2012 Dementia

ORIGINAL ARTICLE: EPIDEMIOLOGY,CLINICAL PRACTICE AND HEALTH

Dementia on the Byzantinethrone (AD 3301453)ggi_779 405..412

Effie Poulakou-Rebelakou,1 George Kalantzis,1 Costas Tsiamis1 andDimitris Ploumpidis2

1History of Medicine, and 21st Psychiatric Clinic, Athens University Medical School, Athens, Greece

Aim: To present the consequences of the prolonged age of the emperors, especially ifcombined with symptoms of dementia, during the Byzantine period (AD 3301453).

Methods: A review of the original historical and literal sources referring to the life andpolitical course of all the aged Byzantine emperors (a range of 87 total persons whoascended the throne).

Results: Seven Byzantine emperors out of 87 reached older age and showed symptomsthat are attributed to dementia, as well as other manifestations of prolonged life. Most ofthe Byzantine medical authors attempted to connect dementia with certain multifactoragents and some of them interpreted the symptoms as being influenced by the brainspathogenic humor or focused on the role of vascular diseases. However, an elderly leaderafflicts his personal destiny, as well as the succession of the throne and the history of thewhole nation. Sometimes, a delay in diagnosis and recognition of the loss of the somaticand mental ability of the emperor made scientific intervention useless and the patientsbehavior was dangerous for the citizens of the state.

Conclusion: Even in contemporary societies, extended life expectancy results in leadersof older age, suffering from various diseases connected with gerontology. Loss of mentalskills is considered dangerous and remains a problem from antiquity to the modernday. Byzantium handled all these cases with diplomacy. Geriatr Gerontol Int 2012; 12:405412.

Keywords: Byzantine emperors, Byzantine gerontology, dementia, prolonged age.

Introduction

Gerontology seems to have been a well-developedbranch of Byzantine medicine and was of high impor-tance in relation to the care of the elderly. A frequentmanifestation of old age has always been dementia,which was easily diagnosed and described in the medicaltreatises of the era, which also contained theories aboutthe degeneration of physical and mental function.Behavioral changes and gradual loss of motor andmental capacities of an aged person cannot escapeattention, especially if the affected individual happens tobe the emperor. Royal diseases have always been a point

of public curiosity and a topic of general interest inchroniclers narratives. The failure of a state leader todeal with the serious matters of his empire, as a result ofhis own dementia, have caused several occasions ofpolitical instability and have led to dangerous situations.Some of the most likely dementia cases among the Byz-antine emperors are presented in this paper.

Byzantine emperors: Dynasties andsuccession to the throne

The Byzantine Empire (AD 3301453) was the continu-ation of the Roman imperium; the first Emperor, Con-stantine I The Great, rebuilt the old Greek colony ofByzantium on the Bosphorus and transferred the capitalfrom Rome to the new city renamed Constantinople (AD330), which remained the most significant urban centerduring medieval times until its conquest by the Otto-mans (AD 1453) (Figs 1,2). The Byzantine emperor was

Accepted for publication 6 October 2011.

Correspondence: Dr Effie Poulakou-Rebelakou MD PhD, 51,Themidos St, Athens 15124, Greece. Email:[email protected]; [email protected]

Geriatr Gerontol Int 2012; 12: 405412

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2011 Japan Geriatrics Society doi: 10.1111/j.1447-0594.2011.00779.x 405

not only the highest military commander, the supremejudge and the only legislator, but also the protector ofthe Christian church. The senate of Constantinople,although subordinate to the imperial will, acted as anadvisory body in legislation. As long as there was anemperor on the throne, the senate had little influence,but played a significant role when the imperial thronewas vacant. As the succession to the throne was heredi-tary and the power of a dynasty was respected throughall the Byzantine centuries, the senators views were notnecessarily decisive for the election of the new emperor.The last emperor might already have designated hissuccessor or had him crowned as co-emperor and thenthe senatorial ratification was a simple formality. If thethrone fell empty without any successor having beenappointed or after sterile imperial couples without closerelatives, then the final decision lay with the senate andthe military generals.1 The power of the throne was

extremely important and the final decision was influ-enced by the dynastic bonds, allowing the coronation ofwomen (wives, daughters and sisters) and minors (withtheir mothers taking over the regency for them).

