The Birth of the Hospital in the Eastern Roman Empire (‘Byzantium’) – Philanthropic social welfare in the Christian East

»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 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.

Some references in the texts might be taken to imply that hospital doctors were commonplace. They generalise about them in ways that must have been plausible to the intended audience, who would have been unreceptive if the therapy had not been described in terms that the audience would recognise. For example, in a letter to a friend a learned cleric, Nilus of Ancyra, deployed the image of the hospital physician examining patients and making individual prescriptions in the service of an analogy between somatic and spiritual medicine. The analogy itself was old, but the hospital setting for it was novel. Remarkably, Nilus used this setting already at the end of the fourth century, when Christian charitable institutions such as hospitals had been known for at most three decades. Even such references as this fail, however, to solve the problem of how to judge proportions; fail to shed even indirect light on the mass of small, usually provincial, establishments about which we know nothing beyond the fact of their foundation.

In 1136, the Emperor John II Comnenus and his wife Irene established in Constantinople, jointly, though perhaps on Irene’s initiative, the monastery of Christ the Saviour, Pantokrator (Ruler of All). It was built on a prominent hill in the north-central part of the City, overlooking the Golden Horn, and incorporated three already existing churches. Transformed into a mosque after the Ottoman conquest, the three churches still stand, extremely dilapidated, as the Zeyrek Camii. Somewhere in an area of 250 square metres stretching broadly northwards from the churches (now rendered inaccessible to archaeology by the bulldozer and the developer) lay those establishments in which any historian of medieval medicine and charity is bound to take an interest. For information about them we have to turn to the monastery’s typikon or foundation charter.

The obvious disadvantage of using this extensive text is that it tells us how things were
intended to be, not how they were. None the less we must start by looking at the medical
aspirations expressed. The Pantokrator was to be not only a monastery but a hospital and philanthropic centre. Its xenon was intended to provide for the sick and injured, both men and women; to offer them clean beds, adequate food, round-the-clock nursing, and regular medical attention. There were to be 50 beds in normal use, and these (contrary to what medieval hospital historians would expect) were clearly for only one patient each. The beds were grouped in five ordinoi, which I do not think we should necessarily envisage as separate wards (although I would prefer not to commit myself to a definite view of the hospital’s layout).

In the first section were 10 beds for men suffering from wounds or fractures: the surgical
area in effect, with its own hearth. Three other ordinoi, for men, shared a (presumably
central) hearth. The first had eight beds and dealt with eye or intestinal or other acute disorders. The other two, of ten beds each, were also for men – suffering from presumably chronic diseases. The last of the five ordinoi had twelve beds and its own hearth, and it was reserved for women.

Fifty beds in all for fifty patients. But there was to be an extra bed in each ordinos in
case of unusual demand, whether in terms of numbers or the seriousness of a particular
case. Also, there were six beds with mattresses that had a hole in for those who could not
move or were taking purgatives. A grand total, then, of 61 beds.

The hospital was not the only welfare institution planned for the Pantokrator complex.
There was a gerokomeion (old people’s home) for 24 men, both the aged and those so
debilitated that they could not look after themselves. If one of these became seriously ill,
he might be transferred to the hospital for the duration of his illness. The second institution ancillary to the hospital was to be a small one for those afflicted with the hiera nosos (sacred disease) – leprosy, rather then epilepsy as has sometimes been supposed. This was separate from the main complex, partly so that patients in the hospital should not be infected. We are told virtually nothing about its organization, however. The number of lepers that it was to contain is not stipulated. The third ancillary institution was in effect an out-patient clinic or dispensary, and again little can be said other than that anyone could, it seems, call in for advice or treatment; apart from indicating its staff, the typikon takes its workings very much for granted.

After a survey of the principal institutions, I turn to their personnel. The sick were, by
the standards of any age, to be looked after impressively well – and not only in terms of
material comfort. Each of the five sections of the hospital had two iatroi. In the sections
for men, these iatroi were assisted by three hypourgoi embathmoi (titular assistants), two perissoi (lesser or supernumerary), hypourgoi and two hyperetai (or servitors). The two physicians of the women’s section were aided by a iatraina or female physician (who was, incidentally, paid only a half of her male colleagues’ salary). And, taking the women’s ward overall, we can see that twelve women were to be cared for by twelve medical or nursing functionaries. In sum, fifty patients were to enjoy the direct attention of over sixty doctors and subordinates. But there was also the outpatient clinic, served by four doctors, two of them surgeons, and these four had eight assistants. Among the iatroi there was a hierarchy of genuinely Byzantine sophistication, up which it was possible to work one’s way. Two doctors enjoyed the distinctive title of protomenutes (›chief physician‹ or ›leading diagnostician‹; not ›first of the month‹ as it has nonsensically been translated up to now). These were not the only physicians involved in the Pantokrator complex. The typikon is clear that there were to be two primmikerioi (a Byzantine term for various kinds of high-ranking official) who outranked even the protomenutai. In alternating month-long shifts, they were to monitor daily the progress and hear the complaints of each inpatient, and they also oversaw the treatment of serious cases in the outpatient clinic. The total numbers just given create a slightly deceptive impression, however. The doctors in each ordinos also worked monthly shifts, so that there was only one physician (two in the outpatient section) on duty at any one time. When on duty the doctors were to make their rounds once a day (twice from May to September, with the second visit in the evening). The rest of the time, including the night shift, the hypourgoi were in charge.


Beyond all these medical attendants, mention must be allowed to a variety of other
staff – a didaskalos hired to instruct the ›children of doctors‹ (which just means ›doctors‹), a surgeon specializing in hernias, four pharmacists, and so on. Add all these and the doctors together and the figure is of the order of 100 – a very high staff-patient ratio indeed.

Altogether the Pantokrator typikon is an astonishing document, and the aspect of it
that is most astonishing is the number of doctors envisaged as attached to the hospital that it describes. Those doctors are the sticking point of all attempts to interpret this foundation. If there were not so many iatroi, we would not, I think, find the other provisions of the imperial couple so striking; we could in effect dismiss the hospital as really a heavilystaffed nursing home. The senior personnel, moreover, are to be no workaday physicians. The founders expect that they might be tempted outside the city to attend members of the ruling elite, and even the emperor’s relatives. »In general we forbid any of the doctors to carry out additional work«. Modern commentators have assumed that this restriction should apply only during the months when the doctors are on duty because their annual stipend from the hospital was scarcely a living wage and would have had to be complemented by the profits of six months’ private practice. But that is not what the text actually stipulates. So it may be that the emperor was planning to employ only those physicians who had already made their fortunes and could afford to demonstrate their philanthropy in his, or his successors’, service. On either interpretation the leading physicians in attendance on the Pantokrator patients were to be distinguished as well as plentiful.

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« (**)

(**) Miller

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 foreign 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 mainly 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 restrain 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)

(Source: “How Medicalised were Byzantine Hospitals?”, by Peregrine Horden)


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 nowadays, 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 desired proof of ‘continuity’ -i.e. a series of texts covering 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 brutal invasions and population movements Eastern Roman Empire suffered over the centuries; the majority of Institutions and Scripts must have been destroyed over and over by the countless 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 recognized 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 a thing, 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 for NovoScriptorium: Anastasius Philoponus

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