BYZANTIUM: History, Achievements and Medicine – N. S. Angelides MD, PhD, FRCS, FACA, FIUA -RESEARCH

Prologue Historians correctly considered Byzantium as a Greek Empire. Officially, it started as the East Roman Empire and its citizens were “Romans” formed by Greeks, Syrians Armenians, Slavs etc. But the influence of ancient Greek culture, philosophy science and language as well as the influence of Christianity was so great on this newly formed Empire so that Byzantium can be considered not as a Roman Empire but as a Christian Greek Empire.

N. S. Angelides MD, PhD, FRCS, FACA, FIUA


Historians correctly considered Byzantium as a Greek Empire. Officially, it started as the East Roman Empire and its citizens were “Romans” formed by Greeks, Syrians Armenians, Slavs etc. But the influence of ancient Greek culture, philosophy science and language as well as the influence of Christianity was so great on this newly formed Empire so that Byzantium can be considered not as a Roman Empire but as a Christian Greek Empire.

Fig 1: Byzantium can be considered as a Greek Empire

Agia Sophia

Isidoros and Anthemios designed the church of Agia Sofia, which was completed in 537 AD. Previous attempts were burned down by fanatics and earthquakes. The church was so big that it had to be repaired several times after the earthquake of 557 AD, when the dome collapsed, as well as in 869, 989, 1344, 1766 and 1894.

Agia Sofia is considered as the most impressive building of the Empire. The Emperor Justinian whispered upon its completion: “My God, I am grateful to you for choosing me to complete this monument” and added “Solomon I have defeated you!”

Fig 2: The church of Agia Sophia in Constantinople

Crises in Byzantium

In 532 AD, a crisis, the “Nika riots” took place, in which around 30.000 people were killed and many buildings in Constantinople were destroyed. This crisis was related to chariot racing teams of the Hippodromes.  The emperor, Justinian, was about to flee, but Theodora, his wife, convinced him to stay.

A greater crisis was the so-called plaque of Justinian, a bubonic plague outbreak that killed 5000 people in Constantinople each day! At the end, 50% of the city population died.  Finally, around 25 million died – one quarter of the population – in the Eastern Mediterranean region!

Respectable progress in Medicine in the Byzantium

Medicine, one of the sciences of greatest importance for the survival of humankind, has evolved over thousands of years in various parts of the world; initially mixed with superstition, magic and supernatural beliefs, this discipline has slowly moved away from myth and theurgy and landed into the field of rationality, observation, experimentation and what we have come to consider a scientific way of thinking.

Fig 3: Ancient Greek Medicine influenced next generations

As illnesses and trauma have always been part of human existence, multiple approaches to healing were developed in various parts of the world. Mesopotamia, Egypt and Chine are among the places were the first forms of systematic medical treatment appeared. Ancient Greece and, later, the Byzantine Empire greatly contributed to the evolution of medicine, and its transformation into a concrete science, thanks to many step by step figures, discoveries and advancements that shaped the course of medical history. The influence of the Byzantine civilization in transmitting the learning of antiquity across the dark age was significant.  

Fig 4: The Hippocratic Oath

There was one field in which the Byzantium made respectable progress, and this was the field of Medicine. The Byzantines of that time could mentioned among others two great medical men: Aetius (502-575 A.D.) and Paul of Aegina (620-690 AD).

The works of Aetius were of great value, because they recorded the teaching of many of his eminent predecessors. But beyond this aspect he was not lacking in originality. He was the first physician to mention diphtheria, and reported some observations on the paralysis of the palate, which sometimes was following this disease.

Paul of Aegina, belonged to the Alexandrian School and was one of those remarkable men, whose ideas were centuries ahead of their time. This was particularly true regarding surgery.  He was a brilliant surgeon, mainly familiar with military surgery. Some of his descriptions on complicated and difficult operations have been only slightly improved upon, even in modern times.  In his books there were descriptions of operations such as the removal of foreign bodies from the nose, ear, and esophagus.

