This article explores the socio-economic aspects of medical care in Late Antiquity with a particular emphasis on how payments and medical costs shaped perceptions of physicians as fee-charging individuals. As it illustrates, criticisms of physicians for greed, hucksterism, and chilly indifference to the poor spanned the gamut of ancient literature, and the limited evidence for physicians’ incomes and fees under the Roman Empire does suggest that medical careers were quite profitable. For ethical and philanthropic purposes, though, many ancient physicians chose to forego payment or adjust their fees for patients of lesser means. This essay concludes with a challenge to a common scholarly assertion that the Christianization of Roman society placed greater pressure on physicians to assume more charitable practices. Christians did not differ appreciably from pagans in their criticisms of avaricious physicians; instead, I suggest, Christian leaders who inherited a tradition of censuring physicians for predatory behavior leveraged established Classical discourses about the greedy physicians and the exclusion of the poor from healthcare to persuade parishioners to support almsgiving, particularly the funding of hospitals. Clerics in this way erected a parallel healthcare economy that was explicitly outside of marketplace norms: volunteers, clerics, and paid physicians were to serve the ailing poor at hospitals, while the rich were to fund these operations by treating their diseased souls through the purgative act of almsgiving.
In a recent and provocative essay Richard Hurton, editor of the medical journal The Lancet, called for a resuscitation of “the moribund body of medical history.” He urged a turn towards a social history of medicine centered on “the political and economic conditions” that shape medical practice as well as perceptions of doctors and their patients.1 As at least one historian of medicine was quick to note in rejoinder, Hurton's dire assessment of the field has the air of a presentist response to the past decade of political debates about the cost of healthcare, e.g., the prolonged Obamacare debate in the United States or the NHS austerity measures in the UK.2 In fairness what historian would not be pressed to consider the politics and economics of healthcare given the environment? Yet, to Hurton's point in regard to the study of late ancient medical practices, the political and the economic dimensions of medicine have somewhat fallen to the wayside in our enthusiasm for cultural and intellectual history. For instance, despite a recent torrent of scholarship on late ancient medicine, which has illuminated topics such as the significance of physiological science within Christian theology and the role that disease and deformity played in articulating social difference,3 almost no publications have directly explored the costs of everyday healthcare in antiquity or how costs and imperial policies shaped late antique discourses about physicians and their patients.4 I emphasize the word directly because historians often reference the high cost of medicine and late Roman, particularly Christian, disdain for greedy physicians, but socio-economic dimensions tend to be ancillary footnotes to larger intellectual, cultural, and religious topics such as the triumph of Galenism or the birth of the Christian hospital.
This has not been the case for the study of medicine in other periods. In the past 15 years, four illuminating and lengthy social histories of medical practice during the Roman imperial period have appeared in publication, all of which directly address physicians’ costs and fees, their incomes, and their status in Roman society.5 These studies have importantly placed new papyrological and epigraphic evidence into dialogue with more traditional literary, medical, and legal sources. What is distilled from these four monographs is the central role that the charging of fees played in molding Roman attitudes about medicine and physicians in general. Furthermore, each of these studies in its own way clarifies the business costs behind the relatively high fees that physicians charged, much to the ire of many of their compatriots. Unfortunately, none of these innovative studies considers the emergence of Christian philanthropic medicine, Christian attitudes toward medicine, or indeed any aspect of the Christianization of late Roman society in any substantive way—even when their stated chronological limits extend into the fourth century and beyond. One wonders why, for instance, Évelyne Samama in her exhaustive study of Greek epigraphic evidence for physicians catalogues a number of epitaphs for charitable Christian physicians including some clerics, but does not address their faith or ecclesiastical employment in her discussion of “les médecins et les affaires religieuses” and “les médecins et l'argent.” Similar points could be raised about the thought-provoking monographs of Marguerite Hirt Raj, Jane Draycott, and Ido Israelowich, all of which investigate the social and economic dimensions of medical practice in the Roman Empire. One infers from these studies a division of scholarly labor: Christianity, Christian attitudes about medical practice, and Christian medical charity are topics for historians of Christianity and Late Antiquity proper, which is a comprehensible, if strangely unstated, cleavage. More problematically, these important studies of ancient medical practice have yet to permeate scholarship on late antique and early Byzantine medical culture.6 This gap is very much to the detriment of how we as scholars assess the radical changes to the ancient healthcare landscape prompted by the Christianization of Roman society and the emergence of Christian charitable hospitals.
Drawing on the insights of these recent studies and incorporating later evidence outside their scopes, this article explores how the socio-economic aspects of ancient medical practices should inform our understanding of Christian discourses about medicine practitioners, their costs and payment, and the fate of the poor in the ancient healthcare marketplace. I will first lay out Classical opinions on physicians and their remuneration up to the fourth century; then I will turn to what reasonable inferences can be made about the actual costs of medical care and the incomes of doctors; and finally I will transition to how Christians in Late Antiquity approached the rhetoric and reality of medicine's transactional dimensions differently than their non-Christian predecessors. I will ultimately suggest that Christian leaders leveraged well-established Classical discourses about the harsh transactional dimensions of indifferent secular medicine to persuade parishioners to pour their money into the coffers of newly created charitable hospitals. By both lamenting the poor excluded from costly healthcare and encouraging the funding of new Christian spaces for charitable care, Christian leaders reoriented the Roman healthcare economy explicitly outside of marketplace norms. Within the Christian hospital the standard medical practices offered by physicians were stripped of venal associations, and charitable giving to hospitals became a salubrious medicine to heal the diseased souls of wealthy men and women.
