphasizing Aretaios’s emotional descriptions of the agonies endured by the seriously ill, Maud Gleason has suggested that On Acute and Chronic Diseases was written in the early third century. Just as the visual arts from this period enhanced scenes of extreme suffering by depicting the grief of several onlookers, Aretaios added descriptions of the terror that gripped servants and family members in the final agony of a terminally ill patient.³⁷ On the other hand, the first medical writer to refer to Aretaios and to quote from his works was the physician Philagrios who died in approximately 350, but exactly when Philagrios wrote his treatises has also eluded medical historians.³⁸

Before a secure date for Aretaios’s floruit can be established, however, medical historians have to solve another problem presented by his work. In what context did Aretaios make his detailed observations? In describing symptoms of some diseases, Aretaios referred to internal lesions that accompanied clinically observed symptoms.