Here we present selected parts of the published paper ‘How Medicalised were Byzantine Hospitals?‘, by Peregrine Horden.
(…) fifty monks were to perform the liturgy; fifty clergy were allocated to the Church of the Virgin; fifty sick people were to be sheltered in the hospital; and the core staff for the five wards numbers – slightly unfortunately for the tidy-minded historian – forty-nine (although of course not all were on duty at any one time). The broad similarity in strength of the monks, clergy, patients, and medical carers reflects their common task as
intercessors for the emperor and his family. The typikon is, it should be stressed, essentially a liturgical document and its medical provisions should all be read in that light. The sick and leprous are to be looked after so as to encourage them to intercede on the emperor’s behalf with all the more fervour. The physicians are at all times to act in the knowledge that they must render account to Christ the Pantokrator for their actions. ›For our Master accepts as his own what is done for each of the least of the brothers [as in Matthew XXV.40] and measures out rewards in proportion to our good deeds‹
The theological approach to the typikon will take us only part of the way towards an
explanation of its contents. It would apply to all monastic hospitals of the period. And yet
the level of medical provision in the main Pantokrator hospital – two doctors and several
attendants per ward – is unparalleled in the explicit documentation now available to us.
(…) apart from the Pantokrator, only three other documented religious houses were to maintain a public hospital (as distinct from an infirmary for monks) with designated medical personnel. None of these is quite comparable to the Pantokrator in scale or staff.
(…) Only the thirteenth-century Lips convent in Constantinople approaches the Pantokrator in intensity of medicalisation. There was to be a twelve-bed hospital for women staffed by three doctors, an assistant, a nurse, a pharmacist, two apothecaries, six attendants, and a bloodletter. That outperforms the Pantokrator women’s ward in staff-patient ratio. But it is an isolated analogue from a later age.
(…) By the beginning of the twelfth century, Alexander Khazdan has suggested, doctors become quite frequent recipients of the letters of which texts survive (much more so than can be accounted for by positing a change in epistolographic fashion). The doctors are very much part of the court’s intellectual and social world. One Comnenian emperor, Manuel I, was himself skilled in medicine. A physician is even named in the list of those to be commemorated in the Pantokrator Church: Nicetas ›the first‹, presumably another leading physician or protomenutes. Theodore Prodromus, John II’s court poet, satirised the bunglers, including a dentist who broke his aching tooth with an instrument that would have done justice to an elephant. But he also paid tribute to a few men of outstanding skill, among them Nicholas Kallikles, physician to Alexius I. We can thus discern in the ›high profile‹ achieved by a few doctors at least one reason why they, and some of their colleagues, should have been seen as a necessary adornment of the Pantokrator complex.
(…) the only evidence we have that describes the Pantokrator’s charitable facilities gives much of the credit for them to the empress. These few texts make it clear that some kind of impressive medical institution (a iatreion, so they call it) was actually built. An anonymous poem may even attest a Pantokrator hospital patient – the emperor’s daughter-in-law no less.
(…) Separate wards, leprosaria, gerokomeia, the presence of different grades of doctors and surgeons, distributions to the transient poor at the monastery gate, clean bedding, large numbers of beds – all are documented, many of them in imperial foundations. There had after all been large and lavish philanthropic complexes in Byzantium since the ›Basileias‹ of Caesarea in the later fourth century.
»[T]he Pantocrator Xenon operated fully within the tradition of Constantinopolitan
hospitals […]. In the complex rules governing the Pantocrator 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«. (*)
(*) Nutton, Ancient Medicine
(…) the hospitals of late antique Hermopolis in Egypt were staffed by hypourgoi, as in the Pantokrator. Again, according to a seventh-century collection of miracle stories, the Sampson xenon in Constantinople had surgical facilities and an eye clinic (much as the Pantokrator would some four centuries later), and the Christodotes hospital was staffed by archiatroi and (once more) hypourgoi.