THE PHYSICIAN AS ECONOMIC ACTOR
One of the most salient conclusions of recent studies on medical practice in the Roman world is that tensions around the transactional nature of medicine drove many ancient discourses about physicians, their stereotypes, and their self-presentation. A second, though not unrelated, observation is the sheer diversity of individuals who claimed to be doctors in Roman society. The most common ancient terms for physicians (medicus and iatros) encompassed a wide range of medical practitioners from peasant folk-remedy healers and trained slaves, to plebian artisans and aristocrats.7 The education and training of these individuals varied as much as their social backgrounds and incomes.8 Unlike the rigid categories used in societies such as Imperial China, e.g., ruyi (scholar-physicians), shiyi (hereditary physicians), yongyi (vulgar doctors), and lingyi (itinerant doctors), the Greco-Roman lexicon did not possess neat classifications for physicians that indicated their social status, their education, or whether they charged.9 Ancient physicians may have been specialists, e.g., an opthalmikos iatros, or may have followed one school of medicine or another, e.g., Methodism, but the umbrella terms medicus and iatros enveloped them all as paid healthcare providers. “A doctor was a[ny] person, male or female, who carried out medical treatment for a fee, or who, like Galen, devoted much of his time to healing, even if he never actually made any monetary charge but merely received presents.”10 Thus in late antique sources one encounters roughly contemporaneous doctors as bought slaves,11 as illiterate guildsmen,12 as high-ranking officials, and as influential players in imperial politics.13
What united this range of medical practitioners in the popular Roman imagination was the association of medicine with gain (quaestus) regardless of the social background of the physician. Without qualification Seneca, for instance, grouped physicians with merchants (mercatores) and slave-mongers (mangones) as men who offer services to their respective clients, “arriving at the convenience of others through seeking their own interest.”14 Merchants and slave-traders may seem like strange bed-fellows for the philosopher-physician lauded by the likes of Galen, but Seneca's assessment offers very much the unvarnished Roman opinion on doctors.15 Physicians like merchants and slave-traders were essential to the functioning of Roman society, even if their mercantile disposition was unsavory to more aristocratic Romans.16 As with these other occupations, moreover, it was assumed that individuals pursued medical careers with their own gain in mind. Hence late Roman emperors from Hadrian to Theodosius I granted liturgy and tax-exemptions to physicians alongside other professionals, artisans, and merchants in order to incentivize individuals to pursue these trades for the greater benefit of Roman society.17 At its core medicine was no less a transactional occupation than the proffering of necessary wares. This fact accounts for many of the derogatory criticism of physicians as well as much of the distance that doctors attempted to place between their profession and mercantile “trades” in their self-presentation.18
Of greater significance for discourses about physicians was the common presumption that medicine was a disproportionately lucrative art. Complaints about steep medical bills and the avarice of physicians pervade ancient literature, and these complaints had deep roots in Greco-Roman culture. A wisecrack about physicians’ heavy fees (misthoi) appears as early as the poet Theognis (sixth century BCE).19 Discourses about whether “a physician is a moneymaker or a healer of the sick” can be found across Classical genres from Plato to Plautus, from Aristophanes to Apuleius.20 Even the archetypal physician and succoring deity Asclepius was criticized for his greed. As Pindar taught, it was not philanthropy but “gold appearing in his hands with its lordly wage (misthos)” that pushed the future god to ever grander medical feats. “Even wisdom is enthralled to gain (kerdos),” the poet lamented.21 Poets still derided the greediness of physicians in lyric verse as late as the fifth century.22
Neither misthos (merces) nor kerdos (quaestus) was an inherently abhorrent concept to Greco-Roman sensibilities. Market transactions and self-interested gain were accepted, even if somewhat resented, norms of Classical society. More importantly for our period in question, Romans of the high and late empire relaxed many of the earlier prejudices against fee-remunerated professions and mercantile activity. Even the service of bankers, so often maligned for their greed, could be lauded as an officium atque ministerium, a causa publica within high and late imperial society.23 Yet, the remuneration of physicians always differed from the payment of other merchants and professionals for their goods and services in that physicians most often proffered their wares and treatments during periods of anguish, desperation, and vulnerability. As Seneca pointed out, “doctors make their money (quaestus) in the unhealthy season.” They represented a class of economic actors who like “a great part of the human race derives gain (lucrum) from another's distress.”24 Seneca did not condemn physicians for this point; rather, like many others he simply acknowledged it as a fact of the physician's livelihood. His contemporary Pliny the Elder was less forgiving on the matter. As he explained in his long and well-known critique of medicine in Book 29 of his Natural History, the physician's “avarice” was so egregious because doctors made “rapacious bargains (nundinae) with their patients while their fate is in the balance.” Physicians placed “a rate (indicatura) on the easing of patient's agonies.” The patient's desire to alleviate his suffering could be so inelastic that the physician could in essence set the price arbitrarily high as he wished. The only reason, Pliny surmised, that medical costs did not rise to astronomical levels was that “rivalries between physicians, not any sense of shame (pudor), suppress prices.”25 Nor was Pliny alone in seeing the patient's disadvantage as the source of medicine's profitability. Plutarch in his Sayings of Kings and Commanders illustrates the uncomfortable financial compliance that physicians could exact from their distressed patients through a brief anecdote about Philip of Macedon. “When he lay wounded after battle with a broken shoulder (kleis), every day his attendant physician demanded insistently another fee. Philip responded, ‘Take as much as you wish; for you have the key (kleis).’”26 Physicians set the toll on the road to recovery, and they accordingly held the keys to the patient's treasury.
As these elite reflections highlight, physicians earned their quaestus in asymmetrical transactions between life-saving doctors and ailing patients at the physician's mercy. Hence baser financial motives could always be imagined behind every negotiation over price or every suggested treatment. The common slander of doctors as avaricious predators becomes more comprehensible in light of this anxiety about the patient's disadvantage, an anxiety which was often intensified by status-based antagonism.27 The fact that many physicians were “servi, libertini, and peregrini” added to the suspicion of doctors and their motives.28 The ability to vanquish sickness and pain lent lower-class physicians a discomforting amount of authority beyond what their social status would have typically assigned them, and their pharmacological knowledge of toxins and poisons aroused further discomfort.29 Itinerants, slaves, freedmen, and tradesmen were also the type of individuals that elite Romans presumed to be laser-focused on bettering their situations through subterfuge. Pliny the Elder's oft-cited barb that “there is no art more profitable than medicine nor any art more inconsistent and prone to change” encapsulates how many Romans including physicians felt about dubious medical practitioners.30 There was always some new dietetic fad or medical treatment that unscrupulous physicians were pushing. Writing as Pliny the Elder, some three centuries after his death, an anonymous African fourth-century compiler still complained of the “frauds of physicians selling the vilest remedies at excessive prices.” Even worse for Pseudo-Pliny were those physicians who “for the sake of greed” delayed the improvement of patients to extend their pay by hours if not days.31 Another African author, Tertullian, who had considerable medical knowledge and a deep respect for physicians, took it for granted that there were some physicians “who would nurture a disease by delay and prolong the danger of disease by holding back the remedy so that their care might be more costly and more renowned.”32 A hundred and fifty years later, Gregory of Nazianzus relied on the image of the disingenuous physician as the climax for a homily on the hypothetical last hours of an unbaptized man. He painted a portrait of how the physician would “fatten his fees (misthoi) by timed withdrawals and by speaking darkly of the man's desperate condition.”33 The physician's deceit was a last and insulting financial blow before the dying man paid the wages of sin.
