This article discusses a unique case of a miraculous fish therapy used for a variety of skin diseases, which seems to have been practised in the mid-fifth century at the shrine of St. Michael in the city of Germia (mod. Gümüşkonak). It aims to enhance our knowledge of Byzantine therapeutic approaches to ‘elephant disease’ and contribute to debates on modern fish spa therapy.

Leprosy, also known as Hansen's disease, is a chronic infection caused by Mycobacterium leprae, along with the recently discovered Mycobacterium lepromatosis,Footnote ¹ and affecting the skin, peripheral nerves, and mucous membranes. It is characterised by flat, red lesions, which may progress and cause severe skin disfigurements. Palaeopathological evidence attests to its existence in the Mediterranean area from the Hellenistic period.Footnote ² Ancient and medieval societies did not share the modern scientific understanding of the disease and in most cases there were no clear boundaries or differentiation between a variety of skin ailments. The Greek term elephas/elephantiasis, which is literally translated as ‘elephant disease’, is nowadays likely to be identified with various types of leprosy and has nothing to do with the modern use of the term elephantiasis, while the word lepra was used for a similar, but much less serious, skin disease which was not life threatening.Footnote ³ The latter term may be associated with a variety of skin disorders that turned the skin scaly or flaky, comparable to today's eczema or psoriasis.Footnote ⁴ It is important to note the lack of any comprehensive palaeopathological study on leprosy in the Byzantine empire, which seriously limits our understanding of how widespread the disease actually was.Footnote ⁵

It is mainly from literary sources that we get any information about the disease, which inter alia entails the risk of retrospective identification based on modern knowledge, methods, and terminology.Footnote ⁶ For example, the healing of those suffering from elephant disease was quite a popular topic in the works of the early Church Fathers. When combined with related evidence from a variety of other more or less contemporary literary sources, this might signal a considerable increase in the number of elephant disease cases between the fourth and sixth centuries AD.Footnote ⁷ Subsequently, a special home for the care of lepers, the ‘leprosarium’ of St. Zotikos, was set up on the outskirts of Constantinople. Although the construction of this institution cannot be dated with complete certainty, it seems to have functioned continuously at least between the tenth and thirteen centuries.Footnote ⁸ In Byzantine therapeutic approaches to elephant disease we can discern two distinct pathways. Byzantine medical authors, such as the seventh-century practising physician Paul of Aegina, emphasized the incurable nature of the disease and recommended various techniques of venesection in association with strong purgatives which might help alleviate some symptoms.Footnote ⁹ On the other hand, the power of miraculous healing, which enjoyed significant popularity and to which great importance was attached by medieval Christians, was often attributed to holy springs associated with the cults of particular saints. In the case of elephant disease, the late thirteenth-century Byzantine poet Manuel Philes, for example, recounts the story of a male patient in an advanced stage of the disease, who was healed after venerating the miraculous icon of the Mother of God of the Life-giving Spring (Zoodochos Pege).Footnote ¹⁰

In what follows, I would like to draw attention to a unique case of fish therapy for elephant disease and other skin diseases in Byzantium, which has hitherto been overlooked by medical historians and specialists studying Byzantine and western medieval history.Footnote ¹¹ This case study may also add to the current widespread debates on modern fish spa therapy, a practice which has enjoyed considerable popularity during the last few years across a large number of countries.

Among other places mentioned in an as yet unpublished Byzantine collection of miracles of St. Michael composed by a certain deacon Pantoleon,Footnote ¹² most probably shortly after the second half of the ninth century,Footnote ¹³ there are a couple of paragraphs recounting cases of miraculous healing at Germia (mod. Gümüşkonak). The city is located in western Galatia below Mount Dindymon (mod. Arayit Daği) and lies 120km southwest of Ankara.Footnote ¹⁴ According to the story, when Studios,Footnote ¹⁵ consul in 454, was treated there, he restored the church of St. Michael (probably identifiable with the most obvious extant early church, a five-aisled basilica), and erected homes for the sick (xenodocheia) and aged (gerokomeia). Germia subsequently became an important healing centre and pilgrimage site. Interestingly, it is attested that even Justinian visited the shrine in 563 at the age of 81, although we have no details to confirm whether or not he sought healing.Footnote ¹⁶

