Chryssi Bourbou's Health and Disease in Byzantine Crete is the first of a new series of books devoted to medicine in the medieval Mediterranean. This collection considers various approaches to medical issues (from textual to archaeological and palaeo-pathological data) in a medieval Mediterranean world defined broadly, namely the Byzantine world and the cultures that interacted with it. With its original approach and focus, Bourbou's book is, in this respect, a fitting start for this series. The result of several years of research on Cretan archaeological sites, more specifically on the bio- archaeological data that may be gathered from cemeteries, the book focuses on what skeletal remains reveal about the health, diet, breastfeeding and weaning patterns of a Byzantine population in its cultural context. This is a subject that has been relatively unexplored--little has been published on the daily life of common people in Byzantine studies, but is part of a recent surge of interest in the history of Byzantine diet (e.g. Leslie Brubaker and Kallirroe Linardou, eds., Eat, Drink and Be Merry (Luke 12:19): Food and Wine in Byzantium, 2007), and in the Byzantine culture of childhood (e.g. Arietta Papaconstantinou and Alice-Mary Talbot, eds., Becoming Byzantine: Children and Childhood in Byzantium, 2009). Bourbou's major originality and contribution to these topics is her thorough analysis of bio-archaeological remains, which complements ideally any textual and archaeological study of these subjects.
The purposes of the study are clearly outlined by the author: "the analysis and interpretation of lifestyle and disease in Byzantine Crete through the study of human skeletal remains and the use of innovative techniques such as chemical analysis (stable isotopes) for the reconstruction of dietary, breastfeeding and weaning patterns." (1) Studies of skeletal remains for Byzantine populations are generally lacking: systematic excavation of Byzantine cemeteries is wanting, or has been poorly done, even more so for Crete. This study is based on the data from 445 individuals excavated in six Cretan sites (three sites by the author herself), dating mostly from the 6th- 7th centuries and the 10th-12th centuries. The strength of Bourbou's approach is her original combination of different disciplines to reach an interactive picture of a population's physiology, culture and environment. Indeed, she carefully pairs, with her bio-archaeological analysis, relevant archaeological and/or textual records whenever possible, framing the raw data provided by skeletal remains into a cultural context. Saints' lives, medical works and canon law find thus a place of choice in this study as well. Ultimately, the author expresses the hope that human remains will attract more public attention in the future and their importance be recognised, notably by museums; she also envisions her careful methodological approach becoming a model for future studies of health and disease patterns in past societies.
This concise book is organised in four chapters. The first surveys the relationship between human populations and their natural and cultural environment, i.e. Crete in the early and middle Byzantine period, so as to characterize the general health of this group and its individuals. The second and third chapters analyze pathologies visible on human remains from six Cretan sites, respectively for adult and non-adult populations. The fourth is devoted specifically to dietary, breastfeeding and weaning patterns in the Byzantine population in general, on the basis of stable isotope analysis. In this chapter, data from Crete is supplemented with sites from mainland Greece.
In Chapter 1, Bourbou provides the historical, archaeological and methodological settings of her data. The history of Byzantine Crete is little documented in primary texts, and medieval descriptions of the island are "of little value" for the author's specific purposes (17-18), most essentially to determine the economic, social and medical contexts of the skeletal remains analyzed in the following chapters. In many ways, therefore, this part of the study leaves the historian a little frustrated. More appears from archaeological data on settlements and housing, however, particularly for the middle Byzantine period. The image of Cretan environment and society that emerges is, respectively, that of a fertile self-sufficient land with the potential for a balanced diet, and of a rural world of smallholding peasants living in densely populated houses lacking sanitary facilities. Parameters and methodology are also set up at the end of this chapter, notably the description of the six excavated cemeteries, criteria for determining the sex and age of the 445 analysed human remains, their repartition between the various sites, as well as the categories of health disorders studied.