These were, of course, ignoble physicians of the Roman imagination who padded their pockets at the expense of their patients and their patients’ families—ignoble in both senses of the term. Class-based prejudices always hovered around the question of the physician's payment: physicians of humbler social origins were inherently suspected of sharing the baser motivations of merchants and tradesmen. Accordingly, physicians often tried to recast their craft as a Hellenistic ars litteratarum, appealing to aristocratic sensibilities established during the Second Sophistic.34 Elite physicians such as Galen stressed that true medicine was only properly executed by educated physicians who lived more as abstemious philosophers than fee-seeking tradesmen.35 Galen and other physicians of the Hellenistic medical tradition saw themselves in a hierarchy of medical practitioners organized by motivations: “some practice the medical art for money, some for exemptions given to them by the laws, some for philanthropy, and others for glory and honor.”36 Only the latter two groups in Galen's opinion were capable of reaching the pinnacle of medicine.37 The best physicians were men of means like himself who practiced medicine out of intellectual and philanthropic interest and only accepted the occasional gift for services.38 Galen hence had no qualms boasting about a sumptuous gift of 40,000 sesterces that he received for healing a man's wife because he had technically not sought a fee.39 The sum was a merely a surprising, albeit appreciated, benefaction made after the fact. Galen was not alone in his expressed disinterest in money. As a grandiose epitaph for one of Galen's second-century colleagues at Rome reads, “Dionysius, best of all doctors…hating gold, but wholly gold.”40
Physicians like Galen and Dionysius looked back to the Hellenistic medical tradition as the basis for a form of medical professionalism unsoiled by lucre, which they traced back to Hippocrates. Although The Hippocratic Oath is vague on remuneration, leaving only a general sentiment that the health of patients trumped personal economic interest,41 other prescriptive texts of the Hippocratic corpus are much more direct about the physician's responsibility not to pollute his discipline with “base and disgraceful pursuit of gain, ” to quote the Hippocratic text Decorum.42 Physicians, it expounded, were to avoid all “greed” and “robbery” in their practice.43 Likewise, the text Precepts asked the doctor “to consider carefully the patient's substance or means,” when pricing their fees. “Sometimes he [the physician] should offer services for nothing, recalling a previous benefaction or present satisfaction, and if an opportunity arises to serve a stranger in financial straits, he should give full assistance to all such men.”44 A Chrysostom sermon seems to indicate that the practice of a sliding scale still existed in Late Antiquity,45 and a contemporaneous Latin medical textbook posing as the work of the noted physician Soranus is also quite direct about the optionality of payment: “if indeed a payment (merces) is offered, accept it. It should not be refused. If one is not offered, one should not be pressured out [of the patient] since however much someone might give cannot actually equal the value of medicine's benefits.”46 The good doctor should remain modestus. “He should heal the poor and the rich, the servile and the free equally.”47
Well-born physicians and their friends set this type of noble, fee-avoiding physician in purposeful contradistinction to “quacks” of low birth and base morality who unjustly made their fortunes through unwarranted fees, deception, and the selling of poisons. Galen, for instance, ridiculed his rivals in the saturated medical market of Rome as a throng of greedy sycophants who were not true physician but “dyers” and “blacksmiths” having “leap[ed] into the practice of medicine” for its profitability. Such parvenus, Galen pointed out, frequented the doors of the rich, seeking money and political power as much as “pretty boys” to be their tuition-paying students.48 Galen's attacks were, of course, intended to highlight his own abilities, his own philosophical character, and his own financial means to forego payment. Elite medicine in the Roman empire was “a highly competitive, zero-sum struggle for status and reputation that involved aggressive self-promotion and the ruthless humiliation of rivals.”49 Elite texts from the high and late empire would have us believe that unlearned, greedy physicians were a numerous threat. Galen himself devoted an entire treatise to how one should examine potential physicians to discern their true competence and intentions.50 It was unconscionable in his opinion to leave the wealthy open to the chicanery and flattery of avaricious quacks.
Roman emperors and their jurists for their part sought to regulate the population of “recognized,” i.e., liturgy-exempt, physicians in the empire by capping their numbers per city and mandating an examination of their skills. The measures were meant to expose and exclude individuals whose medical techniques seemed more like those of magicians than physicians.51 The purposes behind such legislation was obviously financial: municipalities wanted liturgy-paying “physicians” back on the local rostrum and no one wanted charlatans duping citizens. The jurists concluded that recognized doctors were only “those who promised the healing of a certain part of the body or of a certain pain” through accepted “scientific” methods. Not included among recognized doctors was “anyone who chants magical spells, anyone who invokes a deity, or, to use the vulgar phrasing of imposters, anyone who exorcizes spirits.”52 This fascinating contrast between “magic” and “medicine” aside, Ulpian's Latin is instructive on how an elite Roman jurist surveyed the Roman healthcare landscape. These men were impostores, a category of people which elsewhere Ulpian lumps with “gluttons, liars, and litigious men” as vulgar individuals characterized by mendacity and fraud.53
In this way, Roman discussions of dilettante and greedy doctors very much resembled the ridicule of profit-seeking philosophers, shady magicians, and swindlers as immortalized by authors such as Lucian of Samosata (d. after 180 C.E.) and Diogenes Laertius (d. 240 C.E.). Lucian, for instance, found it noteworthy that Alexander the archetypal trickster and false prophet was first patronized by a public physician (iatricos dēmosiai) who proffered “spells, miraculous incantations, charms for love-affairs, and curses for enemies.”54 Enamored with Alexander's roguery as much as the boy's beauty, “the physician gave him a thorough education and constantly made use of him as a helper, servant, and acolyte.” This physician-mentor of Alexander had an especially disreputable lineage: “His teacher and admirer was a man of Tyana by birth, one of those who had been followers of the notorious Apollonius and who knew his whole bag of tricks.”55 The charlatan physician for elite authors was little different than the sham sophist or the false prophet who preyed upon credulous victims and their purses.
