With The Birth of the Hospital In the Byzantine Empire, Dr. Timothy Miller has produced a work of assiduous scholarship. Miller provides a thorough, comprehensive account of the birth of the hospital in the East Roman Empire of the 4th century, its evolution through the 13th century, and its decline and ultimate destruction at the hands of the Turks in 1453. Exploring the relationship between the nascent Xenon and the Orthodox Church is arguably the secondary objective of this meticulously researched work. An illuminating description, of astonishing detail, of the emergence of the hospital out of early Christian philanthropic institutions is contained therein. Dr. Miller draws on a wide range of sources to support his contentions throughout, including monastic typika, hagiographical text, imperial edicts, iconographical and archaeological evidence. His level of erudition is made evident by the intimidating frequency of ancient greek terminology throughout the text. Miller’s survey emphatically asserts the importance of the Xenon, and its place within the complex web of interdependent social, political, religious, and economic spheres that formed the society of the East Roman Empire.
Classical Greek medicine from Hippocrates to Galen had a profound influence on the development of the medical profession from the early Christian age through to the middle ages; the emergence of the hospital in Byzantium can also be attributed to the influence of Hellenic physicians of antiquity. It is in this context that Miller places the early Xenones. The cultural and religious assimilation of medicinal traditions originating from pagan ancient Greece into mainstream Byzantine theological doctrine regarding philanthropic institutions under the purview of the church is discussed in detail by Miller in support of his arguments in this volume. In support of this acceptance of secular medicinal expertise by the Episcopal leadership, Miller points out a general shift away from belief in the power of healing miracles (examples of early pagan temples where afflicted would go to receive guidance from the god of healing, or early christian healing via prayer are both given by Miller) and toward the gradual assembly of a body of accepted medical practice, which was both clinical and secular in nature, that was embraced by the Christian Church in the 4th century as the best method of charitable healing. In his exploration of the terms used to refer to early Byazantine philanthropic institutions, Miller attempts to impose a degree of philological clarity on the ambiguity stemming from the variety of words found in Hagiographical sources as well as typika. In the chapter on Eastern Christianity, Miller gives specific examples of ecclesiastical support of the practice of medicine in the context of Agape, or charity. He clearly expresses the importance of the acceptance of secular medicine by Christian institutions throughout the book, though with particular detail in this chapter. The relationship between Byzantine Ecclesia and historically pagan medicine is further illustrated by Miller’s inclusion of various christian metaphors which invoke medical terminology to express religious concepts. A prime example of this is the emergence of the phrase “The Great Physician” into the parlance of greek theologians, as far back as the third century, to refer to Christ. “Since greek society considered good doctors the most charitable of men, it was fitting for Greek Christians to see christ as the paramount physician.” (P. 58).
In support of his main arguments, Miller demonstrates a rigorous capacity for historiographical inquiry. In tracing the development of the hospital in Byzantium, Miller asserts the claim that not only did the hospital, in the modern sense, originate in the Byzantine Empire, but the most advanced medical institutions in the whole of human history before the 19th century were forged through a unique mixture of religiosity, professionalism and statecraft. One of his main arguments is that the Xenones of Byzantium have more in common with modern hospitals than any charitable institution from antiquity to the industrial revolution. Miller finds evidence for autopsies, as well as bloodless surgery for the removal of kidney stones, among other feats of early medicine that occurred centuries ahead of their time. The specific inclusion of evidence supporting the performance of autopsies by Byzantine physicians is further indicative of an unprecedented level of clinical advancement. In addition to the considerable time devoted to the Xenones themselves, Miller fastidiously elucidates for the reader the political and social undercurrents of support and opposition surrounding these early medical institutions. He supplements his arguments with an almost endless assortment of historical and historiographical data. In developing the argument of the technological superiority of the Xenones, (compared to the philanthropic institutions of the Latin West) Miller describes how the level of optimization of function and efficiency reached by Byzantine hospitals by the 12th century was such that they had instituted, at the Pantokrator Xenon at least, in addition to the normal course of treatment of patients in varying stages of convalescence, a system akin to a modern residency, wherein physicians in training observe doctors at the hospital to learn the craft. This fact gives substantial support to the position, advanced by Miller, that Byzantine hospitals were unrivaled by anything in the Latin West nor the East until modernity. According to Miller, certain 12th century Xenones even had physicians assigned to treat clients on an outpatient basis. This supports the contention that Byzantine hospitals attained a degree of sophistication and efficiency, in function as well as administration, unmatched anywhere in history until the mid 19th century.
