Here we present selected parts of the published paper ‘How Medicalised were Byzantine Hospitals?‘, by Peregrine Horden.
»Philanthropic social welfare and medical assistance institutions [in Byzantium] […] were in every respect perfect and nearly similar to present day institutions of this kind. In any case, they were the first fully equipped European hospitals«
So wrote the medical historian G. C. Pournaropoulos in 1960. Even the most ardent
of Byzantine hospitals’ more recent admirers might find his verdict somewhat hyperbolic. Yet many scholars would pardon the hyperbole and acknowledge an element of truth within it. Only two monographs have been devoted to Byzantine philanthropic institutions, and neither is wholly opposed to Pournaropoulos in outlook. The first monograph surveys the whole range of hospitals, hospices, orphanages, old-age homes and the like that were founded during the Byzantine millennium. Its author, Demetrios J. Constantelos, takes the space to quote Pournaropoulos’s judgement – as an exaggeration, but not, it is implied, a complete distortion – and lauds one Byzantine hospital as »a medical center in the modern sense of the term«. The second book, by Timothy S. Miller, announces its narrower scope, and its conviction of the subject’s significance, in the title, ›The Birth of the Hospital in the Byzantine Empire‹: the birth, that is, of the modern hospital. »Byzantine xenones [hospitals]«, he writes, »resemble more closely modern hospitals than they do any of the institutions of pagan antiquity or any of the houses of charity in the Latin West during the Middle Ages«. Miller takes the huge medical staff of one exceptionally documented establishment as broadly indicative of the whole trajectory of Byzantine hospitals, and argues that east Roman hospitals were, quite generally, highly medicalised. They were staffed by doctors whose purpose was cure rather than care. More than that, after the mid-sixth century they were the focus of the entire medical profession: leading physicians concentrated their activities within them. Those activities were regularly supported by facilities for the copying and conservation of medical manuscripts (i.e. scriptoria and libraries) and the education of doctors. In Miller’s pages, hospitals become decisive for the character and evolution of the entire medical profession in the Byzantine Empire.
For the optimists, Byzantine hospitals were clearly ancestors of modern hospitals in
focusing on cure by doctors, and they characteristically functioned at a high level of medical sophistication – approximately the level of the best known and most striking examples. In this they distinguished themselves from contemporary medical hospitals in western Europe, where (with the exception of Italian institutions) doctors were hardly in evidence until the end of the Middle Ages and the distinctions between curative hospital and caring hospice can scarcely be drawn.
Three general statements are, I think, beyond reasonable challenge.
The first is this: from at least the mid-fourth century up to the late twelfth (and to a much lesser extent from the end of the Latin conquest until the fall of Constantinople) a very wide variety of philanthropic institutions were founded in the Byzantine empire by emperors, churchmen, monks, and lay individuals; and many of those institutions must be regarded as basically therapeutic in character. We encounter the xenodocheion (house for strangers), the xenon (literally meaning much the same), the nosokomeion (house for the sick), the ptochotropheion (poor house), the orphanotropheion (orphanage), gerokomeion (home for the elderly), and others. This array has especially impressed those optimists who see Byzantium as, by medieval standards, a uniquely charitable society. But the specialised designations may reflect changing fashion, or perhaps the desire of donors to individuate their achievements, rather than the functions actually performed by the institutions in question, either at their inception or as they evolved. A lesson to be learned from the study of western European foundations is that hospitals may have many more functions than their various labels suggest, and that the principal function can change quite rapidly over time. In the case of Byzantium, it is clear that the sick, whether transient or not, might be received in a xenon or xenodocheion, that the poor in a ptocheion or ptochotropheion might be impoverished because chronically ill, and so on. Xenodocheion, nosokomeion, and xenon have all, moreover, sensibly been translated as ›hospital‹. In short, it is clear that the particular designation in the written evidence is no guide to type of clientèle. We may find the sick in a variety of (superficially) different institutions.
The second point to be made about Byzantine charitable institutions is that no scholar, however optimistic, supposes that doctors were available in all of them, or even in all those in which the sick predominated among inmates. The pessimist views this lack as a matter of economics: doctors were too expensive for the smaller or poorer establishments. It is not a question of which foundations were hospitals and which were not. On a minimal definition of the hospital as a more or less independent institution for the overnight relief of the poor and/or sick, of course, most of the philanthropic establishments we know about would qualify. It would follow that – out of poverty or some other reason – there were numerous hospitals without doctors. The optimists naturally view the availability of doctors in a different light. They adopt a more stringent definition of the ›true hospital‹ as one that focuses exclusively on medical treatment of the sick (whether it is called nosokomeion or xenon or ptochotropheion) rather than just nursing. On this argument, the statement ›all Byzantine hospitals were medicalised‹ becomes, optimistically speaking, true by definition rather than through historical enquiry. Yet even the optimists are then, like the pessimists, left with other types of foundation, not (on their definition) true hospitals, in which the attendance of doctors was at least unusual. On either account we have to deal only with a portion of the whole range of Byzantine philanthropic foundations for the sick.
The third general statement is that, even on the minimal definition of the hospital (that is, the most inclusive definition), doctors were indeed on a number of occasions explicitly associated with hospitals in Byzantium. This is true of the very beginnings of
Christian hospital history in the mid-fourth century, as exemplified in the Basileias, the medical-philanthropic complex established outside Caesarea (modern Kayseri, Turkey) by St. Basil. (The hospital really was, to that extent, ›born‹ in the Byzantine Empire, as Miller advocates.) It is even true of the later phase of the empire’s history – after the end of Latin occupation in 1261 – at least in Constantinople. We can find traces of doctors (iatroi) active in hospitals in late Egyptian papyri, in inscriptions, correspondence and encomia, and, perhaps most vividly, in hagiography.
Let us confine discussion to the pre-1204 period because it is the better documented. My very rough count of the number of specific hospitals in which doctors are attested is at the most 23–25. This figure is based on evidence collected by Miller
Counting hospitals and the like began in 1680 when Du Cange published his »Constantinopolis Christiana«, listing some 35 charitable institutions. Janin’s more recent tabulation for the capital – not wholly reliable – finds 28 xenones, some 6 hospitals, and 27 old people’s homes. The most recent general survey for the provinces of the Byzantine empire (excluding the capital), up to the mid-ninth century, gives a total of over 160 charitable facilities of various kinds, of which the most numerous are those called xenodocheia (59), nosokomeia (49), and ptocheia (poor-houses; 22). How many of these actually admitted the sick and included medical facilities is, naturally, unknowable. But on any estimation it is clear that explicitly ›doctored‹ hospitals were a minority. If we inflate the number of the latter by making allowance for those of which we have only an imprecise record, we must also inflate the total number of institutions. True, medieval hospitals were always going ›out of business‹; they were, often, by modern standards, ephemeral creations. So we cannot tell how many known foundations were actually functioning at any given date. On the other hand there are always likely to have been more hospitals than we know about because of the great scarcity of archaeological evidence and the disappearance of texts. The Egyptian papyri have, of late, markedly increased the number of identifiable hospitals from just one corner of the early Byzantine Empire. Yet there is no reason to suppose that Egypt was atypical in its philanthropic provision, which extended to small towns, and even to villages. Close regional studies of charitable activity in later periods nearly always substantially increase the numbers of foundations.
(End of Part 1)
Research-Selection: Anastasius Philoponus