Download PDF | Timothy S. Miller - The Birth of the Hospital in the Byzantine Empire -The Johns Hopkins University Press (1997).
324 Pages
Introduction to the 1997 Edition
When first published in 1985, Birth of the Hosptial in the Byzantine
Empire represented the first monograph devoted solely to tracing the history of Byzantine hospitals, the philanthropic institutions designed exclusively to treat the physically ill. Byzantine medical texts, imperial laws, monastic rules, saints’ biographies, narrative histories, poems, and formal orations all provided information for reconstructing how Byzantine hospitals functioned.
The evidence extracted from these sources revealed that Byzantine hospitals (xenones) had begun to focus exclusively on caring for and curing the sick as early as the fourth century a.p.; that these philanthropic centers continued to expand their medical services, especially during the reign of the emperor Justinian (527-65); and that by the eleventh and twelfth centuries they had become the principal theaters of the Byzantine medical profession, providing both specialized treatment to hospital patients and walk-in clinical services to the general population. Moreover, by that time these xenones were also providing instruction in the theory and practice of medicine to those who wished to become physicians.
These Byzantine hospitals, tied closely to the medieval Greek medical profession and focused solely on curing their patients, do not fit the image that twentieth-century historians of medicine and medievalists have presented of premodern hospitals—an image of poorly equipped almshouses more concerned with comforting the sick in their distress than providing medical cures. Indeed, since the Enlightenment, intellectuals have ignored the achievements of medieval charitable institutions and have established a wall between enlightened science and the imperatives of Christian morality. As John Locke observed:
[the study of naturel, if rightly directed, may be of greater benefit to mankind than the monuments of exemplary charity that have at so great a charge been raised by the founders of hospitals and almshouses. He that first invented printing, discovered the use of the compass, or made public the virtue and right use of kin kina ([quininel, did more for the propagation of knowledge, for the supply and increase of useful commodities, and saved more people from the grave than those who built colleges, workhouses, and hospitals.’
The history of Byzantine hospitals, however, clearly reveals that Christian philanthropy and scientific medicine were indeed wed, at least in the Eastern Roman Empire, where a strong medical profession survived throughout the Middle Ages.
Because Byzantine xenones do not fit the accepted notions conceming premodern hospitals, several scholars have rejected some of the evidence presented in Birth of the Hospital and questioned its conclusions, especially regarding the kind of treatment xenones provided and their relationship to the medical profession. While many historians have come to hold views similar to those I present in Birth of the Hospital, others have raised a series of objections. One critical opinion faulted the book for relying too heavily on evidence regarding a single hospital, the Pantokrator Xenon of twelfth-century Constantinople.* A second criticism has been that the book makes assertions without sufficient evidence to support such views. A third assessment, based primarily on currently accepted ideas about the history of hospitals in Northwestern Europe, labeled as absurd the notion that a society before the twentieth century would have organized its provision of medical care around hospitals.’
In view of the significance of hospitals in the history of medicine in general and of the lively debate that surrounds the subject of Byzantine xenones, this paperback edition of Birth of the Hospital is being issued. In this edition, I have made a number of minor corrections to the original text, especially the footnotes and the bibliography. This new introduction serves in part to restate succinctly the key arguments presented in the book, and also to introduce significant new evidence discovered after its initial publication. Some of this additional material I uncovered myself; other new sources my colleagues found and kindly forwarded to me. In every case, this evidence has confirmed the original conclusions of the book. Some of the new information has been especially valuable in providing a more complete picture of how Byzantine hospitals functioned and how physicians organized their private practice around their xenon duties.
For many years the majority of Byzantinists have maintained that some hospitals in the East Roman Empire were organized to offer the best medical care possible for those afflicted by disease. These scholars based their view on the Pantokrator Typikon, the foundation charter and monastic rule of the twelfth-century monastery of Christ, the Ruler of All’ In 1895 a Russian scholar, Aleksei Dmitrievskij, first published the Greek text of this typikon, a document which not only regulated the daily routines of the monks but also outlined in detail two philanthropic institutions the monks were to maintain. The first of these was a nursing home for twenty-four aged or infirm men; the second a hospital for fifty patients. The Pantokrator Typikon describes how many physicians and medical assistants were to staff the hospital, how these medical professionals worked in monthly shifts, how much pay they received as compensation for their work, and even how these professional employees advanced to the higher ranks of the medical staff.°
Impressed by the hospital regulations of the Pantokrator Typikon and by the similar but less extensive descriptions of Byzantine xenones in the seventh-century Miracula S. Artemii, the tenth-century Sampson Miracula, the thirteenth-century Lips Typikon, and a variety of other sources, historians such as Georg Schreiber, Alexandre Philipsborm, Herbert Hunger, Hans Georg Beck, and Demetrios Constantelos have recognized the superiority of Byzantine hospitals over any institutional health care available in the Latin West.’ Recent studies by Paul Magdalino and Armin Hohlweg have reiterated the importance of xenones not only as centers of medical care, but also as institutions that organized and sustained the medical profession, especially through their training of young physicians?
Although historians have recognized the sophistication of Byzantine hospitals and their role in sustaining the medieval Greek medical profession, Birth of the Hospital was the first attempt to describe how the xenones actually functioned with respect to the Empire’s physicians. In the course of my studies I noticed that the physicians at the Pantokrator hospital received extremely low salaries. Even the primmikerioi, the highest-ranking physicians on the staff, received only 11.75 noumismata a year, a salary slightly below a living wage in twelfth-century Constantinople (pp. 161-63). More than a century later the Lips Xenon also paid its doctors a remarkably low salary (pp. 201-4). How could hospital physicians survive with so little remuneration?
The Pantokrator Typikon itself and several other sources offered the key to solving this riddle. Since the seventh century a.p., hospital physicians had been working in two shifts. Each month one shift served in the hospital, while the other shift engaged in private practice; the next month the shifts exchanged roles. The rules of the Pantokrator Xenon thus allowed its physicians to pursue a private practice for six months a year, but it restricted this practice to patients who lived within Constantinople. Staff physicians were not to leave the capital to visit patients at their country estates, even if these people held high office or were members of the emperor's personal retinue.” These Pantokrator rules imply that the potential private patients of hospital physicians came from the pinnacle of Byzantine society.