But what is exactly the Byzantine Medicine? Byzantine Medicine is the medicine practiced in the Byzantine Empire from 400 AD to 1453 AD, that is to say for a thousand years’ period.

Medicine was one of the sciences in which the Byzantines improved the results of their Greco-Roman predecessors. As a result, Byzantine Medicine had a significant influence on Islamic Medicine and the Western rebirth of Medicine during the Renaissance.

Fig 5: The art of heeling. “What cannot be treated by drugs can be treated by knife”

Constantinople was the imperial capital of the East Roman Empire-the Byzantium, and also of the Ottoman Empire. No doubt was the center of activities in the Middle Ages, owing to its geographical position, wealth and accumulated knowledge.

Fig 6: A remarkable mosaic of the 6th century, at Kiti (Cyprus), is probable the best example of Byzantine Medical art and Christianity of that time. Another equally remarkable mosaic of roughly the same date, found at Lythrangomi (Cyprus), was destroyed in 1974 during the Turkish invasion of Cyprus.

Among the first prestigious Byzantine Physician was Dioscurides who wrote a manuscript for the daughter of the Emperor Olybrius around 515.

Like most Byzantine physicians, he drew his material from ancient authorities such as Hippocrates and Galen, although this does not mean that Byzantine Physicians did not make corrections to the “fathers of Medicine” or did not make original contributions.

Oribasius, perhaps the greatest Byzantine compiler of medical knowledge, frequently made revisions underlining where older methods had been incorrect. Several of his works, along with many other Byzantine physicians, were translated into Latin, and eventually, during the Renaissance period and the Age of Reason into English and French.

More Original medical work made in Byzantium 

Another Byzantine treatise of the thirteenth century written by Nicolas Myrepsos, remained the principal pharmaceutical code of the Parisian medical faculty until 1651, while the research of Demetrius Pepagomenos (thirteenth century) on gout, was translated and published in Latin by the great humanist, Marcus Musurus, in Venice, in 1517.

Therefore, it could be argued that previous misrepresentations characterizing Byzantium as being simply a “carrier” of Ancient Medical knowledge to the Renaissance are completely incorrect. It is also known that a late twelfth century Latin physician at Salerno (Roger of Salerno), was influenced by the treatises of the Byzantine doctors Aetius and Alexandros of Tralles as well as Paul of Aegina.

The last great Byzantine physician was Ioannis Actuarios, who lived in the early 14th Century in Constantinople. His works “on Urine” became the foundation for farther studies in that field. However, from the late 13th Century to the end of the Empire in 1453, there was little outpouring in medical knowledge, largely due to the pressure the Empire was facing on both fronts and the decreasing population of Constantinople due to plague.

Nevertheless, Byzantine medicine is extremely important both in terms of new discoveries made in that period, of the careful protection of Ancient Greek and Roman knowledge through compendiums, as well as the effect it had in transferring knowledge to both Renaissance Italy and Arabia.

Hospital establishments in Byzantium

An important contribution is that Byzantium was the first Empire in which dedicated medical establishments —usually set up by individuals, Church or the State— were organized in a similar way to modern Hospitals. Although such establishments existed in Ancient Greece and Rome, they were only institutions for Military use or places where citizens went to die in a more peaceful way. Medical Institutions resembling modern Hospitals were common in major Cities of Byzantium such as Constantinople and Thessaloniki.

The first hospital was built by Basil of Caesarea in the late fourth century, and although since then such Institutions flourished in Byzantium, it was only in the 8th and 9th Centuries that they began to appear in Provincial Towns and Cities. Towards this, helped the Justinian’s subsidization of private physicians to work publicly for six months of the year.

Byzantine Medicine was entirely based around the Hospitals or the walk-in dispensaries which formed part of the Hospital complex. In these Hospitals there was a dedicated hierarchy including the Chief Physician (archiatros), professional nurses, and the orderlies (ipiretes).