Medical aspects of old age by ancientGreek and Byzantine authors

The social environment of the Byzantine Empiregreatly favored care of the elderly. Religious conceptsdictated the establishment of welfare institutionsscheduled for the needs of old age.2 It seems probablethat some physicians were specialized in geriatrics, asAetius of Amida (6th century) mentioned the termphysician of the aged.3 Byzantine medical authorsconnected old age with dry and cold crasis of thebody according to the Hippocratic theory of the fourhumors. All of them classified dementia in seniors as amental disease. This was considered an inevitable con-sequence of aging. The Byzantine physician and monk,Meletius the Iatrosophist (8th century AD), attemptedto classify the ages of a man: young, man at his peak,middle-aged and old.4 These four ages constitute anideal number corresponding to the four Hippocratichumors: blood, yellow bile, black bile and phlegm,respectively. Furthermore, the four ages correspond tothe four seasons: spring, summer, autumn and winter.Among the various symptoms accompanying the thirdand fourth age, the Byzantine physicians includedsphincteric incontinence, the whitening of the hair, thetrembling, the weakening of eyesight, the presbyopia,the proneness to bone fractures and the loss ofhearing. They also mentioned the diseases of old age:arthritis, gout and stone disease, intestinal obstruction(ileus), cataract, and strokes.5

Returning to Greek antiquity and examining variousancient texts, it becomes apparent that cognitive declinein aged individuals has long been a well-recognizedcondition. One of the earliest references to the divisionof life into five distinct stages, commencing respectivelyat ages 7, 21, 49, 63 and 81 years, is attributed to thephilosopher, Pythagoras (seventh century BC). The lasttwo of these stages were designated to old age, a period ofdecline and decay of the human body, and regression ofmental capacities.6 The Greek knowledge of dementiadictated the Legislation of Solon from Athens (one ofthe Seven Wise Men of Antiquity) regarding the makingof wills.7 The two greatest philosophers of ancientGreece, Plato and Aristotle, supported that old age isinseparable frommental failure. According to their writ-ings, dementia was inevitable just as the passage of timeis inevitable.6 During the Greco-Roman times, Galen(second century AD) systematized all the existingmedical knowledge and he included morosis (his term fordementia from the Greek word moros meaning silly orstupid) in his list of mental diseases. Showing his

Figure 1 Map of the Byzantine Empire in the sixth centuryAD.

Figure 2 Map of the Byzantine Empire in the 11th centuryAD.

E Poulakou-Rebelakou et al.

406 2011 Japan Geriatrics Society

Hippocratic roots, he agreed that mental deteriorationwas an obligatory condition of the senile period.

Byzantine theories on memory loss

The influence of ancient Greek medicine is apparent inthe extended compilations of the Byzantine physicians,enriched by their personal observations. Oribasius ofPergamum (fourth century AD) was the first to deal withneurological and psychiatric diseases and mentionedmemory disorders among them.8 Nemesius (fourthcentury AD), the archbishop of Emesa, in his workentitled On the Nature of Man, supported the belief thatmemory loss occurred in cases of brain damage focusedon the posterior part of the brain.9 Two centuries later,Aetius of Amida referred to morosis based on the texts ofthe physicians Galen and Rufus, a situation similar todementia, defined as prolonged memory loss combinedwith lack of rational thought.3 He also attributedmemory disorders to damage of the posterior occipitalpart of the brain. Furthermore, Aetius mentioned leth-argy, infections and old age as causative agents affectingmental stability and he added that some cases of demen-tia were noticed among the patients of the Athenianplague (431 BC) during the Peloponnesian War, asdescribed by the historian, Thucydides. Both the phy-sician, Alexander of Tralles, and the historian, Procop-ius, mentioned patients showing lethargy and memoryloss among the victims of another plague, the Justinianplague (AD 542). Paul of Aegina (seventh century AD)considered the loss of memory as a result of the effect ofan accumulation of harmful humors on the substancesof the brain, according to the Hippocratic theory.10