Soon after I submitted the final typescript of Birth of the Hospital to the Press, Robert Volk published his thorough study of references to philanthropy and medical care in the many surviving Byzantine fypika (the medieval Greek term for monastic rules). Of course, Volk devoted many pages to analyzing the Pantokrator Xenon, but in addition he called attention to two other twelfth-century typika which also mentioned hospitals, two references I had not included in my reconstruction of how the hospitals functioned.’
The first of these two references comes from the typikon prepared for the Mamas Monastery in 1158/59. Although originally founded in the sixth century, the Mamas community became prominent only in the late tenth century, but it continued to have financial problems until George Kappadokes and Athanasios Philanthropinos restored the monastery in the twelfth century and drafted a new typikon for its monks.’ Chapter Thirty-four of this rule stipulates how the community was to care for sick monks:
The monks who fall ill with a sudden attack of disease should be allowed to rest in their cells with the knowledge of the superior and to receive there the proper food which fits their sickness. Whoever is commanded by the superior is to serve the sick in all ways: with food, with drink, or with anything else they might
monastery should be able—as I hope and pray it will—the superior should make arrangements that one of the physicians nearby visit the sick brothers [the monks] each day, bring them the required medicaments, and consider them worthy of all possible care. On the other hand, if the monastery should not be able to afford this—which I pray will not be the case—then, the superior is to go for assistance to those who work in the xenones so that the monk in need of medical treatment can obtain a bed, and lying there [in the hospital], he can receive medical treatment. Provision for his food, however, must be made by the monastery so that the monk might not be constrained in some way and utter evil statements, for what is provided in the xenon is not sufficient.”
At the Mamas Monastery sick monks were normally to receive in-house care at the hands of their fellow ascetics; if necessary, they also enjoyed the services of a trained physician who visited them daily and prescribed their medicines. The Mamas document, however, contains two additional pieces of information regarding xenones which both confirm and expand the picture of Byzantine health care presented by the Pantokrator Typikon and other earlier sources. First, the physicians hired to visit the ailing monks at the Mamas were attached to the neighboring xenones (the superior of the monastery was to arrange for one of the hospital doctors to visit the sick monks in their cells). Second, the Mamas Monastery would have to pay a considerable sum for these private visits. The authors of the typikon expressed concern that the Mamas community might not always be able to afford the house calls. If the monastery’s finances were not sufficient, then the superior was to transfer the sick monks to hospital beds in one of the two neighboring xenones. The Mamas Typikon thus indicates that physicians charged a high fee for visits to residences or monasteries. Usually, private patients would therefore have come from the class of wealthy and powerful laymen or from well-endowed monasteries such as the Mamas.
The second passage appears in the typikon written for the Heliou Bomon Monastery in 1162. The author of this document, a certain Nikephoros Mystikos, copied much of his rule from the Mamas Typikon, including sections of chapter thirty-four, the Mamas’ guidelines for the treatment of sick monks.” Nikephoros, however, made sufficient alterations in these regulations to prove that he did not simply borrow from his archetype with no thought toward application. He altered precisely those requirements which did not suit his institution and its location—the Monastery of Heliou Bomon did not stand within the walls of Constantinople, as did the Mamas community, but had been built somewhere in Bithynia across the Bosporos from the capital city (its exact location is unknown).
Just as at the Mamas, when a monk fell ill at the Heliou Bomon Monastery, the superior assigned one of his brother monks to care for the patient and to bring him whatever food or drink was suitable for the illness. If the disease proved severe or lasted many days, the superior was to have the patient transferred to one of several xenones for medical treatment. Unfortunately, the typikon provides no information on where these hospitals were located or how far away they were from the monastery. It is possible that they were in Constantinople.”
The author of the Heliou Bomon Typikon made one major change in the regulations he had borrowed from the Mamas Monastery: if a monk of Heliou Bomon were seriously ill, he had to go to a hospital because physicians never visited the sick at the monastery. That physicians were not available to attend the sick in this monastery might have been a result of urban hospital rules that prohibited staff physicians from leaving Constantinople to treat private patients in the Thracian or Bithynian countryside. Certainly, such restrictions would have barred the Pantokrator doctors from visiting sick monks at Heliou Bomon (pp. 48 and 162).
The evidence from these three monastic typika—Pantokrator, Mamas, and Heliou Bomon—suggests that Byzantine physicians of the twelfth century charged a high price for private visits. As a result, most people in Constantinople, both the poor and the middle class, came to the hospitals for treatment. The evidence for this I have presented in Birth of the Hospital. One passage from the annals of John Kinnamos, however, provides a particularly vivid picture of the central role hospitals played in providing medical services for most twelfth-century Constantinopolitans. Kinnamos had served in the government of the emperor Manuel I (1143-80) and wrote a detailed account of the emperor’s reign, which the historian completed shortly after the emperor's death.” In a digression illustrating Manuel’s skill in the art of medicine, Kinnamos wrote: “And [the emperor Manuel] has contributed many things to the science of the Asklepiads li.e., the physicians], medicines which had been unknown in every [previous] age. Some of these medicines were to be used as salves, others as potions. For anyone who wishes, it is possible to pick up these medicines from the public nosokomeia which are usually called xenones.”"’ Kinnamos clearly states that citizens of Constantinople visited the city’s xenones not only when they were incapacitated, but also when they needed medicines for less serious illnesses. For this they visited infirmaries like the one the Pantokrator Xenon staffed with four novice physicians.
