The art of healing - Roman and Byzantine Military & General Medicine

A scene from Book XII of the Aeneid: the physician Iapyx treats the
wounded Aeneas, who is supported by his weeping son Ascanius.

A Matter of Life and Death

Good health has always been a concern. But keeping the troops 

ready to fight is a priority for governments.

(From the Daily Sabah)  -  The Suna and İnan Kıraç Foundation Pera Museum is hosting an exhibition titled "Life is Short, Art Long: The Art of Healing in Byzantium" to shed light on the medical history of the world during its 10th year anniversary. Curated by Brigitte Pitarakis, the display explores the healers of antiquity from Apollo and Asklepios to the founders of rational medicine, Hippocrates and Dioscorides, as well as the healing methods of the Byzantines including faith, magic and rational medicine, healing and miracle centers in Constantinople as well as the roles of physicians and saints in medicine through icons, reliquaries, amulets, marble carvings, medical equipment, plants and herbs and medical and botanical manuscripts.

Health has been always one of the most important subjects for mankind. Studying a civilization through a perspective of their approach to the body in terms of health and illness reveals the depths of its identity. "Life is Short, Art Long: The Art of Healing in Byzantium" offers a brief glance to Byzantine civilization and its community through three traditional healing methods: Faith, magic and medicine. The display reveals the effects of the Byzantine Empire's ancient cultural heritage on religious and rational thinking as well as contemporary scientific developments and innovations around the Mediterranean. Moreover, the important role of the Byzantine Empire in passing down the secrets of art of healing to the future generations is emphasized through the exhibition as well. 

The exhibition exposes that the belief that illnesses used to be caused by demons, which was a common thought based on the teachings of Hippocrates. This belief coexisted alongside a rational understanding of health and medicine. The display also explores the daily rituals conducted by physicians, saints and magicians in order to cleanse body and soul.

Basil of Caesarea
Byzantium was the first empire in which dedicated medical establishments flourished. These were usually set up by individual churches or the state and parallel modern hospitals in many ways. The first hospital was built by Basil of Caesarea in the late a.d. 4th century.  By the 8th and 9th centuries hospitals began to appear in provincial towns as well as the cities.

Religious images in Byzantine times

Representations of Christ, his miracles and the saints had the function of conveying the biblical story as well as teaching about saints and the Church calendar commemorating them. They also served as an accompaniment to prayer and veneration in church and in private worship. In addition to the conventional nimbus evoking divine grace, the main features of saints, their dress and their attributes, were individualized and consistently represented to allow the faithful to recognize and relate to as well as venerate. Each saint's dress and attributes identified the nature of his or her power. The bishops and deacons recall the recitation of the liturgy, warriors in full military attire do battle with the devil and physicians, their surgery instruments and medicine pots in hand, stand ready to heal the bodies and souls of the faithful.

Demons, symbols and the cosmos

Beliefs surrounding illness and healing in Byzantium stem from the myths, astrology and magic practiced around the Mediterranean by Jews, Egyptians, Mesopotamians and Greeks. Amulets were widely prescribed, even by medical treatises, against demonic invasion, thought to be a primary cause of illness. One also finds green jasper gemstones featuring the lion-headed serpent Chnoubis, hematite stones showing Herakles fighting the Nemean lion and octagonal rings invoking solar symbolism and resurrection that feature astral lions.

Wondrous cures in Constantinople

The shrines that created the glory of Constantinople through their lavish beauty were also repositories of precious relics and thus, sources of healing. Early on, the city was placed under the protection of the Virgin Mary, who sanctified the waters of numerous springs there. In addition to such all-encompassing healing places as the shrine of the physician saints Kosmas and Damian near Eyüp, there were also specialized shrines, like St. Artemios for curing male-oriented diseases and St. Anastasia for mental illness.

Fear of pain, surgery, hemorrhages and infection led many among the faithful to turn to the saints whose healing interventions were painless, immediate and free of charge. Expressions of thanksgiving after miraculous cures contributed to shrines' wealth and fame. Often, the imperial couple influenced devotional practices at healing shrines, as did Leo VI and Zoe, whose son Constantine VII Porphyrogennetos (b. 905) was born after the intervention of the Virgin of Pege.

The medical art

Hippocrates was born on the Aegean island of Kos around 460 B.C., the golden era of ancient Greece. Celebrated as the "father of medicine," he developed a system of rational medicine in which supernatural precepts played a minimal role. Hippocrates characterized the substance of medicine as a "techne" (art) with distinct limits. The medical art requires particular skills that involve training, and the incurable is beyond the boundaries of this art.

Byzantine surgery to separate conjoined twins.

