Unlike the west, Byzantium inherited a multitude of medical schools from its ancient past. It was able to draw on these, in particular the prognostications of Hippocrates and the analytical and philosophical skills of Galen and to develop a highly sophisticated medical system, capable of identifying and dealing with many diseases that were only rediscovered in the later part of the millennium.
The basis of Byzantine medical theory was two-pronged. The first took inspiration from the neo-Platonist philosophers of the Hellenistic era and the writings of Saint Athanasius, celebrating the immortality and purity of the soul while understanding that the nature of the body is weak and corruptible. Thus much emphasis was placed upon spiritual as well as physical healing, the maxim healthy mind in a healthy body being much valued. The theological basis behind physical healing, was that man had been created in God’s image. The human body belonged to God and had to be properly looked after. Byzantine theory also provided an explanation for the origin of sickness. Adam and Eve’s disobedience in Eden had brought disease and death into the world.
Byzantium also had an ultimate role model, of greater standing than Asclepius or Hippocrates of the Ancients. Christ, the Son of God healed the sick and exhorted his apostles and disciples to give proofs of His own divine powers by acts of healing. Some thirty five miracles are recorded in the Bible and the apostles exercises healing as a ‘gift of the holy spirit.’ As a result, a plethora of icons and miraculous relics proliferated throughout the Empire. Sober theologians and clerics were careful to point out that cures by holy oil, relics or baptism should be considered divine providence and not as a routine health service. However, healing through the intercession of saints was firmly imprinted within the consciousness of all Byzantines. Certain saints were said to prevent diseases. St Charalambos and St Christophoros guarded against epidemics, Saints Blasios and Nikostratos were held to prevent diseases of the larynx, Saints Antypas and Apollonios were the patrons of dental care, Saints Stylianos and Therapon of paediatrics and Saint Aegidius the Athenian of psychiatry. Pride of place was taken by Saints Cosmas and Damianos, who as the tradition relates, performed the first organ transplant in the history of medicine, attaching a recently deceased black person’s leg to an amputee.
Byzantium enjoyed the first organized health care system anywhere in the world. Early Christian traditions of help and hospitality were extended and Christ’s instruction to His Disciples to care for the sick and needy assumed institutional form through the appointment of deacons whose purpose was to ensure the needy received a daily food intake. Leontius, bishop of Antioch from 344 to 358 AD set up hostels around his city and Bishop Eustathios of Sebasteia built a poorhouse. Saint Basil the Great of Caesarea built what was described by contemporaries as ‘almost a new city’ for the sick, poor and leprous. In even the most insignificant monastery, a section was set aside for healing, while in the towns and villages, small clinics were set up which were staffed by both men and women
Ultimately, nosokomeia became large and complex. The great hospitals were run co-operatively by the State, the Church and the noble families of the Empire. Medical care in the hospitals was always provided free of charge for the poor, while the well-off were charged in accordance with the magnitude of their wealth. Many noble families such as the Thalassinoi and the Komninoi granted large tracts of land to the hospitals which provided them with a steady income with which to fund their activities. By the mind sixth century, Jerusalem had one with 200 beds and Saint Sampson’s in Constantinople was bigger still, with surgical operations being performed and a wing for eye disorders. Edessa had a women’s hospital and major hospitals at Antioch and Constantinople were divided into male and female wards. By 650, the Pantokrator in Constantinople and the Ptokhotropheion of Mikhail Attaleiatos had a hierarchy of physicians and even teaching facilities, a home for the elderly and beyond the walls of the City, a leper house. To care for lepers and thus expose oneself to infection was a mark of holiness. Such a spirit of charity would eventually pervade the West with the advent of the Crusaders, whose Hospitaller Knights would adopt the medical ethos of Byzantium.
As well, the State arranged for the creation of a public officer known as the kouratoras who was charged with the duty to ensure the welfare of the sick, invalid or pregnant after the death of their spouse. Of great importance also was the creation of the office of paravolanos. The duties of the paravolanos were similar to those of a modern day social worker: to counsel the sick, the poor and those in emotional anguish.
Thus emphasis was given to the psychological and not only the physical aspects of an illness. The need to take a holistic approach to treating illness was lost and rediscovered only in the nineteenth century. Indeed, psychological manifestations of anguish were treated as seriously as physical ones. Thus, psychoanalysis was used as a necessary tool to establish the patient’s state of mind. St Gregory of Nyssa and Saint Athanasios placed great emphasis on the patient’s right to make informed decisions as to their medical treatment. Psychoanalysis was also used to help bring patients out of states of shock and also to assist them to deal with the emotional trauma associated with their illness.
Mikhail Psellos and Saint Basil the Great were pioneers of a program designed to help reduce alcoholism among the working classes. They also piloted a program for conducting medical examinations of couples that wished to marry, so as to identify any hereditary problems, such as epilepsy, leprosy and schizophrenia.
Most importantly, the theory of medical care for the working classes was introduced, where injured workers could be compensated, treated for their injuries and provided with an income if they proved unable to work. In the legislation contained in the Basilika, Pandektae of Emperor Leo the Wise, we see the Byzantine ethos of medicine was inextricably intertwined with modern ideas of the welfare state.
