Brady Lonergan
Farmington, Connecticut

Institutional medical education in the Eastern Roman Empire bore considerable resemblance  to modern medical education in terms of structure and accessibility.

During the early Byzantine period, medical instruction could be attained in one of two ways: either through an apprenticeship system, often between father and son; or by completing coursework overseen by iatrosophists (medical professors) at a school of medicine in a major city. While the apprenticeship model had the greater historical precedent, higher education was a prerequisite for civic and ecclesiastical positions, and Alexandria was the focus for formal medical education in the Empire.¹

For most, medical education was inaccessible given the expense of school fees and living abroad for four years.² Moreover, much like the premedical and general education requirements for undergraduate studies in North America, medical students would have been expected to have already completed coursework in rhetoric, law, philosophy, mathematics, astronomy, and music under private tutelage or at a university.¹ Despite relative inclusiveness in the medical field, no evidence for formal medical education for women exists at any of these institutions. They were likely limited to following the same intrafamilial apprenticeship pathway as some of their male counterparts.³

The medical curriculum consisted primarily of Hippocrates and Galen, and by the sixth century, the iatrosophists of Alexandria had established the canon of Hippocratic and Galenic texts.⁴ The standard program consisted of a set of introductory subjects followed by a series of main courses, which made up the bulk of medical instruction. The required introductory classes included logic, physics, mathematics, pharmacology, astrology and medical ethics, and the required reading for these courses included works by Euclid, Ptolemy, Aristotle, Hippocrates, and Galen among others. The Galenic canon, which consisted of sixteen books and made up the greater part of the source material for the Alexandrian curriculum, was broken up into seven successive grades.¹ The required reading and lectures were likely spread over the course of four years.² During these talks, the iatrosophists provided both their own commentaries on and synopses of the required reading; unfortunately for their students, however, the general style appears to have been decidedly dull.⁵ According to the sixth- or seventh-century notes left by Palladius and John of Alexandria, the iatrosophists approached each assigned reading in three steps during these classes. First, the instructor discussed the language of the text, then proceeded to expound upon the meaning of the material, and finally discussed the commentaries of other medical writers and explained how to identify worthwhile texts in the medical literature.² In short, the Alexandrian curriculum consisted of anatomy, physiology, and therapeutics as well as some discussion of hygiene and dietetics.

Despite being Galenic in scope, the Alexandrian medical curriculum did not include experimental anatomy. Although dissection may have been a tool for learning, it was not used as a means of further research in anatomy and physiology. Instead, in contrast to the spirit of Galen, books on anatomy and physiology were emphasized over actual dissection.⁵

According to the available evidence, the iatrosophists of Alexandria were theoretical medical experts. Some of these professors, like the fifth- to sixth-century iatrosophist Gesius mentioned in the Suda, had extensive real-world experience and students accompanied them in clinic. The responsibilities of non-practicing physicians were undoubtedly focused on the exposition of medical theory in the didactic curriculum.² Some of these Alexandrian instructors also taught subjects other than medicine.⁵

After the loss of Alexandria and the Empire’s eastern provinces in the seventh century, the focal point of Byzantine medical education shifted to Constantinople.⁶ Although medical schools  continued to function throughout the remainder of the Empire, medical education began to revolve around other institutions in the wake of the Arab conquest. The xenon (hospital) became the next major center for medical education, and in the imperial capital in particular, monasteries and ecclesiastical schools also began to serve as centers for medical pedagogy.⁵

The sixth-century Emperor Justinian’s relocation of the previously independent state-funded archiatroi (public physicians) into local hospitals also contributed to the eventual transition to the hospital as the center of institutional medical instruction.⁶ By the twelfth century, hospitals like that associated with the Pantokrator monastery complexeven hired high-ranking physicians to act as professors to teach medical theory; the Pantokrator Typikon (monastic foundation document) outlined the following:

We also prescribe that there should be a teacher to teach the principles of medical knowledge, who will also receive exactly the same allowances as the infirmarian. The aforementioned food allowances have been prescribed for him for this reason, that he may attend to the task of teaching and teach the student doctors of the hospital the knowledge of medicine in a consistent and zealous manner. For the teaching post is not being set up by us as an office so that the man thought fit for this responsibility receives his food allowance but neglects his teaching, since the man who is discovered not to be performing this service will be deprived of the receipt of his food allowance and someone else will be appointed instead who will carry out in full the teaching of medical knowledge according to our instructions.⁷

Additionally, as centers of learning, these hospitals collected medical texts and maintained extensive libraries. The xenon-based medical education consisted of a relative progression similar to that of the Alexandrian period. First, students studied medical theory via the Galenic and Hippocratic corpora. Then, they transitioned to the clinical setting and studied medicine through practical experience.⁶ Finally, after establishing a theoretical framework and applying it in the wards, each medical student underwent an evaluation by one of the chief physicians. The correspondence of the thirteenth- to fourteenth-century physician John Actuarius suggests that if the student completed this process, he would become a licensed physician.⁸ This series of steps may explain the perissoi iatroi (extra physicians) and embathmoi iatroi (ordained physicians) in the Pantokrator hierarchy outlined in the Typikon. Whereas the embathmoi iatroi would have been certified physicians, the perissoi iatroi were probably student physicians who had only completed the first portion of their training.⁶ The requirement for professional certification was an expression of the state’s concern for establishing a level of quality control among physicians; although this system was finalized by the twelfth century, regulation of the medical profession began as early as the fifth and sixth centuries as seen in the Codes of Theodosius and Justinian.⁸ As during the Alexandrian period, prior to embarking on this course of study, medical applicants were also likely to have achieved some minimum level of education prior to matriculation. Despite the Latin occupation of Constantinople in the thirteenth century and the gradual contraction of imperial territory thereafter, medical schooling within the context of the hospital continued into the final decade of the Empire’s existence.

While the accessibility of medical schools and our understanding of anatomy, physiology, and therapeutics have certainly improved over the last several centuries, the current state of medical education bears some striking similarities to that of Byzantine Alexandria and Constantinople.

References

1. Prioreschi, P. A History of Medicine: Byzantine and Islamic Medicine (Vol. IV). New York: Edwin Mellen Press, 2001.
2. Duffy, J. “Byzantine Medicine in the Sixth and Seventh Centuries: Aspects of Teaching and Practice.” Dumbarton Oaks Papers, 38 (1984): 21-27.
3. Parker, HT. “Women Doctors in Greece, Rome, and the Byzantine Empire.” Women Healers and Physicians: Climbing a Long Hill, ed. Lilian Furst. Lexington: The University Press of Kentucky (1997): 131-150.
4. Nutton, V. “From Galen to Alexander, Aspects of Medicine and Medical Practice in Late Antiquity.” Dumbarton Oaks Papers, 38 (1984): 1-14.
5. Temkin, O. “Byzantine Medicine: Tradition and Empiricism.” Dumbarton Oaks Papers, 16 (1962): 95-115.
6. Miller, TS. The Birth of the Hospital in the Byzantine Empire. Baltimore: The Johns Hopkins University Press, 1997.
7. Thomas, JP and Hero, AC, eds. Byzantine Monastic Foundation Documents: A Complete Translation of the Surviving Founders’ Typika and Testaments. “28. Pantokrator: Typikon of Emperor John II Komnenos for the Monastery of Christ Pantokrator in Constantinople,” transl. Robert Jordan. Washington, D.C.: Dumbarton Oaks (2000): 725-781.
8. Hohlweg, A. “John Actuarius’ ‘De methodo medendi’-On the New Edition.” Dumbarton Oaks Papers 38 (1984): 121-133.