After completing Birth of the Hospital, 1 found, among the published poems of an anonymous twelfth-century poet, a passage which supports Kinnamos’s statement. The Mangana Poet, as Byzantinists often refer to him, composed a great number of poems which date from the first half of Manuel I's reign. The Mangana Yoet worked for the emperor's brother Andronikos and, after Andronikos’s death, for his widow Eirene, the sebastokratorissa (a Byzantine title for a high-ranking person).’* In Poem no. 62, addressed to Andronikos and Eirene, the Mangana Poet complains that he has fallen ill in a province outside Constantinople while working for this august couple. He has become so sick that he has decided to leave his home province and go to the capital, where he would be able to find “both medicines and hospitals.””” The Mangana Poet did not belong to the very poor or even the struggling artisan class. He had a position of some importance as a manager of Andronikos’s estates, and he had also enjoyed the advantages of a good education.” Still, he did not mention that he was seeking doctors in private practice at Constantinople but, rather, that he was journeying to the capital because of its hospitals.
Three additional passages concerning hospitals refer not to xenones of the twelfth century but to those of the fourteenth and fifteenth centuries, a period during which Byzantine society was disintegrating. After I discovered these passages, | realized that I would have to revise to some extent the view I expressed in the 1985 edition of Birth of the Hospital—namely, that the Byzantine system of hospital care declined noticeably during the difficult Palaeologan period (1261-1453).
The first of these passages appears in the fourteenth-century Vita Atbanasii written by Theoktistos. Athanasios was a forceful protagonist of Byzantine monasticism who twice ascended the patriarchal throne: for the first time in 1289 and again in 1303. When the emperor Andronikos II deposed him for the second time in 1309, Athanasios withdrew to the Constantinopolitan monastery of Xerolophos.”! While there, one of his disciples fell ill with a severe infection of the throat. The disciple approached the holy Athanasios and asked the great man “either to send me to the xenon for treatment or heal me yourself—either with physicians’ medicines or with the medicine of prayer.” After receiving a scolding for his lack of faith, the disciple was reported to have experienced a miraculous cure when he secretly touched the hem of Athanasios’ robe in imitation of the woman who was healed by touching Christ’s garment (Matt. 9:19-22; Mk. 5:25-34; Lk. 8:42-48).”
In this story, Athanasios’s disciple considers a stay at a xenon as one of the two usual ways to receive therapy for a serious disease. Apparently, sick monks at the fourteenth-century Xerolophos Monastery had the same opportunities for care available to them as did the brothers at the twelfth-century Mamas community. They could remain in the monastery and be treated by a fellow monk—in this particular case the disciple asked Athanasios to care for him—or they could go to the nearest xenon.
The second passage describing late Byzantine hospitals appears in a sermon delivered by Philotheos Kokkinos, Patriarch of Constantinople from 1354 to 1355 and again from 1364 to 1376. In this homily Philotheos was commenting on Luke 13:10-17, the passage in which the chief rabbi of the synagogue criticizes Jesus for having healed a crippled women on the Sabbath. The patriarch used an extended metaphor to illustrate how selfishly the chief rabbi had responded to the miraculous healing when he demanded that the sick come for such care only on the six days of the week but not on the Lord’s day. Philotheos asks what sort of a hospital would a person establish, what medicines would he prepare, what sort of physicians and servants would he hire, and what routine for treating the sick could he devise, only to then order that the sick not seek care on the Sabbath.”
Philotheos’s image clearly depicts a hospital founded by a wealthy individual who purchases the medicines, hires the staff, and establishes the routines to be observed. From other sources presented in Birth of the Hospital, we know that private individuals of the fourteenth and fifteenth centuries opened hospitals during the very period in which the emperors were forced to cut back on their support of imperial philanthropic institutions (pp. 195— 99). Philotheos’s sermon indicates that such privately endowed xenones were common enough to serve as a metaphor in explicating the Gospel text.
The third passage comes from the writings of the famous Western intellectual and prelate Nicholas of Cusa (1401-64), the learned German theologian who eventually supported Pope Eugenius IV against the Council of Basel. In 1437 Nicholas made a voyage to Constantinople on behalf of Pope Eugenius. While on this embassy he also attempted to find manuscripts containing the Arabic text of the Koran. In searching for these manuscripts, Nicholas met a learned Turk whom he described as supremus praeerat bospitalibus, an officer who apparently supervised all the hospitals of Constantinople. This Turkish physician and several Moslem associates had become interested in Christianity and wished to visit the pope with Nicholas serving as their escort. Before the Turkish physician could leave with Nicholas for Rome, however, he had to inspect the hospitals of the Byzantine capital. On his rounds, he caught the plague and died.™
Nicholas’s strange account indicates that a system of hospitals. still functioned in Constantinople as late as 1437. There is no reason to reject this account because Nicholas portrays a Moslem as the supervisor of Christian hospitals. A late fourteenth-century manuscript (Vaticanus graecus 299) refers to a Moslem physician named Abram who served as director of the Mangana Xenon (pp. 150 and 205). I have found no references, however, to a general supervisor of all hospitals. Nicholas possibly misunderstood the office his Turkish acquaintance filled; instead of supervising all hospitals, the Turkish physician may have served as director of one of the more prominent hospitals of the capital, perhaps as aktouarios (director) of the Mangana Xenon, the post that the Moslem Abram had held.” Despite the questions it raises, Nicholas’s testimony provides additional evidence that a hospital system still existed in fifteenth-century Byzantium.
In the course of examining how Byzantine xenones functioned, Birth of the Hospital addressed the question of finances. Given that these xenones did not demand that patients pay for either medical care or room and board while at the hospital (the Pantokrator Typikon specifically banned any payments or tips for medical services), how did these institutions meet their expenses? My research has shown that support for hospitals came from major sectors of Byzantine society: the imperial government, the church, the monastic movement, wealthy families, and the medical profession itself through many hours of low-paid service in the xenon wards. In addition to large initial grants of land that emperors or wealthy private patrons donated, I supposed that former patients, both rich and poor, often left hospitals legacies or inter vivos gifts in place of payment at the time of treatment (p. 209). I have recently found evidence for such gifts.
A sixth- or early-seventh-century papyrus from Egypt (a province of the Byzantine Empire) preserves part of a will designating a woman as the heiress of an estate. The surviving text does not include the name of the testator or the name or relationship of the female heir. The text does mention, however, that the author of the testament had left a substantial legacy to a hospital, and the will refers clearly to Justinian’s Novel 1, a law issued in 535 allowing a testator to disinherit his heir if that person failed to carry out the legacy within one year after the testator’s death. The author wanted to ensure that the woman he had named as his heir did not fail to deliver the legacy to the hospital he had designated.”