He also expressed the noteworthy opinion that thissymptom might be caused by a defect of the bloodvessels. Leo the Iatrosophist (ninth century AD), monkand physician, attributed the memory loss of the aged toextreme coldness and dryness of the posterior ventricleof the brain.11 Finally, a theory similar to Aetius wasmentioned by Ioannes Actuarius (13th century AD), thelast famous physician of Byzantium, influenced by theancient Greek physician Posidonius, who stressed thatlogical thought is the most significant mental functionand its affection means memory and imagination loss.12

Byzantine emperors withsuspected dementia

Although life expectancy during the medieval centurieswas short, several of the 87 Byzantine emperorsmanaged to reach 70 years-of-age, and were thereforeconsidered as very old. Many of them had a long reignand their health status and behavior are well known,from historical sources. Consequently, those surround-ing them could easily notice any early change in physicaland psychological health, and suspect senile dementia.

Concerning the few cases of emperors who came to thethrone in advanced age, without significant informationabout their previous life, the suspicion of dementia hadbeen spread with considerable, but excused, delay.13

The evidence of seven dementia cases presented in thepresent paper is mainly derived from literary and his-torical sources, and their suspicious symptoms havebeen discussed after a careful review of the last years ofall those who ascended to the Byzantine throne andlived a long life. [Table 1]

(1) Justin I (AD 518527)

Justin I died at the age of 75 or 77 years, after 9 years onthe throne. The historian, Procopius, focused on thelast period of Justins reign, when his nephew and suc-cessor to the throne, Justinian I, (Fig. 3) carried out theduties of the co-emperor. Procopius observed thatJustin had a deteriorated ability to understand seriousissues and his citizens were laughing at his decisions:the Emperor, as an idiot and advanced in age, causedthe laugh of the environment, and was also accused ofdelays in decisions and inability for his duties.14 Justinshowed a certain loss of intellectual function, as he hadpreviously been a very capable military leader who spentmany years of his life on campaigns and battlefields.13

His progressive cognitive and behavioral decline wasrecognized even by the people of the Byzantine capital.

(2) Justinian I (AD 527565)

Information about the possibility of dementia duringthe last period of Justinians reign is not evident from hiscontemporary historians, considering that such a refer-ence could influence the image of the most glamorousByzantine emperor.15 Indeed, Justinian died at theunusual, for that period, age of 83 years, manifestingcurious behavior towards the end of his life,16 so that hiswife, Theodora, undertook his duties for some time.17

Some authors referred either to his gout or his possibleprostate benign hyperplasia, both considered to be dis-eases of older people, but the exact cause of his deathis not clear,18 as the sources simply focus on his pro-longed life.19 The contradictory interpretations of hisbehavioral changes can be explained by an insidiousonset of primary symptoms that nobody from the impe-rial environment could date the exact time of. The onlycertain evidence of an increasing loss of memory andintellectual function is the temporary replacement of hisduties by the Empress Theodora.13

(3) Constantine VIII (AD 10251028)

Constantine VIII succeeded his brother, Basil II (namedthe Slayer of Bulgarians), to the throne after having beenhis co-emperor for almost half a century. Standing in

Byzantine emperors suffering dementia

2011 Japan Geriatrics Society 407

Tab

le1

Symptom

san

dattitud

esof

thesevenem

perors

sufferingde

men

tia

Empe

rors

Age

ofde

ath(years)

Postsymptom

atic

characteristics

Presym

ptom

atic

characteristics

Impe

rial

courts

reactio

nsPo

litical

even

ts

Justin

I(518

527

)Unc

le

75or

77Deterioratedab

ility

toun

derstand

statematters

Delay

incriticald

ecisions

Inab

ility

tocarryou

this

dutie

s

A

capa

blemilitary

lead

eron

thecampa

igns

andthe

battlefie

lds

Citizens

laug

hing

atthe

empe

rorsde

cision

sHis

neph

ewJustinian

carriedou

thisdu

ties

attheen

dof

hislife

JustinianI

(527

565

)Nep

hew

83The

mostintelligent

and

activ

eem

peror

Insidiou

son

setof

prim

ary

symptom

sthat

nobo

dyco

uldda

tetheon

set

His

wife

,the

Empress

The

odora,

carriedou

thisdu

tiesforsome

time

Con

stan

tine

VIII(102

510

28)