The stereotype of social-climbing physicians had staying power in late antique literature. Themistius mocked physicians who were more like charcoal-makers turned soot-covered doctors merely proffering powdery concoctions. Such men, he added, were inherently “base, money-loving and rapacious.”56 Gregory of Nyssa appealed to the inveterate image of the social-climbing quack to demolish the Arian genealogy of his opponent Eunomius.57 In a lengthy attack on the Arian Eunomius, Gregory revealed to his readers the obscure and scandalous origins of Eunomius’ Arian mentor, a physician named Aetius, who as an impoverished goldsmith “became the trainee of a certain doctor from among the beggars, so as not to be pressed so much by destitution. In medical guise Aetius made his rounds among the obscurer houses and among the most rejected of men.” He tricked them with his fallacious treatments, and ultimately Aetius forced his master “to raise him to the name of doctor” so that he might with these bona fides gain more stature. He then proceeded to disrupt “medical conferences” in a manner foreshadowing his future as an Arian provocateur.58 This Aetius eventually became a noted physician, a courtier, and a bishop who retired on a large imperial estate.59
Libanius similarly lamented greedy physicians’ preference for wealthy clients. “Disease and being weakened by illness is a terrible thing for men,” he explained to his students, “but for the wealthy, encouragement, doctors, drugs, continual care, and the medical art are everywhere; yet, when the poor man is ill, he wrestles with a double disease.”60 More praiseworthy in his opinion were those physicians “who strive for fame of having conquered disease more than for money… physicians who instead of receiving fees, have themselves spent money on the poor.” Such exceptional men, he emphasized, merited the affection of the populace. “We look upon them… as if they were gods.”61
REAL COSTS AND INCOMES
The stereotype of the profit-seeking physician was widespread and has understandably left quite the impression on the scholarly understanding of ancient perceptions about physicians. That said, the stereotype was not necessarily baseless even if class snobbery amplified the image to grandiose proportions. By all accounts medicine was a capital-intensive and time-consuming career to pursue in antiquity; no doubt, late antique physicians set their prices with these steep costs in mind. Most non-aristocratic doctors spent years as unpaid apprentices to masters, surviving on subsistence incomes in order to learn their craft. The meager resources afforded these apprentices led Alexander Severus (d. 235) to provision poor physician's apprentices with public food rations (annonae).62 These pupils worked as paides iatrōn, “doctors’ boys,” and as this common and diminutive title implies, apprenticeship was in many ways an arduous and thankless task. An epigram from fifth-century Carthage jests about a local professor of medicine who rode his apprentices so hard that he truly earned the name “horse-master,” that is, Hippocrates.63 Wealthier aspiring physicians pursued university medical education at great personal expense. Their families such as those of the late fourth-century court physicians Oribasius and Caesarius of Nazianzus had to bear the cost of travel, board, and tuition to attend renowned schools of medicine such as the one in Alexandria, which both Oribasius and Caesarius attended.64
In addition to the cost of training, physicians had to purchase surgical tools and drugs not readily accessible in local environs, as well as cover the rent for spaces in which to operate a practice.65 A fourth-century papyrus from Oxyrhynchos, for instance, records a physician in hard times forced to request from his mother and grandmother aid to acquire bronze for the melding of surgical tools, a hot water bottle, and cupping vessels in addition to the books and other goods, which they had already sent him—the reverse of the fragment also asks for three pounds of mixed ointments. They were to send these items to his iatreion, his medical office which was likely a rented space in the agora.66 Pompeii offers several examples of such spaces in the main market area where medical equipment has been uncovered.67 A sixth-century fragmentary lease for such a workshop (ergasterion) made between the physician Aurelios Aukolos and the Church of the Evangelist at Oxyrhynchos seems to set rent at half a solidus and five keratia. Whether this represents monthly, twice a year, or per annum rent is unclear. Given that Aukolos is illiterate and has a proxy sign for him suggests that he was a man of humble means. We then should probably expect the rent to be annual or semi-annual, but at any rate this was not a small amounts of funds for a plebeian.68 A third-century letter between two brothers about their mercantile business mentions that an unnamed local doctor had racked up a 240 drachma debt to them, either as a tab for supplies or as a loan.69 That amount is equivalent to six months to a year's income for a day-laborer.70 High material costs also explain the widespread phenomena of family medical practices and collaborative medical associations such as guilds.71 Resources could be pooled and capital costs spread out. Finally, although Roman law did not have a perfect parallel to modern malpractice legislation, physicians still risked costly litigation for being accused of supplying dangerous drugs or willfully injuring a patient. Physicians had to hold possible legal costs in consideration when pricing their services.72
The high fees commanded by physicians, as well as complaints about physicians’ greed, become more comprehensible when situated against this backdrop: payments for medical services had to offset a range of expenses as well as provide a living surplus for physicians. Exact figures for treatments and consultation are rare, but the few surviving figures suggest that medical bills could place individuals in financial peril. An urgent letter from third-century Egypt sheds particular light on the many costs of sickness. In the letter, an unnamed man reaches out to his brother begging for aid since “a great sickness” has befallen his household. “Little Mimos,” possibly the author's child, has succumbed to whatever sickness still plagued the family, and the sender needed his brother's assistance to pay his debt of 20 drachma owed to their local physician so that the doctor could continue to treat the family. With average day-laborers earning less than 300 drachma a year, medical expenses of this scale would have easily consumed the family's budget for subsistence necessities.73 How typical such a bill was for plebeian Romans is hard to say. A late second-century papyrus from Thmouis suggests that even routine surgeries such as circumcisions could range from 20 to 34 drachmae.74 A late fourth-century papyrus records the plight of a soldier who had spent half a gold solidus, meant to be rationed for weeks, “on the doctor so that he might heal me of my sickness.” He beseeched his commander to collect the four solidi that his village had procured for him since he and his colleague “have since been ravaged by hunger.”75 Field soldiers of the fourth century earned only between five and nine solidi per year, so the treatment had cost him somewhere around a tenth to a twentieth of his yearly income.76 On the higher end of the social spectrum, a contemporaneous Chrysostom sermon implies that elites could spend between 25 and 100 solidi on procedures, that is, about 16 to 65 times a day-laborer's yearly take-home.77