A second testament comes from twelfth-century Constantinople. In drafting his will, the testator, a monk, left almost all his property to the Monastery of Saint George Tropaiophoros in the Mangana. He specified particular books for the monastic library, including service books for Holy Week compiled by Theodore Prodromos, the most famous contemporary writer and teacher of the capital. The monk also left twelve gold hyperpyra to the Mangana hospital: eight hyperpyra to purchase sugar and four to buy olive oil for the medicines.”
A third donation, this time an inter vivos gift, sheds some light on what motivated these donations and legacies to hospitals. The tenth-century version of the Vita Sancti Sampsonis added to the text of the saint’s life a series of miracle tales recounting how Saint Sampson had cured patients at his hospital.* In one of these tales, a protospatharios named Eustathios developed a serious eye infection; he sought assistance from his friend Leo, who had just accepted the responsibility of supervising the finances of the Sampson Xenon. Leo persuaded Eustathios to sign a written contract promising to supply the hospital with olive oil. As a result of his promise, Saint Sampson miraculously cured Eustathios’s eye infection.” Such cures, both natural and supernatural, no doubt moved many people to offer some remuneration in return for the help they had received either in xenon wards or in the outpatient clinics.
Having highlighted some of the most important features of Byzantine hospitals and introduced several new sources that help to illustrate how these institutions treated the sick and financed their philanthropic services, I shall now address the questions that my colleagues have raised regarding Birth of ibe Hospital. The most significant group of critics has maintained that Birth of the Hospital and other studies describing Byzantine xenones rely too much on the detailed description of the Pantokrator Xenon, found in the twelfthcentury typikon for the Pantokrator Monastery. These critics claim that this remarkably well-organized hospital was an exception, perhaps even a unique institution in the history of the Byzantine Empire. They warn that the Pantokrator Xenon should not be used as an example of hospital care in most Byzantine xenones. According to these scholars, the majority of Byzantine hospitals offered general charitable assistance—food, shelter, and some nursing care—to many categories of needy people.*® In sum, they believe these xenones differed little from the hospices and hospitals of the medieval West. Some of these critics have even suggested that the Pentokrator Typikon’s hospital instructions were never implemented. They were meant to serve, instead, as an example of a perfect hospital—a utopian ideal for hospital planners, not a description of a functioning institution?
In addressing these views, I shall begin by stating emphatically that the Pantokrator Xenon was not unique, nor did it hold the first place in prestige among Constantinopolitan hospitals. A laudatory vita of the empress Eirene, the wife of John Il] Komnenos and cofounder of the Pantokrator Monastery, states explicitly that the Pantokrator Xenon “almost” held the first place among such institutions, outshining most—but not all—of them in beauty, fame, location, and effective organization.* Two hospitals which it surely did not surpass were the ancient Sampson and the more recent Mangana, founded in the eleventh century.
Byzantine texts, both legal and literary, always accorded the greatest honor among hospitals to the renowned Sampson Xenon. Opened sometime in the late fourth century, the Sampson was indisputably the oldest philanthropic medical institution in Constantinople. After the Nika fire of a. 532 destroyed the original hospital, the emperor Justinian rebuilt it as a multistoried complex of elaborate buildings. Before a.p. 600 the archiatroi, the leading physicians of Constantinople, were supervising patient treatment in its wards. In the seventh century, it had specialized rooms for surgery and for patients with eye diseases. Sources from the eighth and ninth century reveal its continuing importance. The Miracle Tales of Saint Sampson, a tenthcentury addition to the ancient vita of the hospital’s founder, reveals that even a leading aristocrat of a patrician family, a courtier of the emperor Romanos II, was assigned a hospital bed by the Sampson Xenon staff.** When Constantine Akropolites described the Sampson hospital in the late thirteenth century, he compared it to Justinian’s great church of Hagia Sophia.*! Although two panegyric texts praise the beauty of the Pantokrator Monastery, the hospital, and the gardens which surrounded the complex, neither compared this foundation to the great domed church of Justinian”
Among the more recent philanthropic foundations of Constantinople, the Mangana Xenon also outranked the Pantokrator hospital. The emperor Constantine IX (1042-55) had expanded the old imperial palace of the Mangana into a vast complex of buildings including the Monastery of Saint George Tropaiophoros, a dependent xenon and gerokomeion (old-age home), and a renowned law school. Evidence presented in Birth of the Hospital links the Mangana Xenon with the imperial physicians who supervised the emperor's health. For example, the aktouarios, the highestranking physician attached to the imperial court, also served as a key official on the Mangana Xenon staff, probably its director (pp. 149-50). The imperial government restored the Mangana Xenon after Michael VII regained control of Constantinople from the Latins in 1261 and continued to support this hospital throughout the fourteenth century; such government attention reflects the high status held by this hospital (pp. 183-84 and 195). Meanwhile, there is no evidence that the Byzantine government considered restoring the Pantokrator Xenon after 1261.
Though it is beyond doubt that the Pantokrator Xenon was not a unique institution in Constantinople, one must admit that Birth of the Hospital, as well as other studies of Byzantine philanthropic institutions, have relied heavily on the wealth of detailed information supplied by the Pantokrator Typikon. In many areas of ancient and medieval studies, however, historians often must depend on a single source to reconstruct the past. For example, without the Notitia Dignitatum, a detailed outline of the late Roman bureaucratic structure ca. A.D. 400, historians would have been unable to reconstruct the complex civil and military bureaucracy of the imperial government after the reorganizations of Diocletian and Constantine.* Without the comments of Galen, penned in the second century after Christ, we would understand much less about the development of Greek medicine during the Hellenistic period.”
In writing Birth of the Hospital, | attempted to use the Pantokrator Typikon with care. I have never assumed that organizational features of the twelfth-century Pantokrator Xenon were present in earlier hospitals unless I found contemporary evidence to justify such an assumption, nor have I ignored the element of change while tracing the evolution of Byzantine hospitals through the many centuries covered by the book. In the final analysis, it rests with each reader of Birth of the Hospital and with future scholars to determine whether I have correctly employed the Pantokrator Typikon in explicating earlier sources describing xenones.