Father

73Allhistorians

referto

his

degen

erationof

all

system

sor

natural

degene

ratio

nHemarried

hisda

ughter

toamarried

offic

er

Co-em

perorfor49

years

Zoe

(104

2)Dau

ghter

Over70

Pa

ssiona

teab

outpo

ison

mak

ing,

neglectin

gsleep

Lackof

stab

ility

Igno

rant

ofpu

blic

affairs

Neglectinghe

roffic

eob

ligations

Aba

ndon

edhe

rpe

rson

alcare

(dressingan

dba

thing)

Apa

thy

Han

dtrem

orDeafness

Hob

bies:p

repa

ring

fragranc

es,c

osmeticsan

dmed

icines

inhe

rprivate

labo

ratory

Po

ison

mak

ing

Veryap

pearan

ceThree

marriages

Greatly

admired

forhe

rspiritu

alpo

wer

Cha

nged

characteran

dhe

rbe

havior

Micha

elVI

theMilitary

(105

610

57)

Calledthe

Old

Called

veryold

Igno

rant

ofstateaffairs

Degen

erated

physical

ability

Apa

thy

Motor

prob

lems

Laziness

Ministerof

theMilitary

Affairs

Office

Exp

ertin

themilitary

affairs

Lazy,

boring

and

mon

oton

ous

Heab

ando

nedthe

throne

andbe

comea

mon

k

Nicep

horus

Botan

eiates

(107

810

81)

80Not

caring

abou

tstate

affairs

Im

pairmen

tof

men

tal

func

tions

Exp

ertin

thewar

campa

igns

And

ronicu

sII

Palaeo

logu

s(128

213

28)

74Indifferen

tan

dun

conc

erne

dReign

forha

lfacentury



the shadow of this famous emperor, he was consideredas a negligible figure, lacking any sense of responsibility,leaving the state affairs to other persons and spendingmost of his time at the Hippodrome of Constantinople.He died at the age of 73 years, spending just 3 years onthe throne, facing many health problems. The chroni-cler, Ephraem, stated: he was much tortured by senilityand diseases and he was looking forward to death.20

The historian, Ioannis Zonaras, attributed the degen-eration of the physical and mental capacities toan unknown disease that eventually caused his death:Having approached the senility and suffering fromdegeneration of all systems and a co-existing ill-ness . . .21 A similar opinion was expressed by thefamous historian and philosopher, Michael Psellus:senility had brought the obligatory natural degenera-tion.22 All the sources considered his sudden decisionto marry his 50-year-old daughter, Zoe, to a marriedofficer (whom he divorced from his legal wife within24 h), in order to arrange the matter of succession to thethrone, as a result of a probable dementia that influ-enced his personality. Maybe the degeneration of allsystems was denoting memory disorders, deteriorationof verbal skills, apathy or motor problems13 and led to afatal stroke.

(4) The Empress Zoe (AD 1042)

The Empress Zoe was one of the three daughters of theprevious Constantine VIII and his heir to the throne,but had probably the same nosological heritage. At theend of her life, over 70 years, she presented physicalproblems related to her old age, as well as to her hobbyof preparing fragrances, cosmetics and medicines inher private laboratory, neglecting her official duties.Legends and literature represent her as passionate withpoison making, even abandoning sleep. Accordingto Michael Psellus, her external features did notcorrespond to her old age, because the empress hadblond hair, white skin without wrinkles and a youthful

appearance. However, he recognized symptoms of cog-nitive failure: When she had grown old, she was some-what lacking in stability. I do not wish to convey theimpression that she was deranged or out of her rightmind but she was absolutely ignorant of public affairs. . . Whatever intellectual advantages she may haveenjoyed in the past, her character did not suffer her topreserve even them . . .22