Great emphasis is laid on the miracle accounts of the holy water (hagiasma) found in the city of Germia, with which patients anointed the affected parts of their bodies. In the case under examination, visitors seeking healing are referred to as leproi (those suffering from lepra), elephantiontes (those suffering from elephant disease), people with withered hands and feet (xeras cheiras kai podas), and those suffering from a great many other ailments of all sorts (pleista kai pantodapa pathe). According to the story, at God's command the fish (ichthyes) in the waters licked the patients’ bodies all over. Instantly cured of chronic and more recent diseases (chronion te kai nearon), both hidden and visible ones (kryphion kai faneron nosematon), the pilgrims then glorified God and St. Michael.Footnote ¹⁷ Although the author attempts to include all possible diseases, there is significant emphasis on chronic skin diseases, including elephant disease. At the end of the narration there is a reference to the aforementioned consul Studios, who personally testifies to the truth of the miracle, which seems to date to the mid-fifth century.

The account implies the existence of a fishpond, whose water was probably supplied by a nearby spring, where a process of balneotherapy took place. What is extraordinary is that, in contrast to other Byzantine miracle stories, the healing power of the holy water is here reinforced by the use of a living agent, i.e. the fish. Although we are aware of other sacred springs with fish in the ancient and medieval world, there is no available evidence to attest to their direct use for healing purposes as in the case of Germia.Footnote ¹⁸ In the absence of any archaeological excavation in the area or any other literary sources reporting a case of fish therapy, it has not been possible to check the veracity of the account. It is, however, noteworthy that the so-called doctor fish, Cyprinion macrostomum Heckel, is today native to the wider area of Anatolia. Furthermore, in three survey campaigns directed by Philipp Niewöhner in the area in 2009–2011, archaeologists, using geomagnetic measurement techniques, revealed the plan of a large enclosure above some ancient walls. It consists of a central square (35m x 35m) that is empty and a surrounding group of buildings; several architectural elements point to a Byzantine date. According to one interpretation, this structure could be the location of the healing fishpond, something which is substantiated by the existence of a nearby thermal spring.Footnote ¹⁹ Moreover, the chemical analysis of the thermal waters of the area has emphasized the extremely high concentration of hydrogen sulphide, which has traditionally been considered to have therapeutic value for skin diseases.Footnote ²⁰

This case of Byzantine fish therapy assumes even greater importance in the light of recent discussions on the rapid expansion of fish spa resorts in various countries over the last decade, including Japan, China, Belgium, Spain, the U.K., Finland, and the U.S.A. Many people who visit these places are not suffering from any disease, but simply look on it as an alternative form of pedicure in which doctor fish are used to clean and exfoliate the skin. The method has been banned in several US states and Canadian provinces on sanitary grounds.Footnote ²¹ More specifically, in the United Kingdom a group of experts under the aegis of the Health Protection Agency published guidance in 2011, which, although it acknowledged the reported risk of infections to be very low, made several references to the potential spread of hepatitis B and C and even HIV, if good hygiene was not maintained. Furthermore, fish spas were not recommended for patients with weakened immune systems or underlying medical conditions such as diabetes and psoriasis.Footnote ²² Subsequently, the British media reproduced parts of these guidelines, putting great emphasis on the health risks, which led to a substantial reduction in the use of fish spas in the UK.

Perhaps the most famous fish health spa in the world is situated in the Kangal district of Sivas in Turkey, which lies about 500?km east of Germia, and has been officially recognized as a treatment centre by the Ministry of Health of the Turkish Republic since 2004. It consists of five pools with two species of healing fish, Cyprinion macrostomum Heckel and Garra rufa obtusa Heckel; the average water temperature is 35°C (95°F). In a recent study involving 87 patients who were diagnosed with psoriasis vulgaris by a dermatologist, 8 out of 14 patients (57.14%) who spent 7.4?hours a day in the spa for the maximum recommended period of 21?days recovered completely. It was observed that, from the very first day, the squamae were totally removed from the patients’ bodies by the fish.Footnote ²³ Another later study by some members of the same research group concluded that the treatment of psoriasis in the spa was not achieved solely by the fish, but rather that the entire process should be considered a method of balneotherapy-climatotherapy in which other factors such as the high concentration of selenium in the thermal waters and the effect of natural UV light also play an important role.Footnote ²⁴ Although the therapeutic effects of fish therapy are still controversial among the modern medical community, our Byzantine example is testimony to the fact that therapeutic methods in pre-modern societies were not as restricted as one might assume. People sought out alternative methods and even sought to combat severe skin diseases.