With regard to the most extreme position advanced by these critics—that the Pantokrator Xenon hospital, as described in the typikon, never in fact existed—one should consider several other twelfth-century sources besides the typikon which describe the Pantokrator Xenon as a center of medical care. Robert Volk cited three of these sources in his study of Byzantine typika.** A fourth source was recently discovered by Michael Jeffreys among the many unpublished poems of the Mangana Poet, a work Jeffreys has identified as Poem 59. Since this poem remains unpublished, I provide a summary here of its contents relevant to the Pantokrator hospital.’
The Mangana Poet addressed Poem 59 to his employer, the sabastokratorissa Eirene, widow of Andronikos Komnenos and sister-in-law of the emperor Manuel I (1143-80). In many of his poems, the Mangana Poet begs Eirene for financial support or for assistance in obtaining favors from the emperor Manuel I. In Poem 59, however, the Mangana Poet describes an illness Eirene contracted and the treatment she was receiving for it from the doctors of the Pantokrator Xenon. Two verses make clear that Firene was occupying a bed reserved for patients of the hospital, a bed the Mangana Poet prays someone else will soon occupy.” That a member of the imperial family would seek help at the Pantokrator is an indication of the high-quality medical care available at this hospital. Other sources, however, also prove that Byzantine aristocrats occasionally made use of public hospitals when they were ill. The tenth-century Miracle Tales of Saint Sampson describe a high court official who occupied a hospital bed while receiving treatment at the Sampson Xenon.”
Poem 59 mentions at least three physicians assigned to treat Eirene: two younger doctors and a third, older physician who outranked the others. These doctors gave Eirene a pill and sprinkled her with a concoction made from figs. The senior physician also bled her by using a leech, a treatment the Mangana Poet harshly criticizes. The poem also stresses how the younger physicians had mastered the logos of medicine and obtained boundless professional experience as well—doubtless a reference to the hospital’s training program, which involved studying medical texts under the teacher of physicians and also an extended period of serving as an apprentice physician in the hospital wards (pp. 156-59).
In reviewing Poem 59, the Pantokrator Typikon, and all the other textsdescribing the Pantokrator Xenon and comparing the findings with what Byzantine sources reveal about other hospitals, one can confidently state that the Pantokrator offered excellent medical care, adequate even for the reigning emperor's sister-in-law. On the other hand, the Pantokrator Xenon operated fully within the tradition of Constantinopolitan hospitals, a tradition stretching back to the reign of Justinian. In the complex rules governing the Pantokrator Xenon, the Typikon does not employ a single novel term or introduce a single new feature of hospital organization. Every term the Typikon has selected, every title ascribed to members of the medical staff, and every detail of daily regime can be documented in sources describing earlier Byzantine xenones.
Some scholars have raised a second objection to Birth of a Hospital, namely that it has attempted to explain too much, to derive more information from the extant sources than they in fact contain. On the basis of such an argument, these historians have rejected my conclusion that the emperor Justinian played a key role in the evolution of Byzantine hospitals by transferring the leading physicians of the Empire, the municipal archiatroi, from the payroll of the Empire’s cities to the staffs of the Christian xenones (pp. 44-49). These historians have stressed that no specific law survives in the huge corpus of Justinianic legislation and administrative regulations to indicate such a shift. Without primary evidence for the reassignment of archiatroi, these critics have denied that Justinian ever carried out this fundamental change in the classical medical profession.”
My argument in support of Justinian’s reassigning archiatroi to hospital service relies on three considerations: first, that all references to archiatroi after the mid-sixth century represent these doctors practicing their profession in association with Christian hospitals; second, that during the reign of Justinian other institutions of the classical polis passed under the supervision of the Christian church; and third, that Prokopios, the chronicler of Justinian’s reign, makes an oblique reference to the emperor’s reform of the archiatroi.
Birth of the Hospital presents the physician Flavius Phoibammon as the first example of an archiatros closely associated with a xenon (p. 48). A lengthy papyrus document dated 570 preserves a testament prepared by Phoibammon, an archiatros of the Egyptian city of Antinoopolis. In addition to other properties listed in the testament, Phoibammon had inherited the supervision of a xenon in Antinoopolis from his father, who had also been an archiatros of the city. The testament does not make clear how Flavius Phoibammon’s father came to administer this hospital, but it is significant for our argument that he was supervising this institution in the years prior to 570, the later years of the emperor Justinian (527-65).*
After describing this Egyptian case, Birth of the Hospital next examines the Miracula Sancti Artemii, a seventh-century text that describes the archiatroi working in monthly shifts at the Christodotes Xenon of Constantinople.“
After publication of the book, I discovered another source that refers to an archiatros assigned to the Sampson Xenon during the reign of the emperor Maurikios (582-602). According to this story, Maurikios had managed to capture a vicious robber who had terrorized the countryside of Thrace. After the emperor imprisoned him in Constantinople, the robber fell seriously ill and was assigned a bed in the Sampson Xenon. At the moment of the robber’s death, the archiatros in charge of the hospital had a dream revealing that God had forgiven the criminal.® This detail of the story supports the evidence from the Antinoopolis papyrus that archiatroi were supervising Christian hospitals by the late sixth century.
In addition to this consistent evidence, I also considered relevant Justinian’s general policy of realigning polis government around Christian institutions. Completing a program initiated by the emperor Anastasios I (491— 518), Justinian transferred the selection of important polis officials such as the defensor civitatis and the sitones (the official in charge of the city’s grain supply) from the old municipal council (curia) to a new group of wealthy landowners headed by the local bishop. Recent research has shown that, as a result of Justinian’s legislation, the patriarch of Alexandria was supervising that great city’s emergency grain stores by the beginning of the seventh century. At Constantinople, the director of the capital’s largest Christian philanthropic institution, the Orphanotropheion (orphanage), had assumed responsibility for maintaining emergency grain supplies by the time of the Persian-Avar assault in the early seventh century.”