The physician must not only have specialized knowledge of the body, but also a broad understanding of the workings of nature and the cosmos. Hippocratic medicine requires that physicians treat the patient as a whole, not merely its parts. The aim of therapeutic practices is to restore the body's natural balance, a peculiar kind of art. The first aphorism of Hippocrates declares that a lifetime would not be long enough to achieve perfection in this art.

The practice of rational medicine
Byzantine medical art was grounded in the Greco-Roman medicinal tradition transmitted by Hippocrates and Galen and new concepts introduced by such physicians as Oribasios of Pergamon, Aetios of Amida, Alexander of Tralles and Paul of Aegina. The 12th century ushered in a significant transfer of knowledge between Byzantium and the Arab and Persian worlds as well.

Men as well as women practiced medicine. Theoretical teaching was coupled with a practical internship in a hospital. Diagnosis relied on analysis of the pulse and urine. Diet and bathing were integral parts of remedies. External remedies included casts, ointments and eyewashes, while internal treatments ranged from pills, powders and oils to gargles, enemas and infusions.

Ophthalmological diseases, epilepsy, hernias and gout were among the most common afflictions. The Byzantines' successful system of hospitals performed more than 100 different surgical procedures, including mastectomy, aneurysmectomy and trepanation along with ear and nose reconstructions. Moreover, some surgical instruments of great utility are still used today.

Treatment with medicinal herbs

Knowledge of plants and the practice of healing are closely entwined. The toxic or hallucinogenic nature of some roots and the dangers associated with picking them conferred a mythical or magical character and power. Pedanius Dioscorides (ca. 40A.D. to 90 A.D.), a physician from Anazarbus,in Cilicia, described more than 500 plants and alimentary products, including medicinal uses, preparations and dosages in "De Materia Medica" (On Medical Substances). Those recorded included varieties from the Mediterranean basin and an array of prized exotic plants. The transmission of "De Materia Medica," including its translation into Arabic and Latin, was made possible through Byzantine manuscripts, the earliest surviving witnesses of the text.

Galen of Pergamon (ca. 129 A.D. to 216 A.D.), a physician and surgeon, employed medicinal plants individually and as complex concoctions devised for specific therapies. His "theriac" (antidote) for Emperor Marcus Aurelius consisted of more than 70 ingredients, among them opium. His pharmacopoeia also covered cosmetics and commotics.

Roman Auxiliary reenactors - Photo timetrips.

Roman Military Medicine

Under Emperor Augustus for the first time occupational names of officers and functions began to appear in inscriptions. Caches of surgical instruments have been found in some legion camps. From this indirect evidence it is possible to conclude to the formation of an otherwise unknown permanent medical corps.

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The term medici ordinarii in the inscriptions must refer to the lowest ranking military physicians. No doctor was in any sense “ordinary”. They were to be feared and respected, just as they are today. During his reign, Augustus finally conferred the dignitas equestris, or social rank of knight, on all physicians, public or private. They were then full citizens (in case there were any Hellenic questions) and could wear the rings of knights. In the army there was at least one other rank of physician, the medicus duplicarius, “medic at double pay”, and, as the legion had milites sesquiplicarii, "soldiers at 1.5 pay", perhaps the medics had that pay grade as well.

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Trajan's Column depicts medics on the battlefield bandaging soldiers. They were located just behind the standards; i.e., near the field headquarters. This must have been a field aid station, not necessarily the first, as the soldiers or corpsmen among the soldiers would have administered first aid before carrying their wounded comrades to the station. Some soldiers were designated to ride along the line on a horse picking up the wounded. They were paid by the number of men they rescued. Bandaging was performed by capsarii, who carried bandages (fascia) in their capsae, or bags.

From the aid station the wounded went by horse-drawn ambulance to other locations, ultimately to the camp hospitals in the area. There they were seen by the medici vulnerarii, or surgeons, the main type of military doctor. They were given a bed in the hospital if they needed it and one was available. The larger hospitals could administer 400-500 beds.

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The posts of medicus legionis and a medicus cohortis were most likely to be commanders of the medici of the legion and its cohorts. They were all under the praetor or camp commander, who might be the legatus but more often was under the legatus himself. There was, then, a medical corps associated with each camp. The cavalry alae (“wings”) and the larger ships all had their medical officers, the medici alarum and the medici triremis respectively.

From Roman Empire.net

The Roman Legions were highly structured and very efficient. By the time the Roman military medical service became a standard part of the legions, the Roman military medical service was also highly organized and efficient. Most sources suggest that the Roman medical service expanded on the Greek military variety of purposes.