Chapter 2 determines the types and frequency of diseases observable in the adult population of Crete during the studied period. Eight categories of pathological conditions observable on bones are organised from the most frequent to the rarer types with, for each, protocols of diagnosis, tables organising the findings in relation to sex and age groups, and their distribution by sites and time periods (early and middle Byzantine). The meticulous care with which the author has drawn these detailed tables is evident; her approach to each pathology, her careful emphasis on the limits of her observations and, ultimately, of the results obtained--precise or not--will undoubtedly prove helpful to scholars in the field. Unfortunately, the possible conclusions about health and disease one may reach are limited, although this is inherent to the nature of the evidence, not a fault from the author. For instance, many of the pathologies observed, such as anaemia, may be the results of multi-factorial causes; or, there are issues related to how representative an observed pathology, an infectious disease for example, is in comparison to the general health of the population. Clearly, this discipline will benefit from the constant refinement of methods and techniques. Yet, Bourbou does manage to portray a society where prevalent health concerns appear in the dentition of the middle-aged and male population, pointing to a lack (if not complete absence) of teeth hygiene and, possibly, a diet in protein richer than what previous studies had indicated. Osteoarthritis, revealing mechanical stress on the joints due to daily activities, is the second most common pathology. This condition, found mostly among younger males, shows that laborious work was taken up early on and may have affected people's quality of life. Frequent cases of bone fractures also point to a life marked with accidents, occasionally violence, where no medical treatment was provided to heal such conditions.
Chapter 3 offers an original focus by being devoted exclusively to children, often forgotten in similar data and studies. Information regarding infant mortality, as well as breastfeeding and weaning patterns, is set against what we know about them from documents, notably medical and hagiographic, and from art. The author cautiously warns against the limits of a bio-archaeological approach, however: many factors may have caused an infant or a child's untimely death, which do not necessarily appear on bones and teeth. There are also problems inherent to the preservation of young bone remains, and questions regarding the representativeness of the sample used. In fact, not many conclusions may be drawn at this point, except observing that child mortality surpassed infant mortality, most likely because of poor sanitary conditions and of specific weaning approaches.
In contrast, the last chapter has more to offer. Analysis shifts from bones and teeth lesions to the stable isotope content in collagen (thus, the chemical signature of food on human bones), a good indicator of diet. Once again, the study is paired with documentary evidence on Byzantine diet, newborn feeding practices and nutrition; the limits of stable isotope analysis are also carefully laid out. In this case, the data collected includes a total of nine sites, six of them from mainland Greece (coastal and inland). Differences between the results from these sites, or according to gender, are strikingly small and offer thus the possibility to paint an overall diet for the early and middle Byzantine man and woman. Such data is an important complement to historical approaches, as it allows us to determine whether the food described in Byzantine recipes was actually consumed in daily life (vetches, for instance). Moreover, while texts are essential sources for our knowledge of dietary habits, they often describe situations of feast or fast that are not necessarily representative of regular consumption (for example, alleged differences between genders). Unsurprisingly, Bourbou's results highlight a Mediterranean diet essentially made of grain (wheat and barley), oil and wine, supplemented with animal and (some) marine protein. More compelling are the results of her study of breastfeeding and weaning practices. Medical texts related to the care of newborns highlight a late weaning age (two years or more), as well as the custom of feeding newborns with honey and goat milk, putting them at risk of developing botulism and anaemia. All these phenomena may be observed on the remains analysed: breast-milk was part of some infants' diet well into the third year, and weaning completed by four; health problems likely related to the use of honey and goat's milk are visible as well. Finally, clusters of death around weaning age suggest stress induced by the introduction of certain types of food and weaning patterns that may be more culturally defined, which, as the author admits, would require further analysis to be interpreted correctly.
A glossary of medical and scientific terms, an extensive bibliography (179-238) and an index follow the summary of the author's findings. While Bourbou's analysis contains remarkable minutiae, the results obtained can only be relatively general. Yet they cannot be ignored, as they touch upon a fringe of the population little described by other sources; her observations provide, therefore, an indispensable complement to textual analysis, which historians should not overlook. A helpful glossary of medical and scientific terms at the end of the book helps the lay reader navigate through the technical aspects of this study, although a few more explanations would have been helpful here and there (notably the concept of stable isotope analysis, which could have been defined briefly when first introduced at the beginning or in the glossary at the end, rather than in the last chapter). This is but a minor criticism for an important contribution to the study of health and diseases in Byzantine society. More studies of this kind are needed; hopefully, Bourbou's careful approach will encourage them.