An assessment of Christian institutions of care and medicalization in Late Antiquity

Recebido em: 10 abr.2020. Aprovado em: 29 mai. 2020. Publicado em: 26 abr. 2021. Abstract: Christian institutions of care, particularly those related to healthcare and the care of the poor, are believed by some scholars to be one of the most important causes for the spread of Christianity in Late Antiquity. However, historiography pertaining to the medicalization of these institutions is scant, and often scholars are at odds with one another regarding key points on the topic. In this article we review the most important positions, as well as give our own take on the topic, through the analysis of written and archaeological evidence. We have found that most of these institutions were not medicalized, and that those that were did not show any clear signs of following traditional ancient medical sects. We conclude that these institutions can mostly be considered important in Christian expansion by their care for, and not by their cure of, of the poor.

be found in the writings of Pliny, the Younger (61c. 113 CE) (PLINY,Ep.,4.1;10.8.1), and in the letters of Symmachus , as well as in other writings of the period. (BROWN, 2012, 93-100;114-116;ANDO, 2009, 307-308;LENDON, 1997) Christian philanthropy was different, for it did not base itself on political favours and honour, but on an urge to help the poor. This can be seen ( BROWN, 2002, 26-32) One particular form of Christian philanthropy, which concerns us here, was the creation of institutions of care, which included houses for orphans, for travellers, for the elderly, and others, all aimed at people who were destitute or at risk of so becoming. (BROWN, 2002, 79) Our objective in the current article is to understand a little better the inner workings of these institutions during this transition period, and particularly of those that seem to have witnessed medical practices within their walls. In the sources, these were termed either xenodocheion (house for travellers), nosokomeion (house for the sick), or ptochotropheion (house for the poor), as well as their Latin variants, all of which seem to have been translated either as hospices or as hospitals in our versions of the extant documents. (VOLTAGGIO, 2011;MILLER, 1997) Therefore, we will not speak of houses for the old or for orphans, for example. This also means that we will not consider monasteries themselves as institutions of care, unless they had facilities that were aimed at treating people from outside the monastery.
The study of these institutions is important because not only can they be seen as embodiments of the Christian ethos, physical landmarks of its expansion, but also because they affected Romans in their daily lives. (HORDEN, 2005, 363-364) Apart from that, there are scholars that argue that Christian philanthropical institutions were of particular importance in the spread of Christianity in Late Antiquity, not only as hallmarks of the general Christian custom of philanthropy but also in more pragmatic ways, by saving more people during great mortality events. (STARK, 1996, 73-94) Our article is divided into four main sections, followed by a conclusion that summarizes our findings. In the first section, we will briefly outline some ancient medical traditions. In the second section, we will outline the general theories of five modern historians regarding the functioning of these institutions, which includes the presence or absence of physicians and the kinds of medical treatment available to people under care. In the third section we will approach written evidence that speaks of this subject, with simple quantification being applied in order to give more robustness to our analysis. The fourth section will take archaeology into consideration, in order to strengthen or weaken our conclusions from the previous section.