The Roman author Vegetius wrote that the Roman army should be "preserved" by providing a good, clean water supply, taking seasonal considerations into account, the use of medicine, and exercise for the troops. Specifically, Vegetius suggested that commanders not march the troops in the hot sun or in freezing weather and that they provide the troops with clean drinking water at all times. Once more, he said that sick soldiers should be "brought back to health by suitable food and cured by the skills of doctors." Likewise, it was recognized that soldiers could get sick from overeating after experiencing a famine. Most important, as recognized in today's best armies, the ranks of the Roman armies were filled with only the most physically fit soldiers, who had to pass a medical examination before their service began.

In the early days of Roman military medicine, there was little distinction between medical and veterinary services, and human and animal hospital services were set up side by side. Later, when formal medical service became as highly organized as the rest of the Roman army, a praefectus castrorum was placed in overall charge of medical services. The optio valentudinarii were responsible for running the hospitals at legion fortresses. Wounded soldiers were cared for by medics called capsarii, who carried bandage boxes.

Archaeologists have found medical instruments at Roman forts and campsites that are classified as probes, spatulas, spoons, tweezers, scalpels, lances, curved and straight needles, medical glassware, small vessels, and ointment boxes. One of the most prolific Roman army medical service archaeology sites is at Baden, Germany, where the remains of a Roman military hospital were excavated. Artifacts described as earscoops, catheters, spoons, and other medical equipment were found. Coins found in association with the medical equipment showed the fort was active between A.D. 100 and 200.

A military hospital unearthed at Vetera (now Xanten, Germany) revealed hospital wards, rooms full of medical instruments, surgical suites, convalescence rooms, and possibly mortuaries. Among the discovered artifacts were levers and scoops thought to be used for extracting missiles from the body and notched probes that may have been used for extracting arrowheads after the arrow shaft was broken off. Although later than the heyday of the Roman legions, surgeon Paul of Aegina described how stones and other missiles from slings were to be removed by an ear probe, modified for the job at hand by adding a scoop.

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Roman army records show that Celsus suggested using a "weapon extractor." Celsus noted that missiles that have entered the body and become fixed inside "are frequently troublesome to extract," because of their shape, size, or the way they have penetrated. "If the head of the weapon has fixed in the flesh," he wrote, "it is to be drawn out with the hands or by laying ahold of the appendage which is called the shaft, if it has not fallen off. When it has fallen out we make the extraction by means of a toothed forceps." 

Celsus went on to say that when he saw a curable wound he looked at two things: preventing hemorrhage and preventing inflammation. He suggested vinegar to staunch the flow of blood yet said that to prevent inflammation, blood must flow. He noted that inflammation was more likely when bone, sinew, cartilage, or muscle was injured. "If the wound is in a soft part, it must be stitched," he noted. "But if the wound is gaping, stitching is not suitable." Celsius also wrote on bandages, preferring bandages of wide linen "sufficiently wide to cover in a single turn not only the wound but to a little extent the edges on both sides."

From Roman Empire.net

Roman industrial arts also aided in the cause of treating wounded soldiers. New metal alloys of bronze and silver provided sharper edges and were less expensive to manufacture. Because of rust, iron was not used for medical instruments. Artwork as well as poetry from just before and after the first century A.D. depict Roman army doctors removing arrows from soldiers.

Amputations were also performed by Roman military doctors. Celsus may have been one of the first military surgeons to discuss the merits of amputating above or through the damaged flesh. He advocated cutting only through good flesh and then sawing through the bone as close as possible to the good flesh, but leaving enough good flesh as a flap to cover the bone.

Roman army doctors also had a firm knowledge of pharmacology. Many medicines mentioned by Celsus are not unlike those of today made for the same purposes. Archaeologists have found the remains of five medicinal plants at Roman fort excavations. St. John's wort, used for blood ailments; fenugreek for poultices; figs for treating wounds; and plantain for dysentery have been found. Medicated wine was also thought to have been used. Some historians have suggested that the courtyard of each Roman army hospital was laid out as a garden for growing medicinal herbs.

The axiom "an army marches on its stomach" could well date to Roman times. Records show that Roman doctors knew that a balanced diet was necessary for healthy troops. Sources suggest that Roman soldiers were kept fed with corn, cheese, ordinary wine, fresh fruit, and vegetables. Bread was considered the most nutritious food, and each soldier received a ration of panis militaris--army bread made of wholemeal. Special diets were prepared for sick and wounded soldiers. Garden peas, lentils, and figs seemed to be popular for treating the sick.