In the sphere of medical knowledge, Byzantine doctors and researches were able to extend the findings of their ancient predecessors. Oribasius of Pergamon in Asia Minor, physician to the emperor Julian the Apostate studied at Alexandria and published three influential books, dealing with hygiene and diet and the properties of drugs. Oribasius correctly described the flow of oxygen in the lungs as well as the flow of blood in the arteries. His most striking feat was the delineation of the nerves. Demonstrating their source in the brain enabled him to conclude they played the part preceding thinkers had ascribed to the arteries: transmitting motor impulses from the brain to the extremities. Oribasius also wrote a practical medical compendium for the traveller.
Aurelianos in 420 established the first microbiological laboratory in the world, while Alexander of Tralles was able to prescribe simple remedies, based on plant matter, such as rhubarb, as a laxative.
Paul of Aegina (640) who studied and practiced in Alexandria, used the writings of the physician Galen as his inspiration. He wrote a treatise on gynaeocology and poisons which are not extant. His greatest work was the publication of a medical encyclopaedia known as Seven Books of Medicine. It opens with pregnancy, the diseases of childhood and of old age and then passes on to diet and healthy living. Illness is dealt is dealt with in Book II. Maladies affecting specific parts are treated from head to toe. Mental illness is also dealt with, with revolutionary methods prescribed. Treatment is to be gentle, with the use of music, the teaching of skills and daily conversation, in order to integrate the mentally afflicted into society. Book IV deals with skin diseases, beginning with scabies and elephantiasis and progressing to herpes, oedemas, cancers and ulcers The other books deal with the effect of toxins on the body, surgery, including an account of tracheoctomy. As a practical introduction, his Epitome was esteemed by Islamic physicians.
To all these physicians, complex medical knowledge, such as the anatomy of the eye was known and cataract operations did take place. Cancer was also known and many doctors attempted to remove tumours through surgery, use of herbal medicines and even physiotherapy.
Geriatrics was developed as a separate science and practitioners such as Nikolaos Myrepsos observed and record the changes of the body as it ages as well as to provide a manual of diseases and ailments that are prevalent among the aged.
Alternative forms of healing were common even in those times. While Oribasius raged against the proliferation of newfangled methods and cures, Theophanos Nonnos was a pioneer of physiotherapy for many injuries, prescribing also a course of messages and thermal baths to his patients. His treatment of septic shock was revolutionary. The sick were isolated inside a glass chamber, which served as an intensive care unit.
Narcotic herbs were used as local and general anaesthetics, while contraception through the use of various plants was known and there are recorded instances of successful hysterectomies, lobotomies of the liver and lungs, tonsils, and hemorrhoids.
Most importantly, Byzantine doctors placed great emphasis on prevention, as opposed to cure. Public sanitary measures were put in place by Paul of Aegina, Saint Basil the Great and Nikolaos Myrepsos to prevent the outbreak of cholera, typhoid and plague, while preparations were created to help prevent the contraction of many contagious diseases, including hepatitis and some forms of cancer. On the same token, pollution of the environment was identified as hazardous to public health and the drainage of malarial swamps was organized, while regulations were implemented for drainage and sewerage, planning of residential, commercial and industrial zones within cities to avoid exposure to dangerous pollutants and laws as to waste disposal, treatment of water and methods of food handling by retailers and primary producers.
Steps were also undertaken to ensure medical knowledge was passed through the generations. At the renowned medical colleges of Constantinople, Smyrna, Pergamum, Antioch and Alexandria, medical students were taught theory as well as practice, while the texts taught were collations of the works of Galen and Hippocrates, as summarized by the greatest of the contemporary physicians.
It is interesting to note that while there was much co-operation between the State and the medical profession during Byzantine times, given the holiness of the profession, medical negligence was severely punished. The Theodosian and Justian Codices prescribed different penalties for offences relating to inexperience, negligence, fraud, violence or illegal surgery, which included castration and abortion, as embryos were considered human beings with rights. Penalties ranged from being forbidden to practise, fines, confiscation of property and in some cases, execution.
Eventually, Byzantine medicine began to wane. The huge economic and social upheavals created by constant invasions of Persians, Arabs, Avars, Slavs and Turks caused a great decline in the opportunity to study and practise. Many doctors began to flee to the West, whose medicine was still in a primitive state. Byzantine doctors were also carried as captives into the Arab sultanates. Carrying their textbooks with them, they were able to modernize and revolutionize Arab medicine. Many ancient texts were copied and preserved by the Arabs, which otherwise would have been lost to the world. The influx of refugees to the West as a result of the Ottoman conquest sparked off a Renaissance in medical thought which can be linked in an unbroken chain today. In understanding the emotional as well as the physical aspects of personality and linking them to an ethic of philanthropy and social cohesion, Byzantium was able to achieve a system far ahead of its time. That it was able to do so in a world filled with internal conflict and barbarism is the apogee of its achievement.
First published in NKEE on 5 and 12 May 2012