II. Some ancient medical traditions
Ancient medicine, especially that related to the Greco-Roman world, presents some complications to its interpretation by modern historians. One of them is the difficulty to create models which include most medical writers considered to pertain to a given current of medical thought and practice.
Medical writers often had many contrasting views and drank from very different sources of knowledge, which turns this topic into as complex a matter as any other in historical studies. However, if one takes categories used by the ancients and combines them with modern categories, three main 'sects' can be detected by the time of Galen (129 -210 CE), which distinguished themselves from one another in the ways they treated patients and in the ways they obtained medical knowledge, as well as in their presuppositions about how medicine should be done.
The first sect is known as the Dogmatists.
Medical writers from this sect based their writings mainly in the teachings of Hippocrates. These doctors obtained their knowledge mainly from past experience and especially from reasoning (NUTTON, 2004, 194), and in this sense their knowledge is closer to modern medical science than the other sects. Doctors from this sect investigated precisely what caused diseases (NUTTON, 2004, 191), defending the use of dissection and in some cases even vivisection to obtain new knowledge. (JACKSON, 1988, 30-31;FERNGREN, 2009, 20) Galen is the most widely known member of this sect. (NUTTON, 2004, 168) Methodist medical writers, the second sect, believed that there were a small number of underlying diseases, which could be treated with general methods, a theory which surfaced in adaptation to the sheer size of cities like Rome. (NUTTON, 2004, 187-188) This methodological simplicity led this sect to be seen as born in a society that knew little and cared less about proper medicine (NUTTON, 2004, 187), although in many cases Methodist treatment wasn't so different from that used by members of other sects. (NUTTON, 2004, 187-188) Methodist writers also rejected complex theories and based their diagnostic and treatment in physical symptoms, and not in the theory of humors. (FERNGREN, 2009, 20) The third sect is that of the empiricists, and as their very name indicates, they searched for past cases comparable in every detail with the patient at hand. They did not invoke any kind of reasoning apart from the search of past cases. (NUTTON, 2004, 191) They avoided the search for hidden causes of diseases (JACKSON, 1988, 30-31;FERNGREN, 2009, 20), for they held the belief that any exercise on dissection modified the structure of the body part under study and was therefore useless for the attainment of new information about its functioning. The only worthwhile practice of anatomical study was, for the Empiricists, the occasional observation of living human beings. (ROCCA, 2016, 354-355) In addition to these three well-established sects, there was a fourth current of medical writers and practitioners known as pneumatists. They interpreted pneuma, a form of air, to be essential to life in conjunction with the soul (ROCCA, 2016, 349), and gave this pneuma a bigger role in the functioning of the body than the humors of Dogmatists. (JACKSON, 1988, 30-31;JONES-LEWIS, 2016, 396) This is a most diffuse group, for there was never a clearly formed association of people who defended the same Pneumatist ideas. (NUTTON, 2004, 206-207) This characteristic is so strong that Galen's thought is also composed of a second theory, that of the body being composed of four physical elements, namely fire, water, earth, and air. This theory was proposed by Plato in his Timaeus. According to Plato everything physical is composed of these four elements, which includes 3 This was a collection of medical treatises which, although attributed to an ancient man named Hippocrates (c.460 -c.370 BCE), is composed of texts from many sources and reflects many medical traditions. See discussion by Jackson (1988, 21) and Jones-Lewis (2016, 387-388). the human marrow, from which stems the bones, flesh, "and everything of that sort. " (PLATO, Timaeus, 73b-c) Although the marrow is made of the four elements, it must be noticed that flesh and bones do not have air in them. (PLATO,Timaeus, Apart from these four physical elements, Plato also argued that the body possesses three souls, being one of them divine and the other two mortal. The divine soul is located in the head, while the rest of the body is seen as merely a means to move the head. (PLATO, Timaeus, 44d-45b) The first mortal soul, characterized by passion and courage, is located in the heart, while the second, marked by its appetite, is located beneath the diaphragm, in the same region as the liver, which acts as a deterrent to its impulses. (PLATO, Timaeus, 69d-72d) It is necessary to emphasize that even though Plato's objective with these divisions was to corroborate his theory of the tripartite soul, this line of thought turned itself very influential in later centuries. (ROCCA, 2016, 348)

III. How Christian hospitals worked
Before dwelling into the historical evidence for the functioning of the hospital, we find it important to consider different modern theories as to the medicalisation and functioning of these institutions. Having these in mind will let us have a better understanding of how the extant evidence can be used to promote or criticize any of them.
For this list we have considered important to mention solely authors that have a more extensive take on the subject, and that don't just mention them in passing. Therefore, Peter Brown's views, for example, are not included here, for even if he does speak of xenodochia he did not express any positioning as to the functioning of these institutions. (BROWN, 2002, 33-35)

III.1. Demetrios Constantelos
Constantelos' work emphasizes Christian philanthropy and its relationship with institutions of care, be them medicalised or not, that aimed at helping the poor. (CONSTANTELOS, 1968, 68-86) Although the author does not focus his research on medicalised institutions, he still states that these kinds of monastic establishments played a role when famines and pestilence plagued the Roman Empire. (CONSTATELOS, 1968, 101) He also included a chapter on hospitals in his work.

III.3. Vivian Nutton
Nutton's take on the working of hospitals was also obtained mainly through written documents. He Crislip, which will now be described.

III.4. Andrew Crislip
This author is the only one to make more use of archaeological reports on the subject, even if these are still rare, and by their use he reaches new conclusions. Crislip first divides Christian monasticism into two main categories: 1) lavra monasticism, which was marked by its decentralized organization and the absence of physicians; 2) coenobitic monasticism, more centralized and often with the presence of infirmaries in which physicians were to cure sick monastics. (CRISLIP, 2005, 5-7;9-14) The second kind of monasticism is credited by Crislip as the originator of the ancient hospital, described by him as having three characteristics: 1) inpatient facilities, for people being treated to have a place to sleep and to eat while they are treated; 2) provision of professional medical care; 3) provision of care out of charity. (CRISLIP, 2005, 101-102) The difference between the infirmaries of coenobitic monasteries and Christian hospitals is that while the former only offered care for monastics, the latter extended its services for the outside community at large. This was a development that first appeared in Basil's institution. (CRISLIP, 2005, 133) The author considers that even if this is not directly stated in the evidence, it is safe to assume that Basil's institution was home to the performance of medicine in the Greek tradition described in part I. He also states, based on Cassiodorus, that it is certain that this tradition was followed in the Latin West. (CRISLIP, 2005, 35) Crislip also believes that monastics had access to the best medicine of their times (CRISLIP, 2005, 37), and if in lavra monasticism the refusal of treatment was accepted as an ascetic practice, in coenobitic settings monastics were morally obliged to accept this treatment as a form of getting better to continue with monastic duties. (CRISLIP, 2005, 95) From this thoroughly optimistic view, we will now turn to something of a middle ground. Ferngren believes that even if Christian institutions of care did not have physicians working in them, they could nonetheless offer nonmedical care for those that stayed in them. Even Basil's institution is seen as having a "nonprofessional staff of doctors and medical attendants". (FERNGREN, 2009, 127) He also believes that the care available in these institutions was mainly palliative, and that physicians within monasteries were there by 4 A discussion of the prevalence of medicalised hospitals, that does not quantify the available evidence, is done by Horden (2007, 217-218). 5 The appendix contains a full list of all mentions of hospitals. In the table contained in the appendix we also take into consideration sources that leave unclear to how many institutions they are referring -there are four such sources, and here we consider that each one of them adds one institution to the general count. If these are disregarded, the total proportion of institutions that surely had doctors working in them is raised to 10,9%, which does not affect our conclusions. chance, and not in some pre-ordained manner. (FERNGREN, 2009, 115) These were probably overcrowded institutions, given the small number of beds in relation to the number of inhabitants of ancient cities, and only a small portion of them would have had the financial means to employ physicians. (FERNGREN, 2009, 128-130) In conclusion, there are many different approaches to the matter of the medicalisation and general functioning of Christian institutions of care. What these authors agree on is that at least some of these institutions had physicians working in them, even if for most of them this cannot be said for sure. What they disagree upon is not only in matters of the origins of these institutions, a topic that will not be approached here, but also on the proportion of medicalised institutions in relation to the total number of institutions.