Roman army doctors also understood that soldiers were prone to overeating after a battle or after going without food for a long time. The Roman historian Appian wrote after the siege of Mutina in 43 B.C. that a number of soldiers fell sick after "excessive eating." The Roman remedy--drinking a concoction of wine and olive oil--probably cured many.

Not only did Roman military medical instruments influence military doctors for the next millennium, their experience and their records, particularly those kept by Celsus and Galen, directly influenced future military surgeons, who improved the art and science of military medicine in the eighteenth and nineteenth centuries.

Modern reconstruction of 15th century Byzantine archer.

Byzantine Military Medical Corps

The Western Empire may have fallen in 476AD, but there would have been no sharp break in military formations, organization and command structure for the surviving armies of the Eastern Empire. 

Soldiers were still being wounded and treatment would still be needed. The medical units attached to Eastern Roman Legions would have continued. The medical lessons learned on the Roman battlefields would naturally have been passed down to future generations of military doctors.

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Serious detailed contemporary Byzantine military histories are thin at best. It is hard enough to get an account of a battle. Reports on the medical care given to the troops after the battle are neglected.

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Byzantines at Sea - A 7th century manuscript by Paul of Egina remarks on medical men at sea. In his De Re Medica Paul reminds the seagoing physician of the importance of taking with him text books on healing. Ships would be in remote locations where immediate treatment was needed to prevent death. Paul's remarks were directed at government officials (navy) as well as private merchant ships.

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The large Byzantine Navy, with thousands of men, was a vital part of the defense of the Empire. It is logical to assume that there would be a degree of medical care to keep the sailors fit for battle and to treat the wounded. Though we lack details we can assume some type of naval medical service would have been active at sea.

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Byzantine Army - The many lessons learned over the centuries would have continued in the Eastern Armies.

We do not have a lot of detail, but both the Emperors Maurice (582-602) and Leo IV (886-912) wrote on medical subjects. The Eastern Army had deputati and scribones - first-aid men.  

Maurice says it was their duty to rush into the thick of battle are carry out wounded soldiers to the rear. For the cavalry there would be a unit of 8 to 18 men assigned to each detachment of 200 to 400 men. They would follow some 200 feet behind the front line troops in order to bring the badly wounded away from danger. To that end, the saddles of their horses had two ladder-stirrups on the left side, and flasks of water to revive the faint.

The bearers received a piece of gold for every wounded soldier rescued. After the battle they collected the arms of the wounded and of the survivors to prevent plundering. They would also get a share of any booty.

The same organization is described 300 years later by Leo and showed the rigidity of Byzantine administration.

Army surgeons were classified as non-combatants. The litter bearers were selected from the weaker elements of the command and the old arrangement of the ladder-stirrups and water flasks was still in place.

The Emperor Leo writes: "Give all the care you possibly can to your wounded, for if you neglect them, you will make your soldiers timorous and cowardly before the battle, and, not only that, but your personnel, whom you might preserve and retain by proper consideration for their health and welfare, will otherwise be lost to you through your own negligence."

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I suspect that many of the wounded troopers (perhaps based on rank?) many have been referred to the system of Byzantine hospitals. The Byzantines appear to have provided asylums for disabled soldiers. Emperor Justin II (565-578) had the Lobotropheion. Emperor Alexis Comneus I (1081-1118) had the Orphanotropheion for sick and invalided soldiers.

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The Hospital of Sampson was located between the Hagia Eirene and Hagia Sophia.  
All were destroyed by fire during the Nika Riot in 532. They were subsequently restored by Emperor Justinian.
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This image used under FAIR USE from Byzantium1200.
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Doctors themselves were well trained. Some attended the University of Constantinople, as medicine had become a scholarly subject by the period of Byzantium. Despite the prominence of the great physicians of antiquity, its status as a science was greatly improved through its application in formal education, particularly in the University of Constantinople. This rigidity through professionalism (similar to the professionalism exhibited in the Byzantine bureaucracy) bears many hallmarks of today's modern hospitals, and many comparisons are made by modern scholars studying this field.
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We know that in the 12th century, Constantinople had two well organized hospitals staffed by medical specialists (including women doctors), with special wards for various types of diseases and systematic methods of treatment.
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The Princess Anna Komnene was capable not only on an intellectual level but also in practical matters. Her father placed her in charge of a large hospital and orphanage that he built for her to administer in Constantinople. The hospital was said to hold beds for 10,000 patients and orphans. Anna taught medicine at the hospital, as well as at other hospitals and orphanages. She was considered an expert on gout. Anna treated her father during his final illness.

(daily sabah)      (Military Surgeon)      (Military Medicine of Ancient Rome)

(Byzantine medicine)      (Medical community of ancient Rome)    (Military Medicine)