Annual incomes for physicians are discussed more often than the specific cost of treatments and also clarify the ubiquitous presumption of profitability. Pliny the Elder (d. 79 C.E.), for instance, suggests that physicians could earn hundreds of thousands of sesterces a year, placing them well within the yearly household income range of first-century Roman Senators.78 Closer to our period of interest, the chief physician at Carthage earned a hefty 99 solidi a year in the 530s C.E. with his subordinates pulling in between 50 and 70 per annum.79 The 570 C.E. will of Flavius Phoebammon, the municipal physician of the smaller city of Antinoopolis informs us that he received a prosperous 60 solidi a year for his services.80 Although far from the hundreds of thousand sesterces that Pliny reported that court physicians made in the first century, an income of between 60 and 90 gold solidi per annum would have placed these physicians on par with imperial bureaucrats.81 Like many doctors, Phoebammon also supplemented his stipend with agricultural activity and was a man of some means. He bequeathed a vineyard with farm equipment to a monastery, placed the family-owned hospital (xenon) under his brother's management, and provided a stipend for his apprentice (speculatively his love child) until he was of age—it is also worth noting that he died 50 solidi in debt.82 75 miles up the Nile, the public physician of even smaller Antaiopolis earned a still respectable 25 gold solidi on par with the salary of estate managers.83 In the fifth century the Egyptian abbot Shenoute paid seven doctors 125 solidi for three months of service during a refugee crisis after a barbarian onslaught in his region.84 This would mean an income of 5.95 solidi per month. It should also be said that, like other tradesmen, doctors could also be paid in kind, e.g., in wine or in wheat. For instance, a certain Heraclammōn at Oxyrhynchos received ten artabas of wheat for a six-month pay period, only amounting to about a single solidus. This humble physician, who is not explicitly listed as a public physician (archiatros) made less than the porter and the grammarian also on salary.85 Presumably the incomes for publically retained physicians would have been somewhat comparable to what physicians could earn in private practice in order to attract qualified individuals.86
Physicians also augmented their incomes by teaching their skills to slaves either by accepting a fee from a slave-owner to train his slave or by purchasing their own for resale. Legislation of Justinian sets a price ceiling for a physician-slaves at 60 solidi: three times the maximum for unskilled adult male slaves (nulla arte imbuti), double the value of skilled slaves (arte praediti), and 12 percent more than scribal slaves at 50 solidi.87 Such physician-slaves were often rented out by their masters.88 Like their free counterparts, physician-slaves could earn handsome sums to place in their peculia. A third-century physician from Assisi in Umbria earned enough to pay his master 50,000 sesterces for his freedom. Later he became a local sevir and willed 30,000 sesterces to build a temple to Hercules and an additional 37,000 for the paving of streets in his community.89 Free doctors seemed to have resented the practice of physician-slaves, and Domitian in a 93/4 C.E. censured the “avarice of doctors and medical educators whose art, which should be transmitted to certain freeborn adolescents, is sold most dishonorably to many household slaves instructed and sent out, not for the benefit of humanity but in order to augment their profit.90 The concern seems to have been that free pupils could not find apprenticeships and that free doctors met unfair competition from slave-physicians.91
Besides incomes there were other appealing incentives to pursue a career in medicine. As mentioned above, like other professionals deemed publically beneficial such as grammarians and lawyers, doctors of late Empire received exemption from military billeting, civic liturgies, and mercantile taxes by imperial decree. Lower-class physicians also gained exemption from physical torture in interrogations and punishments, which was no small gain in the harsh Roman legal system.92 As indicated by two second-century petitions from aggrieved physicians to the governor of Egypt, some municipalities attempted to circumvent these exemptions and yoke resident physicians with civic burdens. Both petitions requested the governor to remind local officials of the physicians’ exemption (aleitourgēsia) on account of his occupation.93 As much as exemption from liturgies was a financial boon, it was also mark of honor in Roman society. Accordingly, we find monuments for specific physicians from the imperial period touting their liturgy-exempt status. A certain physician Hērakleitos from second-century Lycia, for instance, is commemorated for “healing freely, being honored with liturgy-exemption.94 A Brēsos son of Brēsos from Lesbos is remembered as “a liturgy-exempt chief-physician” who served his city “without pension or fee unlike those who came before him.”95 As his liturgy exemption and monumental epitaph demonstrates, Brēsos was an aristocratic physician from among the empire's approximately 150,000 legally designated elites.96 Like Galen he likely drew a considerable portion of his income from agricultural production or from ancillary mercantile activities. To give a comparative scale, the wealth minimum for curial status for the early empire was HS 100,000 and in the fifth century 300 gold solidi.97 These theoretical minimums were far removed from the fortunes that senators possessed, but were sufficient for a comfortable lifestyle. Unlike many humbler physicians, Brēsos could afford to operate with limited concern for his practice's profitability—and he was proud of that fact.
MEDICAL PHILANTHROPY AND PHYSICIANS’ FEES
Brēsos somewhat overstates the exceptionality of his philanthropy. Many of the 524 Greek inscriptions dedicated to physicians, which Évelyne Samama has catalogued, praise the philanthropic and unpaid services that physicians offered to their communities, as do their Latin counterparts.98 This remained a common epigraphic trope well into Late Antiquity. The most famous example of this trope for Late Antiquity memorializes a survivor of the 410 sack of Rome.