While Miller considers that most Christian
institutions contained some form of medical care, and Constantelos and Crislip consider that the medicine practiced in them was one of the best available at the time, Nutton and Ferngren disagree with both assessments. We will now turn to our take on the subject.

IV. What the written evidence tells us
Written evidence is scant on the medicalisation of Christian institutions of care, and particularly so regarding institutions that had physicians working in them. 4 What follows takes into consideration written evidence that is described in the Appendix 2, located in the end of the report.  Aaron, who from an early age decided to pass his days on retreat and religion within a monastery.
In is probable that he would only hire physicians who also did so. It is too bold an affirmation to state that medical practice was generally widespread and followed the Greek tradition of medicine.
In response to this, it might be argued that if physicians were commonly found in these institutions, then it would not make sense to mention them whenever the institutions are mentioned; it would always be implied that they were there. But we seem to have no grounds to assume that this is the case, for it is noteworthy that some sources found it important to emphasize the presence of physicians in some institutions but not in others. Chr., 149) Although this is only weak evidence that physicians were uncommon enough to deserve mentioning whenever they existed, it seems to be a more plausible position than assuming that they were ubiquitous to this kind of institution. This

V. What archaeology tells us
It must be emphasized that not all archaeological reports used by authors in this academic field were of easy access, and that the one analysed below was the only one that could be accessed online and that had useful information. 7 New conclusions based on this corpus of evidence will necessarily have shaky foundations. Nevertheless, we think that this study was enough to outline a better critical understanding of the current interpretations regarding the functioning of ancient institutions of care, particularly regarding their functioning and the kind of medicine practiced in them.

The Monastery of Apa Jeremias
In the beginning of the 20 th century a big archaeological project was conducted in Saqqara,  As can be seen, the monastery divided into two main complexes of buildings, one to the south, and another to the northeast. We believe that the infirmary of this monastery was located in the section to the northeast, and specifically that it was room 726, the biggest room in this part of the complex. In the images below these can be seen separately, with a better resolution. The report also mentions inscriptions that speak of medical treatment and explain how to apply certain medicines to certain wounds.
These inscriptions were contained in room 700 D, which we believe is room D shown in Figure 2.
The instructions are shown in the image below.

Figure 4 -Medical instructions as contained in the archaeological report
Source: QUIBELL, 1909, 57 Two points are to be observed regarding this inscription. The first is that medical treatment as described in room 700 D is clearly pragmatic. There is no mention of anything resembling the medical

VI. Conclusion
As is often the case with studies of Antiquity, and particularly so with Late Antiquity, there is little evidence from which to create generalizations.
What we have tried to show is that the arguments some historians have recently proposed are at best weak in their empirical foundations, and at worst plainly speculative. For this, we have studied both written documents and the available archaeological reports on the matter. From the first set we have concluded that there is only an indirect link between Hippocratic medicine and Christian institutions of care, and this only in one instance of the written evidence. It is impossible to generalize, based on only one piece of written evidence, to three centuries and thousands of square kilometres.
From the archaeological evidence the case for the medicalisation of institutions of care is even grimmer, for we had access to only one piece of evidence.
It did not make clear that doctors were an integral part of the monastic establishment, and worse still, it made clear that, if medicine was being applied, it as a completely pragmatic kind of medicine, with no relation to any complex theory of humors. It is therefore more similar to an Empiricist practice, to put it in terms of the medical sects described in section II.
Therefore, the presence of physicians in Christian institutions of care was not a given, and the assumption that physicians were a core part of the functioning of these institutions is, as has been previously stated, an undue generalization based on our current understanding of what hospitals are and how they work. It is clear by our written evidence that some of these institutions did have physicians working in them, but this evidence also tells us that probably these were a minority among philanthropic institutions. This means that, if they are to be credited with an important role in the dissemination of Christianity, this role must be based on their capacity for caring for the poor, via the donation of food and of a place where they could sleep, and not through their healthcare services to these same poor.

Bibliography
Primary sources