Miller emphasizes that the development of institutions like the Pantokrator Xenon in Byzantium, analogous to modern hospitals in function, would have been almost impossible without the support of the Christian church. In the case of the Pantokrator, the hospital (Nosokomeia) itself was only one part of a larger, monastic structure. Its inclusion therein is a perfect metaphor for the growth of the hospital in Byzantium within the framework of religious charity. While highlighting the stimulating effect which the acceptance of secular medicinal methods within the episcopal leadership of Byzantium had on the development of philanthropic institutions like Xenones, Miller identifies cooccurring practical catalysts which necessitated the allocation of resources toward the creation, administration and maintenance of hospitals in Byzantium. “Practical demands, not Christian views on secular medicine and its physicians, actually brought the first hospitals into existence.” (p. 67)
In Chapter 5, Miller places the emergence of the first hospital qua hospital in the fourth century, in the East Roman Empire. “The decades of the fourth century, then, witnessed the birth of the hospital.” (p. 68). While Miller spends a portion of the book exploring the crucial role of the early christian church in the creation of the hospital, he also incorporates into his arguments various social, political, demographic and economic reasons that led to the establishment of early hospitals in Byzantium. “The altered world of the fourth century forced bishops to address social problems and physical suffering on a grand scale. In attempting to meet these needs, bishops and their advisors developed the panoply of philanthropic institutions including the hospitals which emerged by the end of the century.” (p. 69). The financial hardship experienced by city governments in the 4th century, Miller explains, was exacerbated by wealthy local politicians pursuing senatorial positions which, if attained, exempted them from taxation. Miller also illustrates how religious strife in the form of Christological controversies that emerged out of the Council of Nicaea, Arianism in particular, accelerated the proliferation of philanthropic institutions such as Xenones throughout the eastern territories. “Even the most spiritual pastors, however, were no doubt aware of the political implications of successful charitable operations.” (p. 74). “As part of their efforts to win popularity among the demos, factions promoted conspicuous charitable activities…” (p. 76) The efficacy of Miller’s central argument is supported by the inclusion of a nuanced analysis of the precise combination of social, political and religious forces that created the hospital.
The involvement of the Imperial state in the administration and promotion of Xenones is advanced by Miller in his examination of the role of the Emperor in legislative decisions. He explores the part Emperor Justinian played in the evolution of the capacity of Xenones to effectively administer medical treatment when he mandated, by fiat, that the public physicians (archiatroi), renowned throughout Byzantine society, were henceforth required to practice at the Xenones. Miller highlights the fact that this reform of the public physicians essentially redirected all of the Empire’s urban medical expertise into the Xenodocheia. He goes on to describe how the reforms outlined in Justinian’s innovative legislation made hospitals the best funded and most important philanthropic institutions in the entirety of the Empire: “As a result of Justinian’s reforms the hospitals became the largest of the christian charities.” (p. 105). Justinian fused the best practicing secular physicians to the Xenon system. This lead to the Xenon system becoming the nexus of Byzantine medicine from 550 to the early 13th century. Miller asserts that the bureaucratic system of professional development and duty which Justinian inaugurated in the mid sixth century by assigning physicians to Xenones has no analogue anywhere in ancient or medieval history.
The christian virtues of love and charity, according to Miller, are at least partly responsible for the survival of the hospital in Byzantium during the chaos of the brutal conflicts that took place in the 7th century. Other elements of Byzantine society which allowed the Xenones to survive were, according to Miller, the political and ideological conceptions of the role of the Imperial state and the Episcopacy in facilitating the health and wellbeing of Byzantine society. Miller devotes an entire chapter to the relationship between Xenones and Orthodox monks. There are sections of the text which one has to summon a certain amount of willpower to traverse, the monastic chapter is a case in point. Notwithstanding this criticism, Miller artfully develops his arguments throughout with adroit use of source material. In the chapter The Hospital In Action, Miller is able to effectively conjure up an image in the mind of the reader of what these Xenones must have looked like. What at first seems like a rather narrow scope of subject matter, becomes, by virtue of the care and detail with which Miller explores the intersection of different socio-religious and political elements within Byzantine society which impacted the development of the Xenones, an elaborate historiographical mosaic.
In establishing a qualitative assessment of Miller’s work, it is important to evaluate the degree to which the thesis is supported by argument and evidence throughout. The purpose of this study was to establish the origin of the hospital in the modern sense, with evidence, firmly in the East Roman Empire, in the mid 4th century. In addition to this primary goal, the work also sought to prove that Christianity; the christian virtue of philanthropy in particular, was responsible for accelerating the development and evolution of the hospital. Miller’s tertiary objective was to provide an account of the various political, social, and economic forces that impacted the development of the hospital, as well as advancements in the corpus of medical knowledge in Byzantium. While Miller succeeds at each of these, he is especially successful at the second. The rigorous investigation of the role of the church in providing a culture which embraces secular medicine inherited from classical Hellas, in allocating resources to expedite the development of the Xenones, and in fostering a social climate wherein medical practitioners are valued members of the wider Christian society, is the aspect of this work where Miller exceeds his aim. The level of historiographical nuance and depth is remarkable in Miller’s account of the gradual transition from early philanthropic institutions to extraordinary feats of organization and charity like the Pantokrator Xenon. This fascinating work is a composite of medical, religious, and social history. Miller expertly addresses each of the central arguments he laid out in the opening pages, but the work on the Church stands out as the most noteworthy aspect of this well -researched survey. Although seemingly limited to medical history at first glance, The Birth of the Hospital In the Byzantine Empire is a worthwhile read for anyone seriously interested in the Eastern Roman Empire.
THE CONVERSATION PIECE 