A recent study on the baths of the Byzantine Empire has shown that the great public bathing facilities of the Eastern cities began to experience serious difficulties in the sixth century. In the late fifth century, a monastery replaced a bath and gymnasium built on the island of Chios during the reign of Constantine. Excavations at Aizanai in Asia Minor have revealed that the bath complex at that city was converted into a church and a number of other facilities during the reign of Justinian.
As these ancient baths waned, new Christian institutions called diakoniai began to spread throughout the East. Although initially the Monophysites sponsored these philanthropic foundations, orthodox Chalcedonians eventually copied them (pp. 130-32). The main philanthropic service of these diakoniai was to provide baths for the poor. Some diakoniai built their own bath houses; others rented existing facilities. In addition to these diakoniai, monasteries in the sixth century began to build and maintain small bath houses to serve laymen. These smaller Christian baths gradually replaced the vast bathing facilities of the classical polis.*
The imperial government mandated the transfer of polis government from the ancient city councils to the local bishops and encouraged the concomitant expansion of church responsibility by issuing many constitutions confirming the new powers of Christian officers. The decline of the ancient bathing facilities and their replacement by Christian baths, on the other hand, seems to have occurred spontaneously, perhaps as the result of economic forces or of moral considerations—the cavernous classical baths had been difficult to police, and Christian homilists had attacked them as places of immorality. It is, nevertheless, significant that the transformation of polis institutions, whether government sponsored or spontaneous, took place in the sixth century, the same time period during which the municipal archiatroi began to appear as physicians in the Christian hospitals.
The foregoing considerations would not necessarily indicate that Justinian altered the organization of the city archiatroi. The change from municipal physicians to hospital doctors could have occurred spontaneously, as the transformation of bathing practices did. The historian Prokopios, however, specifically mentions that Justinian altered the method of remunerating archiatroi. In his Anekdota, a vicious attack on the character and policies of Justinian and his ministers, Prokopios tries to portray not only Justinian’s wicked personal qualities, but also his ill-conceived government programs, which Prokopios believed were destroying the core of ancient society, the classical city-states. As an example of Justinian’s ruinous acts regarding the ancient cities, Prokopios states:
Nay more, he [Justinian] also caused physicians and teachers of freeborn children to be in want of the necessities of life. For the allowance of free maintenance which former Emperors had decreed should be given to men of these professions from the public funds he cancelled entirely. . . . And thereafter neither physicians nor teachers were held in any esteem.”
Since the second century, the only physicians who received stipends from the government were called archiatroi (p. 46). In this passage, Prokopios clearly records a major change in the nature of the city archiatroi, the direct heirs of the public physicians of classical Greece. But did Justinian merely cancel the government subsidies to these doctors? In view of Prokopios’ love of ancient institutions, his coolness toward the Christian church, and his hatred of Justinian, it is easy to see how he could interpret the reassigning of archiatroi to Christian hospital service as the destruction of the traditional profession of medicine.
Prokopios’s statement implies that a reorientation of city archiatroi resulted from a policy decision by Justinian. Since no official law ordering a major revision of how these doctors were paid survives, it is also possible that the movement of archiatroi into Christian xenon service might have occurred spontaneously, just as the changes in bathing facilities had evolved. With their large endowments, xenones might have offered a more dependable source of income than the financially troubled municipal governments. Moreover, as Christianity grew stronger, devout physicians would have seen hospital service as a way of fulfilling the Gospel’s command to assist those in need.
Whether as the result of imperial policy, as Prokopios seems to indicate, or of a spontaneous development, there is no doubt that the decades of the sixth century saw the archiatroi assume a leading role in treating the patients of Byzantine hospitals. These archiatroi, in turn, bound the Christian xenones more tightly to the medical profession and helped to ensure that these philanthropic hospitals continued to focus on curing illnesses, not simply on caring for the sick (pp. 156-61).
Some researchers, particularly among the historians of medicine, have developed a third argument against the conclusions reached in Birth of the Hospital, an argument based not so much on interpreting Byzantine sources as On experiences in studying how other premodern societies, particularly Western Europe, organized medical care. As one historian of medicine has put it, hospital care in Byzantium “took very much a second place to treatment in the home by privately engaged and self-employed physicians. That is what our literary sources emphasize, and to argue otherwise flies in the face of common sense and of all other parallels for societies before this century.” But were there no societies prior to the twentieth century which developed a medical system in which hospitals occupied a central place?
From the ninth century on, Islamic society maintained a medical organization in which hospitals played a primary role, particularly in collecting important manuscripts, promoting translations into Arabic, and educating new physicians.*! So important did hospitals become to the organization of Islamic medicine that the famous twelfth-century Egyptian physician Ibn Jumay recommended good hospitals as a key step in maintaining a high-quality medical profession because such institutions offered ideal opportunities for the proper training of doctors.’ No historians of Islamic medicine have yet thoroughly studied the role of these hospitals in providing medical care to the people of Baghdad, Aleppo, or Cairo, but it is possible that such institutions performed services similar to the xenones of Constantinople.
Renaissance Florence offers another example of a society prior to the twentieth century in which hospitals occupied a central position in the treatment of illnesses and the training of young physicians. Katharine Park and John Henderson have focused attention on the Hospital of Santa Maria Nuova, an institution that one fifteenth-century humanist hailed as the first hospital among Christians. The rules of this hospital engaged the services of the six best physicians in Florence and required that they come to the hospital each day and supervise the treatment of the sick. In addition, the hospital supported three young physicians who lived on the premises and received room, board, and an unparalleled opportunity to learn from experience in return for dedicating their full-time service to the hospital patients. In addition to its patient wards, Santa Maria Nuova also maintained an outpatient clinic, and everyone who could not afford private physicians came to this dispensary for medicines and other sorts of treatment.”
We have no idea what percentage of Florentines used the hospital compared to those who paid for private treatment, but surviving records of the individual patients at Santa Maria Nuova from the years 1502-14 reveal a discharge rate from the hospital proper of between 86 and 91 percent.™ In other words, only 9 to 14 percent of the patients admitted during these years died in the hospital’s care. These statistics indicate that Santa Maria Nuova was not the death trap that Enlightenment reformers of the eighteenth century imagined philanthropic hospitals to be.