(…) »By the eleventh and twelfth centuries they [Byzantine hospitals] had become the principal theatres 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« (**)
If the claim just quoted has any validity, there ought to be codicological evidence to support it. David Bennett has recently surveyed the relevant manuscripts, in a discussion that supersedes all others in both scope and thoroughness. I am very grateful to him for permission to summarise and disseminate his main findings, as yet unpublished. First, the texts in question. There are five or six of these (depending on how one counts
a text that has at some point been divided into two by its copyists).
A. ›Prescriptions and classifications [of fever?] of the great hospitals, of the kind that
doctors prescribe from experience for healing, especially for patients in the hospitals.‹ Such is the title of one version of a compilation of treatments (parts of which, including the heading, variously appear in at least four other manuscripts). The compilation is divided under sixteen very miscellaneous headings and dates from (very approximately) 1050. It is found in the fourteenth-century Vatican MS. gr. 292. Three other manuscripts (B, D, and E below) also preserve these ›prescriptions and classifications‹ in varying degrees but sometimes without the titular ascription to hospitals.
B. Vat. gr. 299 is an anthology of medical writings dating from the later fourteenth century. It contains, within a long concluding medical compilation (c. 180.000 words), five remedies ascribed to three named physicians of the Mangana hospital, founded in the mid eleventh century, and one other remedy ascribed to a named, but otherwise unknown doctor, for whom no institutional affiliation is given. The named hospital physicians are:
(a) Stephanos, archiatros and aktuarios; (b) Abram ›the Saracen‹, aktuarios and basilikos
archiatros; and (c) Theodore, iatros at the Mangana. (We shall have to come back to the
possible significance of the title archiatros.) There are six other passages ascribed only to
the Mangana hospital (with no physician named). These are dispersed over about a half of the compilation but form only a tiny proportion of the whole. A further six passages in the same remedy collection correspond to parts of the collection in Vat. gr. 292 (A, above)
in which they are derived from ›the great hospitals‹.
C. The fifteenth-century Paris MS. gr. 2194 includes six remedies ascribed to Michael,
aktuarios of the otherwise undocumented Mauraganos hospital (perhaps a mirage: Mauraganos could be the man’s surname). These six remedies are found in a text headed, in a hand that differs from that of the copyist, dynameron xenonikon dia peiras (»on the potency of hospital prescriptions found by experience«). (That text is succeeded by another similar brief collection entitled, even more simply, xenonika.) Apparently, none of the hospital related material found here survives in any other manuscript.
D. The Vienna MS. med. gr. 48, from the late thirteenth century, has a text attributed in
its title to Romanos, »koubouklesios« of the Great Church (Hagia Sophia) and protomenutes of the imperial Myrelaion Hospital (in an anticipation of the Pantokrator to add to those mentioned earlier). Fragments of this text survive in only two other manuscripts. The title koubouklesios disappeared after the tenth century; the Myrelaion hospital was re-founded by the Emperor Romanus Lecapenus in the mid-tenth century; Romanos koubouklesios cannot be dated any more precisely.
E. Romanos’s text is actually only the first half of a much longer work. Its second half
survives separately under a different author’s name, as the Apotherapeutike of one Theophilos, in which the material is said to be drawn from hospital books (xenonikon biblon). (Apotherapeutike is an odd term: its sense is clear enough but its exact translation hard.) Both these two parts – Romanos’s and Theophilos’s – contain passages similar to those of Vat gr. 292 (A, above) where the hospital treatments are attributed to the Mangana hospital, but here (in D and E) the hospital ascription is lacking.