Paul of Aegina, was in a position to recognize foreign growths such as polyps in the air-passages, and gave the method of their removal. Such operations as tracheotomy, tonsillectomy, bronchotomy, staphylotomy, etc., were performed by him, and he also advocated and described puncture of the abdominal cavity, giving careful directions as to the location in which such punctures should be made.

He also performed mastectomies for the cure of cancer, and described extirpation of the uterus. However, we do not know how successful this operation was as it is considered one of the latest achievements of modern surgery. Nevertheless, the fact that he was practicing this operation supports that it should be successful at least for some cases.

Formal medical education and practice

Doctors of the empire of Byzantium, were well trained and most likely attended the University of Constantinople. Medicine, became a truly scholarly subject by the period of Byzantium, despite the prominence of the great physicians of antiquity.

Medicine, was greatly improved through its application in formal education, particularly in the University of Constantinople. Comparisons are always made by modern Scholars studying this particular field. Thus, we know that in the twelfth century, Constantinople had two well organized hospitals staffed by medical specialists, including gynecologists, with special wards for various types of diseases and systematic methods of treatment.

Christianity and Medicine in Byzantium

Christianity always played a key role in the building and maintaining of hospitals, as it did with most other functions of the Empire. Many hospitals were built and maintained by the Church. Hospitals were nearly always built near or around churches, and great importance was given on the idea of healing through salvation. When medicine failed, doctors would always ask their patients to pray.

After the iconoclastic problems were resolved, this usually involved symbols of saints such as Cosmas and Damien, who were killed by Diocletian in 303, and were the patron saints of Medicine and Doctors.

Christianity and charity

Christianity also played a key role in propagating the idea of charity, and promoting medicine “accessible to all, and simple”. This idea, appeared for the first time in history, involving a state which has actively sought to expend resources on a public healthcare system!

First pandemic in Byzantium 
The endemic that stroked Constantinople and the surrounding countries during the reign of Justinian in the middle of the 6th century, was the first documented pandemic in history. It marked the beginning of plague as a nosological problem that would afflict the world for years to come. The symptoms of the disease, were described by various writers, especially the historian Procopius, and the two church historians, John of Ephesus and Euagrius.

The monastic habit and monasticism
The institution of monasticism was one of the most important characteristics of Byzantine society, and touched the life of every imperial subject in many ways. First of all, a substantial number of Byzantine men and women took monastic vows: some in their youth, some in middle age, and many more at the end of their lives. Countless Byzantines, when they realized they were on their deathbed, took the monastic habit for their final hours or days, in the belief that, by dying this, they were more likely to achieve salvation in the world to come.
Silk manufacture in Byzantium
The first silk looms were set up in the royal palaces of Byzantium in the year 533 A.D. The raw material was brought from the East. Two Greek monks, while in China, studied the method of rearing silk worms and obtaining the silk, and on their departure they have concealed the eggs of silk worms in their staves.

These monks are accredited with the introduction of the manufacture of silk in Greece. After that, Greece, Persia and Asia Minor made this material, and Byzantium was famous for its silks, which were gradually introduced into the western Europe.

Great Mathematicians in Byzantium

Manolis Moschopoulos, a 14th century mathematician published in Greek the first known publication in the West about Magic squares and Francesco Mavrolico, an Italian scientist of Greek origin, worked on the same lines as Manolis Moschopoulos. He was considered one of the greatest geometers of his time.  Another one geometer, again Greek in origin, was Marcos Musuros (1417 – 1530)

The remarkable experimental fact that all objects fall with the same acceleration was known to the ancients. In the fifth century, a Byzantine philosopher, named Ioannis Philoponus, recorded and possibly performed a Galileo-style experiment, as part of his commentary on Aristotle’s Physics, “A cultural history of gravity and the equivalence principle”.

Later on, Leon the mathematician from Thessaly (790 –868 AD), Did the same. He had a classical education for which he was accused to be a pagan. His knowledge was obtained by his research of ancient sources that he found in various monasteries.