Here lies Dionysius the deacon (levita), a man of an honorable art. He fulfilled the duty that medicine gave him. Whose trained hand, surrounded by sweet fame, despised the pursuit of the sordid lucre of wages (pretium). With a generous right hand, he comforted men of small means (tenues), offering everything to the approaching sick for free (gratis). He fulfilled with his deeds what he taught in his exhortations. He sung heavenly praise with a faithful mind, and he refused to be accused of illicit acts. Remaining strong when wealth was wiped away around him, he lost nothing. Patient in a time of plunder, he was a rich man. His art venerated his faith. The ornament of his faith increased his art. Thence it was proven what sort of man he was to both citizens and associates. Even his enemy vanquisher could love him. Afterward as a captive he left the city of Rome, then his master supplied his skill to the Goths…99
Dionysius’ monument recalled an inscription dedicated to an earlier fourth-century Christian physician memorialized as “a dear friend to all, an ingenious physician, prudent to the poor (pauperes), greedy (cupidus) towards no one, whose benevolent acts (beneficia) were known to everyone.”100
The question stands whether a distinction should be made between Christian charitable physicians who forewent fees and their pagan philanthropic predecessors such as the first-century physician Damiadas who served “the poor like the rich, slaves like free men,” or the physician Sarapion, a friend of Plutarch and a Stoic philosopher “who like a savior deity treated equally slaves (dmōes), the poor (akteanoi), rich men (afneioi), and kings (anaktes*), proffering his treatments to everyone as a brother because we are all of the same blood.”101 If we take such epitaphs and literary sources such as Galen and Libanius seriously, then pagan physicians much like later Christian physicians offered their services freely to the needy out of a sense of humanitarian obligation (philanthropia). To many historians, however, the free medical care offered willingly by pagan physicians was very different from the religiously-motivated acts of charity that set the foundation for Christian charitable medicine. I quote the astute Gary Ferngren for this communis opinio on medical philanthropy before Christianity:
Graeco-Roman society recognized philanthropy as a motive for the practice of medicine, but it was never essential to the ideal of the classical physician. The meaning of the concept changed over time: in Precepts [Hippocrates] it is kindliness; for Galen, being a philosopher. Galen, in surveying the several motives that might attract individuals to engage in the medical art, recognized a variety of incentives, of which philanthropy was one, as were desire for money, honor, and immunities from taxation. But only competence was essential. In excluding pity as a basis for personal assistance, classical philanthropy differed markedly from Christian charity in both motive and practice. The Stoic conception of apatheia (insensibility to suffering), moreover, encouraged an attitude of quietism that was content to accept the world as it was rather than to try to change it. While it would be presumptive to doubt that many pagan physicians exercised compassion in medical treatment, there existed in the classical world no external impetus, no elevated ideal, no specific virtue, of compassion. With rare exceptions (e.g., Scribonius Largus), ancient philosophical or medical writers did not expect the virtuous physician to be humanitarian or philanthropic in the practice of medicine. That expectation had to await the coming of Christianity, which substituted the idealization of very different virtues for those that had long dominated the classical world. In the medico-ethical literature of the early Middle Ages the new religious and philanthropic ideals of monastic medicine were merged with the older secular tradition of Hippocratic medical ethics and etiquette.102
Like many others, Ferngren sees “no religious or ethical impulse” for the care of the impoverished sick in Classical medical ethics. Social and political calculus determined when medical benefaction should be offered.103
As relates to charity and benefaction, the Christian shift of Greco-Roman sympathy toward the wretchedly poor and sick is Gospel. Indeed, as Peter Brown has repeatedly instructed us, Christian leaders invented the very concept of “the poor” as a distinct class. But when we consider the evidence for how the new late antique-emphasis on the poor affected professional medical ethics and practice, it does not suggest that private physicians of the Christian Empire were exceptionally more philanthropic or more concerned with the poor than those of earlier days.104 For instance, the two well-known Latin Christian monuments above, which praise deceased physician's care of the poor do so in very generic terms for the poor (tenues and pauperes respectively) not out of step with their pagan exemplars. While one may see in such monuments, as Mela Albana does, an adaptation of pagan formulae “in a new spirit derived from evangelical principles and the exaltation of the law of charity,” evangelical principles and the law of charity are conspicuously absent in the particular case of physicians’ epitaphs.105 The sole line Ars ueneranda fidem, fidei decus extulit artem, for instance, in the Dionysius inscription is hardly a specific call for physicians to offer free care in Christ's name. Likewise, prescriptive medical literature from Late Antiquity reveals no increased sympathy for poor patients or an efflorescence of medical charity. For instance, Paul of Aegina, the doyen of Byzantine medical science, is quiet on the plight of the poor and the ethics of fee-charging.106 The fifth-century Introductio ad medicinam produced in Christian North Africa simply offers the standard medical advice that physicians should not actively squeeze a patient, rich or poor, slave or free, for a fee or a gift.107 The authoritative Aetius of Amida only references financial matters when the prohibitive cost of drugs necessitates that a physician take a fee prior to treatment.108 His only reference to the poor that I can identify comes from a citation of Galen about diseases of affluence.109
One also does not uncover new lengthy exaltations in fourth- and fifth-century ecclesiastical sources for doctors serving the poor or foregoing fees. Gregory of Nyssa praises the physician Eustathius, flattering him that “all you who practice medicine surely have philanthropy for your profession,” but the remark comes only as an empty compliment to persuade the man to treat the mental illness of heresy in his district.110 Chrysostom has ample plaudits for physicians, especially his own whom he missed in exile, but he remains silent about their advocacy and treatment of the poor.111 Gregory of Nazianzus’ words in his funerary panegyric for his physician brother Caesarius perhaps capture the continuity between pagan and Christian perceptions about physician's philanthropy. In the eulogy Gregory narrates Caesarius’ noble birth, his education, how he “held first place among doctors” even over his social superiors, and his crowning achievement of attracting imperial attention, which raised him to the quaestorship of Bithynia; yet, of his philanthropy Gregory only notes that “he placed the philanthropic function of his art at the disposal of those in power free of cost, knowing that nothing leads to further advancement than virtue and being known for honourable deeds.”112 Caesarius was unabashedly an ambitious physician, and Gregory takes this as typical for physicians. The ascetic-minded Gregory thus spoke with near joy about his brother's unfettered respite to come in the afterlife:
He will amass no riches, but neither will he be open to envy or his soul pained by a lack of success, or ever seeking to add to the gains he had already amassed. For such is the disease of wealth, which knows no limit to its desire of more, and ever makes necessary the drinking of medicine for thirst.113
If Caesarius served the impoverished or if Gregory had qualms about physicians offering their philanthropy to the powerful over the ailing poor, Gregory never mentioned it. He only has the brief lamentation of physicians’ wealth-seeking. Here was the funerary oration for a physician son of a Christian bishop, a man raised in the faith, whose brother would extol to the highest the philanthropic medicine of Basil of Caesarea's renowned hospital for the poor. It is worth adding that after Caesarius’ untimely death from plague, Gregory discovered that his brother had many outstanding debts, which troubled Basil for some time after his death. The first praise for a physician's care of the poor, whom the author directly knew of, seems to be Augustine's brief commendation of the physician Gennadius, “a man known to almost everyone… a religious man and most benevolent, actively compassionate and eager in his merciful care of the poor.”114 It is unclear, however, though whether the cura pauperum signified medical care or almsgiving generally.
Even the establishment of a “Christian” charitable valetudinaria at Rome by Valentinian in 368 has been shown to conform much more to traditional medical ethics and practice than one might expect. The edict establishing the institution reads:
With the exception of the ports of Xysti (?) and of the Vestal Virgins, however many regions of the city there are, let that same number of archiatroi be established. Knowing that they receive their subsistence allowances (annonaria) from the people let them prefer to minister to the poor (pauperes) honorably rather than to serve the rich shamefully.