Indeed, Zoe had considerable zest for life, marryingthree times from between the ages of 50 years and65 years. After then, she started to neglect her officialobligations that were imposed by her public office andabandoned even her personal care (dressing andbathing), making her restlessness evident. In addition,she lost her spiritual power, for which she was greatlyadmired by people in the past, and started having lack ofconcern for social problems, emerging as an egocentricpersonality. Maybe her apathy that appeared withadvancing age led her to the acceptance of her lasthusbands mistress in the Imperial Court. IoannisZonaras excuses the lack of interest, because the life ofthe empress was prolonged over 70 years.21 Zoe alsodeveloped hand tremor, probably denoting an extrapy-ramidal lesion, and gradual deafness attributed to braindamage. The progressive deterioration of her symptomsthat affected her character and personality, such asanorexia and sudden impulses, can be attributed to Par-kinsons syndrome, which causes generalized cerebralinsufficiency. There is also a possibility that Zoe devel-oped disturbances of the cerebral blood supply andsubsequent signs of senile dementia. Some historianssupport that her personality, her marriages and herlack of responsibility brought the end of her powerfulMacedonian dynasty13 (lasting almost two centuries;Figure 4).

(5) Michael VI the Military (AD 10561057)

Michael VI had held the office of the Minister of Mili-tary Affairs for a long time, therefore called the old orthe military. When he ascended to the throne, he wasconsidered very old according to public opinion. Thehistorian, Ioannis Zonaras, records: Man born in Byz-antium, improper for great responsibilities because ofhis natural laziness and aphelia, whose life had beenprolonged.21 A second historian, Ioannis Scylitzes,agrees with him: Michael the patrician the Military,man originated from Byzantium, boring and monoto-nous and from his youth only in military matters spe-cialist, and ignorant of other themes, and now at hisdecadence and approaching the old age, he has all thequalities the imperial environment needs for thethrone, ironically meaning they needed a willingnessand not a thinking man, and actually insinuated that theroyal councillors were using Michael as a puppet.23 Twochroniclers also characterize the emperor senile and

Figure 3 The Justinian Dynasty (AD 518602).



degenerated24 and old man, weak, incompetentemperor because of physical disability and old age.20

Finally, he was forced to leave the throne, as he wasincapable of carrying out his duties, and take themonks habit, because some characteristic features ofhis behaviour (insensibility, inactivity, ingenuousness)were incompatible with the duties of his office. Indeed,the lack of strong opinions on state affairs, the apathyand the motor problems described as weakness com-bined with mental decline disguised as laziness com-plete the symptoms of the possible diagnosis of aprogressive dementia.13

(6) Nicephorus III Botaneiates (AD 10781081)

There are several descriptions of Nicephorus III Bota-neiates diseases as a result of his prolonged life. He wasconsidered as a mild and sweet-tempered man, but atthe same time dull and indifferent to public issuesbecause of his old age, his illnesses and perhaps hisnatural indolence: not caring about state affairs.20 It isa common topic for the historians to characterize anemperor as mild, in order to express the degenerationof mental abilities and the lack of a strong will tradition-ally attributed to a leader. Ioannis Zonaras statedthat: The Emperor in very old age and because of hisnature indifference was not much involved with rulingmatters, probably denoting a withdrawal as a resultof dementia.21 Therefore, there is evidence that theemperor, although experienced in war expeditions, dra-matically changed during his last years (he died at the

age of 80 years), presenting signs of impairment of hismental functions. As no other diseases are mentioned inthe texts, it might be that his dementia disorders mainlycontributed to his inability to appropriately rule theempire.13

(7) Andronicus II Palaeologus (AD 12821328)

The historian, Nicephorus Gregoras,25 stated thatAndronicus II Palaeologus died at the age of 74 years,after having reigned for almost half a century. He alsomentioned that the emperor was idle, cruel and indif-ferent towards his citizens during his last years on thethrone, indicative of signs of senile dementia manifes-tations or simply as a consequence of his prolonged agemaking him unconcerned.13

Discussion

For many years, the term, Alzheimers disease, waslimited to cases with onset of symptoms before the ageof 65 years.26,27 The change in the worlds age demo-graphics and the rise in the incidence of age-relateddiseases, including dementia, is a source of major publichealth concern.28 The traditional practice of givingAlzheimers disease and senile dementia the status ofseparate diseases is probably attributable to the rela-tively young age of the patient originally studied by AloisAlzheimer29 (18641915), known as the psychiatristwith the microscope30 who discovered the characteris-tic lesions that cause the disease and were baptized with