(NovoScriptorium: well, Apotherapeutike is not really an ‘odd’ term; every modern Greek, or anyone who understands modern Greek, knows the meaning of the term, that is treatment after -the main- therapy. In other words, after some kind of initial medical treatment or surgery, the patient is ordered to follow e.g. a specific diet, a specific sleeping pattern, specific exercises, to receive specific medicines, etc., so that a full recovery or the best possible therapy is achieved)
F. MS Laur. 7. 19, of the thirteenth to fourteenth centuries, is a collection mainly of
theological works. Like nine other manuscripts, it contains a text (mostly but not always
the same text) with the title: ›Therapeutic medicines set in order according to the defined
procedure of the xenon‹. This is a short piece of some 2.750 words, which in none of its
versions lives up to the orderliness implied in its title. It includes abbreviated versions of
remedies recorded in four other manuscripts under the name of an otherwise unknown
John archiatros, in one other manuscript under that of Galen, and in a sixth, under both
names. Overall, then, five or six texts, known to us from eighteen manuscripts, have hospital connections made explicit in their titles or their contents. To them can be added two manuscripts (Paris gr. 2315 and 2510) that were copied for hospitals, a manuscript (Scorialensis Y. III. 14) dedicated to a hospital by George, its scribe (all three of these from the fourteenth century), and perhaps three or four others that may at some stage have been owned by a hospital, including such luxury products as the ›Niketas codex‹ and the ›Vienna Dioscorides‹.
These figures should set against the estimated aggregate of 2.200 medical manuscripts
surviving in European libraries. The numbers of hospital manuscripts could of course
be inflated a little. Many that once existed will have succumbed to ordinary wear and tear, let alone the Fourth Crusade or the Ottoman onslaught. As the examples above show, hospital material can survive without its title. And more hospital texts doubtless remain to be discovered, hiding behind misleading or inadequate catalogue entries.
(NovoScriptorium: even though the writer recognizes the impact of the barbaric conquests on the Roman lands, he fails to realize the full magnitude of it. Anyone who has studied the sources on the event of the Fourth Crusade and generally the Western conquest-looting of the Eastern Roman lands has no doubt as to who is fully responsible for the loss of any possible archives. The Ottoman Turks actually destroyed much less, as there were few left after the Western atrocities. Of course, Time itself must have destroyed a good part of the more ancient scripts, even though the Romans never stopped using Scriptoria. Financial and external invasion reasons seem to have dictated a restriction of the practice of copying-to-preserve)
(…) Two points of a more positive kind ought to be made none the less. The first is the sheer longevity of the tradition of hospital writing. What survives are mostly later medieval copies of ninth-to-eleventh-century texts. And some of the xenon remedies continued to be copied in the sixteenth century. Given the cost of the materials and the skills required for the making of the least pretentious Greek codex, this longevity is a tribute to the perceived value of xenon remedies. (That is especially true of those in Vat gr. 292, which recur in several other contexts.)
The second point is an amplification of that. It relates to the considerable stature that
must have attached to xenon remedies and treatments as well as xenon doctors (with or
without some grandiose title). This is a medical world in which texts mutate with each
copying, and bits of them detach themselves and (as it were) wander among the stemmata. A title, if there is one, becomes an assertion of value rather than a certificate of authenticity. Witness the remedies which are now given to a hospital, now to John archiatros, now to Galen. What matters in the present context is not which (if any) of those ascriptions is the right one. Nor is it whether a given remedy generally originated, or was used, in a hospital. What is significant, rather, is that, at some stage in the remedy’s manuscript career, someone thought that the hospital ascription was an appropriate measure of value. A hospital remedy is as good – so the manuscripts imply – as one supplied by Galen. A xenon archiatros is as good an authority as any of the other possible names that might be attached to a treatment. And this is so even in the later medieval period when there were fewer Byzantine hospitals and it is far from clear that even the ›great ones‹ continued to function after the Latin conquest ended. By the same token, hospital texts – when they are labelled as such – keep very good company in the medical anthologies that have preserved them. They can be found associated with all the ›big names‹ from Hippocrates to John »Aktuarios«, one of the last of the stellar Byzantine physicians.