The exclusion of the territory of the Vestal Virgins and the particular emphasis on the poor has led some scholars to see a Christian ethos behind the law, but the next lines in the text undermine such an interpretation: “We do not suffer it for [physicians] to accept the [larger] offerings, which healthy persons offer them for their services, but not those offerings from those in peril who promise them such for the sake of their health.”115 The same law also prohibits the appointment of physicians through favor of the rich the physicians. The logic behind the law is to prevent salaried physicians from pursuing gifts or fees, thereby essentially disregarding the labor contract to the state implicit in accepting the position and its salary. Secondly, the excessive greed of the physicians in question would dishonor the Hippocratic medical ethos by preferring the healthy and wealthy over the truly sick who offer more modest gifts. In Owsei Temkin's words, “the edict did not direct the archiater to cease treating rich people and instead dedicate himself exclusively to the poor, that is, people of rather limited means but not necessarily indigent. It contrasted honest treatment of the poor with shameful service of the rich.”116 Classical medical ethics regarding payment were still at play. Moreover, the employment of 14 physicians for hundreds of thousands of Rome's inhabitants could hardly represent the novel establishment of far-reaching free medical service on the Christian state's bill. Tellingly, the formula for appointing the head (comes) of these archiatroi, which Cassiodorus (d. ca. 585 C.E.) preserves in his Variae, does not mention any concern for the poor; neither do the laws under Justinian appointing public physicians at Rome and Carthage.117 Indeed, the doctor most celebrated in Late Antiquity for his equal service to the rich and the poor, receiving accolades and a statue from the Constantinopolitan Senate,118 was the openly pagan Jacob Psychristes who did not charge fees but was rather “content with his mere public salary.”119 If Justinian's pay schedule at Carthage is indicative of Jacob's salary, then this pagan philanthrope lived on a respectable 50–99 solidi a year that he received from the Christian capital for his service.
MEDICAL CARE IN A CHRISTIAN HEALTHCARE ECONOMY
Here with physicians’ profits and medical philanthropy, we arrive at the perennial question of what difference did Christianity make? In many ways, the Christianization of society had little effect on the economic dimensions of medical practice. Like their pagan compatriots, late antique Christians took it for granted that “many doctors practice their art merely for the sake of gain,” to quote Isidore of Peleuse, the ascetic and intimate of numerous physicians (d. ca. 450).120 Christian authors even appealed to the payment of physicians in positive ways with their theological metaphors. For instance, while extolling the fleeting pain of martyrdom, Tertullian (d. ca. 240) offered that “the groaning and bellowing patient fearful of the doctor's touch will afterwards reward the doctor's very hands and will declare them the most skilled…”121 Valerian of Abbenza (d. 457) stressed that the bonds of trust within Christian communities were not dissimilar to a physician's relationship with patients. “It is difficult for a doctor to manipulate his hand with full faith, if the ailing man's empty promise has often left him defrauded of his fee.”122 The remuneration of physicians had its fair and understandable place in Roman society.
Christians similarly acknowledged that physicians added to the suffering of the ailing poor by charging them heavy fees or refusing to serve them at all. It was common knowledge for late Romans such as Chrysostom that “the poor man often has to go away deprived of treatment since his income does not even cover the preparation of medicine”—to say nothing of the physician's fee.123 In light of the papyri evidence above, Chrysostom was not speaking hyperbolically. In the traditionalist words of Jerome, “illness has some solace, if it has wealth, but to add poverty to the weight of sickness, now that is a double infirmity.124 Like their pagan compatriots Christians recognized that both physicians’ fees and the poverty of patients limited healthcare access. The voluntary foregoing of the physician's fees for whatever social or ethical motivations remained the easiest solution to this unfortunate reality. Most ancient physicians, however, were humble men with costs and income requirements of their own. Offering free care for all patients with meagre means would have likely been impossible for all but the limited number of salaried public physicians, and Christians did not mandate individual Christian physicians the assume a personal burden of the poor.
That said, among Christian hagiographies one often detects a noticeable hostility towards greedy physicians and “the entailed cost” of medicine as regards the impoverished sick, as opposed to the traditional Greco-Roman literary focus on how physicians dupe and fleece the rich.125 Indeed, the vitriol that Christians spewed about the costly and predatory physicians in hagiographical texts gave some 19th- and early 20th-century scholars the misguided impression that ancient Christians were hostile to medicine in itself and instead placed their faith solely in miracles.126 The past century of scholarship has made it clear, however, that ancient Christians held assumptions about “medicine and the healing of disease that did not differ appreciably from those that were widely taken for granted in the Greco-Roman world.”127 Among these were assumptions about the high cost of medicine, the sometimes unseemly profitability of medical occupations, and the potential exclusion of the poor from quality care. Whereas pagan authors focused more on bemoaning, if not deriding, the former two aspects of ancient medical care, Christian authors placed more emphasis on the predicaments and frustrations of the ailing poor. Although most often of middling to high status, late antique Christian authors cultivated a sensitivity to the vulnerable conditions of the poor, particularly their inability to afford care when they or their family members fell ill. I use the term cultivate because, as scholars have rightly observed, Classical Greco-Roman philanthropic values did not traditionally ask the more affluent elements of society to empathize with, or imagine themselves as, the wretched poor.
The propagated Christian emphasis on the poor and their economic condition vis-à-vis healthcare partially explains the widespread Christian trope, one rooted in the Gospels, that the humble were excluded from medical care because of its cost or were impoverished by the medical bills of ineffectual, fee-charging physicians (Cf. Mk. 5:26). No doubt, many Christian authors heard firsthand heart-rending stories among their congregations about the poor being turned away or swindled by physicians. We imagine then that this heightened awareness of the imagined or real suffering of the poor accounts for Christian condemnations that stereotypical physicians “practice their art, despite knowing that the patient would not prevail or that they would not banish the illness, but nevertheless deceive the poor man in hope of payments.”128 As research onto perceptions of modern doctors has indicated, even modest physicians in countries with for-profit healthcare systems are disproportionately more distrusted than their peers in countries with socialized medicine. The motive of profit itself and perceptions of relatively high incomes for physicians engender distrust. More significantly, in those countries with for-profit healthcare systems, lower-income individuals regard physicians with more suspicion than middle- and upper-income individuals in the same country.129 As we saw above, elite Greek and Roman authors for centuries had considerable suspicions about their physicians’ motives. Combining that sensibility with a new empathy towards the poor who would understandably be wary of physicians demanding their limited funds explains at least in part the popularization of this new stereotype in Christian texts.
