Health, Illness and Death

Evidence about health comes from human remains, images, chronicles, saints’ lives, and medical texts, all of which differ in reliability. Three miniatures in the London Gospels depict people with damaged limbs and devices that helped them move. Healed bone and muscle injuries suggest that such trauma could sometimes be treated successfully. Of 1,520 examined skeletons, 500 date from the twelfth to the fourteenth century, and some display joint and bone changes consistent with tuberculosis. This indicates that the disease was widespread and probably made a substantial contribution to mortality.

Individual narratives describe remarkable medical interventions. The boyar Voysil suffered severe mushroom poisoning and remained unconscious for three days; his relatives believed him dead and began his funeral. He was reportedly saved at the last moment with ternak, an antidotal mixture, and other known remedies. The physician Eustathius relates an even more unusual twelfth-century case from Sosk in Macedonia. A Frankish surgeon opened the bladders of two boys and removed from each a stone about the size of an egg. Eustathius did not witness the operations, but claimed to have seen both the stones and the resulting scars.

Healers travelled great distances, and their reputations could readily assume legendary proportions. The Life of John the New of Suceava mentions Persian and Indian physicians at Akkerman, near the mouth of the Danube, who were credited with curing severe wounds. In the Old Bulgarian tale of Queen Persika, doctors take the pulse of a lovesick prince and recognize that his suffering does not arise from physical disease. Salernitan physicians enjoyed particular international fame, while a Venetian manuscript dated 1200 records the appearance of eyeglasses. This reflects the wider medical world of the period, but does not prove that spectacles were used in Bulgaria.

Medieval texts use the word vrachilishte for a hospital or infirmary, but they do not unambiguously identify such an institution in the Bulgarian lands. The monasteries of Mount Athos maintained infirmaries, so similar facilities may have existed in some Bulgarian monasteries, although direct evidence is lacking. Poor people more often turned to charm-healers, prayers, and spells against fever, snakebite, rabies, stabbing pains, and diseases of the mouth and gums. Some texts were inscribed on lead sheets and worn around the neck as amulets. Fever, also called ognenitsa, was imagined as seven sisters who tormented the patient in succession.

For people unable to obtain expensive treatment, saints’ relics offered an important source of hope. Hagiographic accounts regularly credit relics with restoring sight or the ability to walk, but these texts were intended to glorify saints rather than provide medical records. When the relics of Saint Philothea were transferred to Tarnovo during Kaloyan’s reign, the procession was guarded by 300 soldiers under a commander named Theodore. Patriarch Euthymius recounts that Theodore had suffered for years from a white opacity in his left eye, which disappeared after he venerated the relics and brought the saint’s hand close to the eye. The story reliably demonstrates the strength of the cult, but the reported cure cannot be verified.

A similar account concerns Saint Sava, who was buried in Tarnovo’s Church of the Forty Martyrs. A lame monk named Neophytus came to the saint’s tomb after prolonged drinking and fell asleep there. According to the saint’s life, his disability had disappeared when he awoke. News of the event attracted many residents of Tarnovo, and the Church proclaimed the relics miraculous. The circumstances and the nature of the source make a medical explanation impossible.

Mortality was especially high among children, who were vulnerable to disease, hunger, and deprivation. The age of sixty was regarded as a biblical limit to the human lifespan. Osteological estimates from cemeteries give a mean age at death of about fifty for men and approximately forty-three for women, but these figures represent particular burial communities rather than a complete demographic record. At the cemetery near Kovachevo in the Pazardzhik region, 66 men and 34 women were buried over nearly a century. A single site cannot show that men outnumbered women throughout Bulgaria, although frequent warfare and heavy physical labour probably increased male mortality.

Seasonal deviations in the alignment of graves from the west–east axis have been used to estimate when the greatest number of deaths occurred. In village communities, mortality appears to have been highest in early spring, followed by winter, while summer and autumn were more favourable. Food supply mattered alongside the cold weather: poor households often exhausted their grain reserves at the beginning of spring, ushering in a hungry season.