(…) There is a hitherto unnoticed reference in MS Vat. gr. 299, f. 422v, to instruction in phlebotomy within a hospital. But that is best seen as evidence of exactly the kind of clinical training that we might expect. It is hardly a sign of institutionalised medical education. Finally, John Argyropoulos, one of the great figures of late Byzantine medicine, is depicted in a miniature as giving a lecture in front of a xenon and is recorded as having taught somewhere within the monastery to which the xenon was attached.
(…) Around 1070, only a generation or two before the imperial dream of the Pantokrator, the revered Persian mystic al-Hujwiri set down the following description of hospital practice in Byzantium:
»It is well known that in the hospitals of Rum they have invented a wonderful thing
which they call angalyun; the Greeks call anything that is very marvellous by this name, for example the Gospel and the Books of Mani. The word signifies ›promulgation of a decree‹. This angalyun resembles the gut strings [of a musical instrument]. The sick are brought to it two days a week and are forced to listen while it is being played, for a length of time proportionate to the malady from which they suffer; then they are taken away. If it is desired to kill anyone, he is kept there for a longer period until he dies […]. Physicians and others may listen continually to the angalyun without being affected in any way, because it is consistent with their temperament.«
(…) In the writings of St Basil, who founded the first clearly medicalised Byzantine hospital, medical analogies are easy to find. In particular the ›psychotherapeutic‹ effects of psalmody are described in his homilies on the Psalms and in his correspondence. »A Psalm is a tranquillity of soul […] it settles one’s tumultuous and seething thoughts. It mollifies the soul’s wrath and chastens its recalcitrance«; »the consolation of hymns favours the soul with a state of happiness and freedom from care«, and so on: sentiments that can be given either a theological or a medical gloss – or both simultaneously. Basil knows all the anecdotes bequeathed by antiquity about the power of music – a power also shown, and to exemplary effect, by the Biblical King David:
»The passions born of illiberality and baseness of spirit are naturally occasioned by this
sort of music. But we must pursue that other kind, which is better and leads to the better,
and which, as they say, was used by David, that author of sacred songs, to soothe the king
in his madness«.
(NovoScriptorium: it is rather clear that the Christian Graeco-Romans continued the Tradition of the Ancient Greek Medicine; the use of music, especially for psychotherapy, is found in many ancient Greek texts)
NovoScriptorium: From his side, the writer has done an excellent job on this paper. Indeed, ‘medicalisation’, in the sense we understand it nowdays, cannot be fully proven. Nor can we be 100% absolute and certain that ‘Hospitals’, in the sense we use the word nowdays, existed in the Eastern Roman Empire. The very few scripts that survived Time and brutal looting of the Empire give though some hints and clues on this direction. The proven ‘continuity’ -i.e. a series of texts covering continuously all the existence time of the Empire- the researchers seek cannot really be found; one will be convinced about this just by reading how many barbaric invasions and population movements Eastern Roman Empire faced over the centuries; the majority of Institutions and Scripts must have been destroyed over and over by the countless barbarian invasions. It is actually a ‘miracle’ that there was a relative ‘continuity’ of most things that constituted ‘Graeco-Roman Tradition’ from the very beginning of the Empire until its Fall. But it is this ‘miracle’, this ‘continuity’ of almost every other aspect of the Ancient Tradition that leads us to the rational conclusion that Medicine and Medical Institutions must have existed and evolved, more or less, from the beginning to the end of the Empire. Whether we talk about ‘Hospitals’ in the modern sense or not, it has to be recognised that there was a State, an Empire, that lasted more than a 1,000 years, in times when most other states and empires could only dream of such things, where Philanthropy and Medical care could be found everywhere and at all times, for all people – we strongly doubt that things are better, even in our era, for the majority of people around the world. Indeed, the strong belief in -Orthodox- Christianity played the most vital role for this to have happened. Women’s equal participation in this Christian Roman Philanthropic System, as doctors and medical personnel, must be noted, too)
Research-Selection-Comments: Anastasius Philoponus