The way Byzantium assimilated the West

Byzantium, prepared the ground on which the Middle Ages were formed and the modern world later grew. Many characteristics of western civilization appeared there for the first time. It was then that Christianity conquered northem Europe and the Germanic, Slavic and Arab peoples emerged on the world stage. Byzantium’s contribution beyond its boundaries has been detected in domains as the music, art, thought, political symbolism and language of the early medieval West. It was Byzantium that supplied the organs introduced into church services. Early and middle Byzantine masterpieces inspired the world, while the court of Constantinople provided the very manuscript which stands at the beginning of western theology’s mysticism. The extent to which the medieval West assimilated the Byzantine inheritance includes state welcome ceremonies, and Greek words for “ink,” “pasta,” “bronze,” “boutique,” etc.

Female desire for imperial power in the Byzantine era

Female desire for imperial power was present during the entire Byzantine era. It was manifested in a variety of forms by women close to emperors, who were their mothers, sisters, daughters or even mistresses.

In the 11th and 12th centuries the presence of strong women from the imperial family in political life was significant. Such was the case of Zoe and Theodora, the women from the Doukas family. After the death of their father Constantine the VIII, Zoe and Theodora became central political figures in a society that, theoretically, was non-hereditary. However, the practical Byzantines found the solution according to which the elder sister Zoe became a legitimizer of the mail rulers by marriage or adoption.

Fig 7: Empress Zoe (left) and Empress Theodora (right)

“The Greek Fire”

The Greek fire, an advanced secret weapon, was first used by the Byzantine navy during the Byzantine-Arab Wars.

Fig 8: The mystery of the Greek Fire. (“Bibliotheca Nacional de España, Madrid”).

The Macedonian renaissance

The military successes of the tenth century were coupled with a major cultural revival, the so-called Macedonian Renaissance. Philosophy, Medicine, Science and Language as well as Charity under the influence of Christianity and so many other novelties appeared for the first time or improved tremendously in the Empire of Byzantium

Fig 9: Miniature from the Paris Psalter, an example of Hellenistic-influenced art.

The decline of Byzantium

The energy of Byzantium as an Empire and a Nation were expended in religious controversies especially towards the decline of the Empire. Therefore, medicine, like other sciences, was gradually relegated to a place among the other superstitions, and the influence of the Byzantine school was replaced by that of the conquering Arabians.

Fig 10: The decline of Byzantine Empire

Crisis and fragmentation

Byzantium, soon fell into a period of difficulties, caused to a large extent by the undermining of the theme system and the neglect of the military. Nicephorus the 2nd (963–969), Giannis Tsimiskis and Basil the 2nd changed the military divisions (tagmata) from a rapid response citizen army, into a professional army increasingly manned by mercenaries. But mercenaries were expensive and as the threat of invasion receded in the tenth century, so did the need for maintaining large garrisons and expensive fortifications. Basil the 2nd left a burgeoning treasury upon his death, but neglected to plan for his succession

Fig 11: Crisis and fragmentation in Byzantium

The capture of Constantinople by the Franks

In 1204, the capture of Constantinople by the Franks occurred. A systematic destruction and looting followed, graphically described by Michael Choniates: “but whatever remained of the capital became the spoils of the conquerors for the entire period of their rule, which lasted about sixty years.” The wealth of books accumulated in the capital suffered incalculable damage: those that escaped the fires were stripped of their precious bindings, and the rest were used as heating fuel!

Fig 12: Sack of Constandinople by the Crusaders (1204)

Ottomans on stage

Things went worse for Byzantium during the civil wars that followed after Andronikos the 3rd died. A six-year civil war devastated the empire, and an earthquake at Gallipoli in 1354 devastated the fort, allowing the Ottomans who were hired as mercenaries during the civil war by John the 6th Kandakouzinos to establish themselves in Europe. By the time the Byzantine civil wars had ended, the Ottomans had defeated the Serbians and subjugated them as vassals. Following the Battle of Kosovo, much of the Balkans became dominated by the Ottomans.

Fig 13: the capture of the capital of the Byzantine Empire by the Ottomans. The city fell (on 9th of May 1453.


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