Figure 4 The Macedonian Dynasty (AD 8671056).



his name.31,32 In the year 2006, some papers on thetopic were published commemorating the 100 years ofresearch into Alzheimers disease, attempting to reviewthe current status of our knowledge concerning behav-ioral, neuropsychological and neuropsychiatric aspectsof the disease.33

Dementia is said to have affected many personalitiesthrough the ages and to have not spared the politicalclasses, being therefore responsible for influencingsome historical events. The inability of a leader tocarry out his official duties as a result of cognitivedecline and behavioral changes might have playeda major role in subsequent catastrophic results. Theattempts to analyse royal diseases leading to mentaldisability, including psychiatric cases and senile demen-tia, have contributed to a better understanding of statecrises.7 Because of a lower life expectancy in medievaltimes (ranging from 40 to 50 years), all the aforemen-tioned emperors lives over 70 years were characterizedas prolonged enough. Their problems becomingextremely important because of their official duties.In every instance, it was politically and socially moreacceptable to interpret every manifestation of the rulersdeclining mental organization as an eccentricity and notas an early symptom of dementia. A possibility that wecannot completely disregard is that dementia could beoverdiagnosed in older patients with various psychiatricdisorders, as is often the case today.34 Byzantine medicalauthors dealt with dementia by using the Hippocratictheory of humors and the pneumatic theory of Galen.7

According to the first theory, mental illness occurredfrom the disturbance of the humor balance (for instancewhen the black bile was dominant the patient developedmelancholy), and the treatment was based on theremoval of the excess humor by phlebotomy, purgativesor enemas. The second theory suggests that the distur-bance of the three spirits the physical, the animal andmainly the mental were the main reason for the onsetof mental diseases.The therapeutic modalities had a very poor outcome,

a result still valid35 even in Emperors diseases, aiming atleast for the preservation and not for the restoration ofbrain function. Additionally, physicians suggested acertain diet, encouraged patients to increase their physi-cal activity and gave several medicines, believing in theholistic concept of the human being, and moving awayfrom prejudices and magical influences.36

The patients suffering from dementia were hospital-ized in special institutions called morotropheia andnot in the Byzantine hospitals, the so-called xenons.37

These institutions were founded in Jerusalem and Con-stantinople. The laws imposed for all patients sufferingdementia were not applicable in the cases of the emper-ors, as they were the actual legislators. However, a kingwas usually protected by his trustworthy councillors orthe empress. For the rest of the civilians, the law was

protecting their life and property. Such laws were ineffect in both the Byzantine and Roman Empire, andactually influenced the western European legal system.As a result, the senile patient was not legally responsiblefor his acts and usually a curator was designated toprotect his property and legal rights. This specific Byz-antine legislation for people with dementia is veryimportant and is regarded the result and evolution of JusRomanum.38

From the seven cases of senile dementia presented inthe present paper, four could be attributed to familybonds: Justin I and Justinian I were uncle and nephew,respectively, whereas Constantine VIII and Zoe werefather and daughter. No further hereditary backgroundwas traced in the rest three cases. The majority of theByzantine emperors came to the throne as members oftheir dynasty and suffered from various, not necessarygenetic, diseases, such as epilepsy, gout and arthritis,but dementia occurred exceptionally, as the two genea-logical tables show. Regarding the consanguineousmarriages of the royal Byzantines families, there is asmall number of known cases from the chroniclers andthe historians the Emperor Heraclius (seventh centuryAD) and his sisters daughter as his second wife andsome consanguineous relations without marriage theEmperor Manuel (12th century AD) and his sistersdaughter and the Emperor Andronicus (12th centuryAD) and his cousins daughter. However, it was notaccepted by the Church and the State and, as the studyof the Byzantine royal families shows, incestuous mar-riages were only exceptional.

Disclosure statement

Authors declare no financial support or relationshipthat may pose a conflict of interest.

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2012 Dementia

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