By Iain Newbigin
A hospital is a building that houses sick and diseased individuals so that they can be treated and, ideally, cured by specialized medical staff. Absolutely central to the sophisticated medical care offered by modern societies, hospitals in fact evolved at a specific time and place – during the 4th century in Constantinople, as a form of philanthropic outreach by the newly Christianized Eastern Roman Empire. The Roman Empire split in half in the 4th century, spurred on by Constantine’s decision to establish Byzantium as his capital city, subsequently renamed Constantinople.
The collapse of the Western Empire, with the sack of Rome in 410 by the Goths, ushered in the Dark Ages for Europe. By contrast, the Eastern Roman Empire flourished until the city’s fall in 1453 CE to the Ottomans – another thousand years.
Constantine, who ruled from 306 to 337 CE, had converted to Christianity. With the division of the empire into two halves in 395 CE, the Eastern Roman Empire (or Byzantine Empire) became both Christian and Greek speaking. As Timothy Miller writes, “the ancient Hellenic heritage, the city environment, the Christian church, the monastic movement, the imperial bureaucracy, and the medical profession all participated in shaping and sustaining perhaps the most fascinating institution of the Byzantine Empire – its hospitals” (Timothy Miller, The Birth of the Hospital in the Byzantine Empire, 1997, p. 11).
The best description of an early hospital comes from the “typikon” for the Pantokrator monastery in Constantinople (of 1136 CE), a document that lays out the rules for establishing the “xenon” or hospital. Part of a larger complex, it featured 50 beds, divided into sections according to the type of illness and gender of patient, a large and hierarchical medical staff, independent managers and serving priests.
While classical Greece had generated a significant body of medical knowledge and a professional class of doctors, both imported into the Western Roman Empire, the concept of a hospital – a building that housed patients of all social strata to be tended by medical professionals with the aim of curing them – did not evolve until the 4th century in Constantinople. Patients either went to the doctor, or the doctor visited the patient. Alms houses also existed for the poor and for travellers, but not specifically for treating the sick. There were also earlier Roman examples of facilities that treated soldiers and slaves, but the xenons of Constantinople were revolutionary. Evidence suggests that the description of the Pantokrator xenon above closely resembles the facilities that were invented in the 4th century and would be recognized today as hospitals.
The conversation of Constantine to Christianity meant that he was both emperor and head of the church, “retaining significant religio-political functions” (Miroslav Ruzica, “Orthodox Christinity, the Nation-State, and Philanthropy: Focus on the Serbian Orthodox Church” in Philanthropy and Social Change). Ruzica argues that the Orthodox Christian Church was therefore “reduced to its spiritual functions” (Ruzica, p. 238), with a form of belief and worship that focused on the spiritual and the eternal, rather than the particular and the present – a focus on the mystical as a part of the process of theosis, of becoming Christ-like. But since Christ’s teachings were emphatic on the need to help the oppressed, the sick and the poor, it was the duty of the church, of the bishops, indeed of the emperor, to help these groups directly. Miller argues that the Christian concept of agape inspired the early church bishops to care for the sick as a form of religious duty, “as expressions of Christian charity” (Miller, p. 61). This care was also necessary for their spiritual well being, as part of their process of theosis. In addition, the emperor had extended tax immunities to the church, allowing the church to amass considerable wealth, which in turn was used to fund hospitals and other philanthropic projects, such as old age home and orphanages.
The church-led effort to help the sick was married to the robust tradition of pagan Greek medicine to create hospitals. In Byzantine culture, both priesthood and medicine were respectable professions, and often there was considerable overlap, in that priests studied and even practiced medicine. The early church rejected the idea that healing should be spiritual only, rather seeing in the practice of medicine the direct application of philanthropia or love in action. Early Greek church writings used the metaphor of Christ as a physician or healer, a metaphor also applied more broadly to the bishops.
However, some writers have pointed out that the number of beds, and therefore the number of patients helped, must have been very small relative to the total population. Ruzica argues that Orthodox Christian philanthropy was almost symbolic, rather than practical. The emperor, for instance, required the sick being treated in the Pantokrator hospital to pray for him, as a way of building up his spiritual “capital”. Regardless, the unique confluence of Christian philanthropy, imperial largesse, Greek medical knowledge and being situated in the capital of an empire all contributed to the development of the hospital, an institution for the public good that is now universal in advanced societies.