The physicians at Santa Maria Nuova also kept a record of effective remedies that they had devised in the course of their hospital practice, the very same kind of lists which xenon physicians collected in Constantinople.” During the sixteenth century the Florentine guild of physicians added hospital experience as a requirement for licensing, and by the end of the same century surgeons had organized formal instruction at the hospital. The medical profession of Renaissance and early modern Florence increasingly came to see hospitals and hospital experience as an essential part of medical practice. In this, they were following the same paths that Byzantine physicians had pursued half a millennium earlier.®
In sum, hospital medicine did not always take “a second place to treatment in the home” by self-employed physicians up until the twentieth century. In Islamic cities as well as fifteenth- and sixteenth-century Florence (and perhaps in other Italian cities), physicians integrated hospital practice into the fiber of the medical profession, especially in training new physicians. After one considers these two examples, the Byzantine xenones cease to appear so exceptional, so isolated from developments in the Latin world of the West and from medical institutions in the Moslem society of the East.
To conclude this introduction, I shall briefly outline three paths for further research which promise to yield additional information concerning Byzantine xenones and their development through the centuries. The first path we have just examined—that is, the history of medieval and Renaissance Italian hospitals. Recent research I have conducted on the Antidotarium magnum, the major twelfth-century pharmacopoeia used at the medical school of Salerno, demonstrates that this treatise included at least three entries derived from Constantinopolitan xenon treatment lists. There might be many more Byzantine remedies in the Salerno text, but determining how many would require a critical edition of the Antidotarium magnum, as well as a careful comparison with the many extant xenon treatment lists. After such careful philological and codicological analysis, it might be possible to gauge to what extent Byzantine hospital medicine influenced the Salerno physicians.*’
The hospitals of Renaissance Florence and Siena offer another area of fruitful study. Did the Florentine hospital of Santa Maria Nuova, so strikingly similar to Byzantine hospitals, evolve its organizational features independent of any outside influence, or did Byzantine refugees from the Ottoman advance instruct their Italian hosts not only in ancient Greek but also in contemporary Byzantine medical practice? One of the leading Greek immigrant scholars at Florence was John Argyropoulos (Giovanni Argiropulo), who had taught science and medicine at a Constantinopolitan xenon before the Turkish conquest of the Byzantine capital in 1453.* So far, historians have found no connection between Argyropoulos and the Florentine hospitals, but the study of these remarkable Tuscan institutions has only just begun.
Archaeology represents the second promising path to future discoveries concerning Byzantine hospitals. Visitors to Hagia Sophia can still see the ruins of the ancient Sampson Xenon to the northeast of the Great Church. One can find there a maze of walls and what appears to be a courtyard. A scientific survey of the aboveground ruins might reveal important information concerning Constantinople’s most famous hospital.” It might also be rewarding to study more thoroughly the walls and vaults surrounding the Pantokrator monastery churches which still stand today in central Istanbul. All around these domed churches one can see the substructures of what once were the xenon, the gerokomeion, and the monastic quarters of the Pantokrator community (p. 12).
Although almost all the documentary evidence presented both in Birth of the Hospital and in this introductory essay refer to xenones at Constantinople, evidence exists that some hospitals served other cities such as Thessalonica, Philadelphia, and Nicea (pp. 165, 193, and 197). Moreover, in the preamble to his Novel 19, a law restricting new monastic foundations, the emperor Nikephoros II Phokas stated that the Empire not only had enough monasteries, but also sufficient xenones and gerokomeia to serve his subjects’ needs. His statement implies that a network of hospitals for the sick and rest homes for the aged and chronically ill existed by the tenth century. Rather than establish new ones, Nikephoros recommended that donors increase the endowment of existing charitable foundations so that these institutions could maintain the facilities they already had.
If such a network of provincial hospitals functioned throughout the Empire, perhaps archaeologists surveying Byzantine sites in Asia Minor or Greece will discover the remains of some of these other xenones. During recent excavations at Corinth, Charles Williams and Orestes Zervos have, in fact, identified the remains of a hospital. This particular structure dates from the years of Frankish occupation (second third of the thirteenth century), but it may contain information applicable to provincial Byzantine xenones of the twelfth century.
Opening the third path to a better understanding of Byzantine hospitals will require painstaking research by philologists and historians of medicine, in order to prepare thorough studies of the many edited and unedited Byzantine medical treatises and treatment lists. In his detailed analysis of the fourteenth- century physician John Zachariah, Armin Hohlweg discovered that Zachariah had made some of his medical observations while working in a xenon. Hohlweg found these references in a work of Zachariah published in the 1840's. Other references may also appear in the extensive unedited writings by this late Byzantine physician.
In addition to the many unpublished works of John Zachariah, Byzantine codices contain a myriad of treatment lists, pharmacopoeias, and epitomes of Classical medical treatises. Careful study of these works and the manuscripts which preserve them may reveal much information on Byzantine hospital practice. Such studies would not only seek to establish the oldest versions of particular treatment lists or pharmacopoeias, but they would also record just as carefully which new therapies physicians added and which they removed as the lists were recopied in later manuscripts. An accurate knowledge of the transformations experienced by these treatment lists and a careful record of the physicians credited with discovering new therapies might unveil much about the practice of hospital physicians.
In Chapter Nine, “Hospitals and Medical Literature,” Birth of the Hospital only touches on this vast subject, but the wealth of information uncovered simply by examining one xenon treatment list, found in Vaticanus graecus 299, folios 368-393", demonstrates how fruitful careful philological and codicological research focused on a wider selection of Byzantine medical manuscripts might be in the future.