Fragmentary reports mention three major waves of plague. Around the middle of the 1230s, the Hungarian wife of Ivan Asen II, one of his children, and the bishop of Tarnovo died. About half a century later, George Pachymeres described another pestilence in which people died one after another. The most severe outbreak was the Black Death of 1347. It travelled from Crimea to Constantinople, where Byzantine accounts claim that it killed half the inhabitants, and then raged for almost a year through the towns and villages of Thrace and Macedonia. These reports show that Bulgarian territories were also affected, although the scale of their losses cannot be calculated.

The ruler’s life was no more secure, though for different reasons. One reckoning of the fates of the twenty Tarnovo emperors identifies only four as having died naturally: Ivan Asen II, Theodore Svetoslav, George Terter II, and Ivan Alexander. Thirteen were killed or died amid conspiracies, coups, and other violence, while three escaped by fleeing abroad. Although the circumstances of some individual deaths remain obscure, violence at court was a persistent danger.

A ruler’s death was often explained through celestial omens. In his Hexameron—a work about the six days of Creation and the natural world—John the Exarch had already presented unusual stars as warnings of a monarch’s death. Halley’s Comet appeared in 1238, while Ivan Asen II died three years later. Despite this long interval, George Akropolites connected the events and treated the “tailed star” as a warning. Such interpretations reveal no actual causal relationship, but show how medieval writers gave meaning to political events.

Orthodox practice required the dead to be buried in consecrated ground, usually beside a church or chapel. Cemeteries were often situated within settlements, and small burial grounds containing as many as roughly one hundred graves developed around the functioning churches on Tsarevets. Larger cemeteries were established beside some Tarnovo monasteries and probably served wealthier inhabitants. Boyars could be interred in family churches. The churches of Saint Demetrius of Thessaloniki and the Forty Martyrs, together with the palace church, served as royal burial places.

Material remains demonstrate the splendour of the highest-ranking burials. The grave associated with Kaloyan contained a coffin and a gold-woven garment decorated with gold embroidery and numerous pearls. The lower part of a sarcophagus attributed to Ivan Alexander was found in the palace church; its relief preserves the ruler’s boots, decorated with double-headed eagles. Another relief from the Church of the Forty Martyrs is associated with Anna Maria, the wife of Ivan Asen II. The same church yielded an inscription commemorating the death of Ivan Asen, the third son of Ivan Alexander.

Western European travellers who crossed the Bulgarian lands after the fourteenth century describe the funerals of ordinary people. Their observations may preserve older customs, but must be applied cautiously to the period of the Second Bulgarian Empire. Professional mourners were hired to weep, beat their breasts, scratch their faces, and pull out their hair. The chief mourner sang of the deceased person’s life and virtues, beginning with birth and ending with the final days.

Royal funerals were more restrained and ceremonial. A miniature in the Vatican copy of the Chronicle of Manasses depicts the funeral of Ivan Asen, son of Ivan Alexander. The emperor, the mother Theodora, the widow, and one of the royal sons stand around the body, all wearing ceremonial dress. White cloths in the hands of the emperor and empress signify mourning, since white could serve as a colour of grief in the Middle Ages. The patriarch of Tarnovo and the clergy perform the funeral service, while an angel in the upper part of the image carries the dead man’s soul towards heaven.

Ordinary dead were placed without coffins in rectangular pits, lying on their backs with their faces turned west and their arms crossed over their chests. Christian ritual coexisted with older beliefs. Some graves contain a “Charon’s obol,” a copper coin placed in the mouth to pay symbolically for passage into the next world. Eggshells and bird bones in other burials are likewise interpreted as survivals of pre-Christian custom.

Particularly strong was the fear that a dangerous dead person might return as a vampire and harm the living. Sorcerers, witches, murderers, brigands, thieves, and people with mental disorders were considered especially liable to such a fate. Nearly one-third of the graves at the Kovachevo cemetery bear traces of actions interpreted as precautions against vampirism. Fires were lit over graves, the burial was fumigated with embers, or the pit was covered with stones. Sometimes a grave was reopened and the dead person’s chest or heel was pierced with a hawthorn rod or thorn. The most extreme interventions involved breaking limbs or removing a hand or parts of the feet; traces of such treatment occur in about one-tenth of the graves. This may have been the ritual called gadaystvo in the Virgin Charter of Constantine Asen. Archaeology can establish what was done to a body, but its connection with a particular belief remains a matter of interpretation.