This introductory essay presents new evidence regarding Byzantine hospitals and attempts to answer some of the objections raised by scholars regarding the history of medical xenones presented in Birth of the Hospital. It is perhaps useful to close this discussion by reducing the debate concerning xenones to its simplest terms. Were Byzantine xenones hospitals in the modern sense of the term, medical centers controlled by trained physicians and designed to cure the sick, as Birth of the Hospital maintains, or were they facilities established primarily to provide care and comfort to the suffering? A passage from the tenth-century biography of Saint Luke the Stylite should help answer this question. Ct is important to notice that the Constantinopolitan xenon described in this hagiographical source is neither the ancient Sampson nor the twelfth-century Pantokrator hospital.)
[Sergios, having been severely beaten] was found sometime later by those assigned the task [of searching out the sick]. Sergios was lying as though dead, scarcely breathing. Sadly, they lifted Sergios up, and carrying him in a litter, they left him at the hospital called Euboulos. There, those learned in the medical art consulted together and examined his condition carefully from the first day to the seventh, but seeing that the injury was greater than any medical study or therapy, they completely gave up and abandoned hope for his life. Moving on, they left him unattended and urged those in charge of his care to make century physician John Zachariah, Armin Hohlweg discovered that Zachariah had made some of his medical observations while working in a xenon. Hohlweg found these references in a work of Zachariah published in the 1840's. Other references may also appear in the extensive unedited writings by this late Byzantine physician.
In addition to the many unpublished works of John Zachariah, Byzantine codices contain a myriad of treatment lists, pharmacopoeias, and epitomes of Classical medical treatises. Careful study of these works and the manuscripts which preserve them may reveal much information on Byzantine hospital practice. Such studies would not only seek to establish the oldest versions of particular treatment lists or pharmacopoeias, but they would also record just as carefully which new therapies physicians added and which they removed as the lists were recopied in later manuscripts. An accurate knowledge of the transformations experienced by these treatment lists and a careful record of the physicians credited with discovering new therapies might unveil much about the practice of hospital physicians.
In Chapter Nine, “Hospitals and Medical Literature,” Birth of the Hospital only touches on this vast subject, but the wealth of information uncovered simply by examining one xenon treatment list, found in Vaticanus graecus 299, folios 368-393", demonstrates how fruitful careful philological and codicological research focused on a wider selection of Byzantine medical manuscripts might be in the future.
This introductory essay presents new evidence regarding Byzantine hospitals and attempts to answer some of the objections raised by scholars regarding the history of medical xenones presented in Birth of the Hospital. It is perhaps useful to close this discussion by reducing the debate concerning xenones to its simplest terms. Were Byzantine xenones hospitals in the modern sense of the term, medical centers controlled by trained physicians and designed to cure the sick, as Birth of the Hospital maintains, or were they facilities established primarily to provide care and comfort to the suffering? A passage from the tenth-century biography of Saint Luke the Stylite should help answer this question. Ct is important to notice that the Constantinopolitan xenon described in this hagiographical source is neither the ancient Sampson nor the twelfth-century Pantokrator hospital.)
[Sergios, having been severely beaten] was found sometime later by those assigned the task [of searching out the sick]. Sergios was lying as though dead, scarcely breathing. Sadly, they lifted Sergios up, and carrying him in a litter, they left him at the hospital called Euboulos. There, those learned in the medical art consulted together and examined his condition carefully from the first day to the seventh, but seeing that the injury was greater than any medical study or therapy, they completely gave up and abandoned hope for his life. Moving on, they left him unattended and urged those in charge of his care to makecentury physician John Zachariah, Armin Hohlweg discovered that Zachariah had made some of his medical observations while working in a xenon. Hohlweg found these references in a work of Zachariah published in the 1840's. Other references may also appear in the extensive unedited writings by this late Byzantine physician.
In addition to the many unpublished works of John Zachariah, Byzantine codices contain a myriad of treatment lists, pharmacopoeias, and epitomes of Classical medical treatises. Careful study of these works and the manuscripts which preserve them may reveal much information on Byzantine hospital practice. Such studies would not only seek to establish the oldest versions of particular treatment lists or pharmacopoeias, but they would also record just as carefully which new therapies physicians added and which they removed as the lists were recopied in later manuscripts. An accurate knowledge of the transformations experienced by these treatment lists and a careful record of the physicians credited with discovering new therapies might unveil much about the practice of hospital physicians.
In Chapter Nine, “Hospitals and Medical Literature,” Birth of the Hospital only touches on this vast subject, but the wealth of information uncovered simply by examining one xenon treatment list, found in Vaticanus graecus 299, folios 368-393", demonstrates how fruitful careful philological and codicological research focused on a wider selection of Byzantine medical manuscripts might be in the future.
This introductory essay presents new evidence regarding Byzantine hospitals and attempts to answer some of the objections raised by scholars regarding the history of medical xenones presented in Birth of the Hospital. It is perhaps useful to close this discussion by reducing the debate concerning xenones to its simplest terms. Were Byzantine xenones hospitals in the modern sense of the term, medical centers controlled by trained physicians and designed to cure the sick, as Birth of the Hospital maintains, or were they facilities established primarily to provide care and comfort to the suffering? A passage from the tenth-century biography of Saint Luke the Stylite should help answer this question. Ct is important to notice that the Constantinopolitan xenon described in this hagiographical source is neither the ancient Sampson nor the twelfth-century Pantokrator hospital.)
[Sergios, having been severely beaten] was found sometime later by those assigned the task [of searching out the sick]. Sergios was lying as though dead, scarcely breathing. Sadly, they lifted Sergios up, and carrying him in a litter, they left him at the hospital called Euboulos. There, those learned in the medical art consulted together and examined his condition carefully from the first day to the seventh, but seeing that the injury was greater than any medical study or therapy, they completely gave up and abandoned hope for his life. Moving on, they left him unattended and urged those in charge of his care to make.
preparations because of this. .. . The people who were responsible for taking care of him received this painful news; they picked up the hopeless Sergios in a litter and carried him to a home in a holy house nearby, named after the martyr of God, Nicholas, and located next to the place called the Tyche of the City. Here they placed him to breathe his last according to the situation.
Sergios, however, did not die in the hospice of Saint Nicholas. Having been judged incurable by the physicians and thus removed from the Euboulos hospital, he received divine healing through the prayers of Saint Luke.
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