As a rhetorical strategy, tropes about the impoverished sick highlighted the efficacious and miraculous healing of Christ and his saints as opposed to costly secular medicine; and such examples are easy to find across hagiographical literature. I would like to add that this rhetoric also served a financial purpose intended to help alleviate the suffering of the sick, namely encouraging almsgiving by describing at length the plight of the pitiable sick and how service to the poor fit into the Christian economy of salvation. Costly physicians and medicines, which excluded the poor from healthcare, became the reason that one should give charitable donations. For example, Jerome in his Life of St. Hilarion recounts the story of an unfortunate woman from the Egyptian village of Facicia, who had been blind for ten years. She came to Hilarion in his desert hut and “affirmed that she had spent all her substance on doctors.” With the application of a little spittle in imitation of Christ, the woman soon found herself healed of her costly affliction, but not before a rebuke from Hilarion: “If you had given to the poor (pauperes) what you have lost on physicians, Jesus the true physician would have cured you.”130 In other words, if the blind woman of “pauperisable” means (substantia), to borrow Peter Brown's term, had sought her cure in almsgiving, not with physicians, she would not have found herself in the double perils of poverty and sickness. Thus, the reader was to sympathize with the “pauperized” woman who had endured a reversal of fortune as well as heed an admonition to donate to the nameless poor for one's own well-being
Jerome, of course, did not consider secular medicine ineffectual or physicians as predatory and useless. He praised medicine as “the skill most useful to us mortals.”131 He advised clerics to mimic the discretion and honor of physicians, and some of his medical references may even indicate a familiarity with Galen.132 Rather, Hilarion's, i.e., Jerome's, chastisement of the blind woman for considering only her recovery rather than those of the poor around her conforms to a larger agenda among post-Constantinian Christians, which argued that all Christians were obliged to care for the sick and the poor if physicians would not. As Augustine explained in a sermon on first Timothy, “Christ's medical arts,” which were first commended to Paul, had passed to every individual Christian who was now a sort of doctor: a doctor who “if he should discover a truly poor man, especially a sick one, will not seek there a payment (merces), but extend him his skills.”133 Chrysostom made a similar analogy. To him the congregation of Christian “physicians” followed the learned techniques of common doctors, but with some stark differences:
We do not set medical bills costing money. We are not of the habit of ordering those sickened to buy whatever it takes to heal. It matters not if they live at the ends of the world, if they are in the midst of barbarians, if they lie at the bottom of misery, even if they are so poor that they lack the basic foods, nothing prevents us from caring for them.134
Christian morality demanded that all who were one in Christ assume the role of the charitable physician in their alms to the poor and in their care of the sick.
Authors such as Jerome, Augustine, and Chrysostom were of the first generations of Christians who could use these rhetorical techniques to direct almsgiving towards institutions that provided targeted healthcare to the poor.135 This almsgiving could take on numerous forms, from the direct establishment of a charitable institution for the poor or the giving of donations, to personally volunteering at hospitals, all of which were perceived as medical care in their own way by Christian wits. Let us consider Jerome's praise for the deceased widow Fabiola, a fabulously wealthy woman who “established the first nosokomeion in Rome,” that is, the city's first charitable sick-house for the ailing and feeble poor.136 In a laudatory letter written to her relative Oceanus, Jerome emphasized her care for the poor and the sick, how “she gathered them from the streets, nursed the limbs of wretches consumed by pains and emaciated from poverty.” He asked rhetorically of their legion afflictions,
Need I describe the diverse ailments of human beings? Slit noses, eyes put out, feet half burnt, hands covered with sores, bloated bellies, atrophied legs, arms swollen with dropsy, diseased flesh teeming with worms? Often she carried on her own shoulders persons infected with jaundice or with filth. Often she washed clean the pus discharged from wounds which others, even though men, could not bear to look at. She gave food to her patients with her own hand, and moistened the barely breathing lips of the dying with sips of liquid. I know of many wealthy and religious persons who, unable to overcome their natural repugnance to such sights, perform this work of mercy by the agency of others, giving money instead of personal aid. I do not reproach them and do not interpret their weakness of resolution as faithlessness. While I do pardon such weakness of the stomach, I praise to the heavens their resolute zeal of mind. A great faith makes little of such trifles. I know though how the proud mind of the rich man clothed in purple was damned by great retribution for not having helped Lazarus (Luke 16:19–24) The poor miser whom we despise, whom we cannot so much as look upon, and whose very sight causes us to vomit, is human like ourselves, is made of the same clay as we are, is formed out of the same elements. What he suffers we too can suffer. Let us then regard his wounds as though they were our own, and then all our hardness to another's suffering will shatter in our clement pity for ourselves.137
Jerome heaped similar praise on other Christian patrons who poured their wealth into charitable institutions for the health of their own souls, figures such as Fabiola's acquaintance Pammachius who founded a guesthouse-hospital in Ostia and served the needy there personally, “ranking himself among the poor, condescendingly entering the tenements of the needy, offering his eyes to the blind, his hands to the feeble, and his feet to the crippled.”138 Jerome intended these circulated descriptions to move souls and to churn stomachs. The blameless giving of alms to hospitals was an acceptable and an undoubtedly more palatable act of charity for elite Romans than firsthand toil at the hospital. Donors need not be real nurses or doctors to the poor, but merely distant benefactors.
Such succoring of the poor either through personal care or donations to institutions for the sick helped the urban poor circumvent the hardships of illness and poverty, hardships that were imposed by medical practitioners (doctors, apothecaries, etc.), by their costs, by their availability, and by their resistance to forgo or lower charges. As we have seen, Classical Greco-Roman communities had a range of tactics to promote philanthropic medical care for citizens such as the subsidization of physicians through exemptions, the funding of municipal physicians and professors, the provision of food to medical students, and lastly the propagation of a set of medical ethics that nudged physicians to give treatment irrespective of financial gain. We might also add to this list the funding of a handful of temples to Asclepius which supported physician-priests. Christian leaders developed a much more effective and audacious cultural system to expand care for the sick at little to no cost by associating the funding of charitable institutions with the active purgation of a soul that might otherwise be poisoned by wealth, greed, and indifference to the plight of others. As individuals such as Jerome, Gregory of Nyssa, and Basil of Caesarea explained, “dealing with wealth makes many sick… what goes beyond need is the disease of greed, hedonism and vainglory.” Excess needed to be purged.139 In the metaphor of Chrysostom, excess wealth was a “fetid tumor” to be excised.140 Giving to the poor, who were synonymous with the physically sick, became the means through which the wealthy alleviated the deleterious effects of their money on their souls. In mimicking the poor and supporting the Church's charitable efforts towards the impoverished, the rich healed themselves. Chrysostom chastised the miserly rich who without hesitation “procure medicines at great cost for their ailing slaves… but not so much as call in the physician… not lay out any money, but acts as paupers” when their own souls were diseased. As the sermon makes clear, the physicians in question are Christ and his clerical servants who offer salvific sacraments. “There is no need though to pay money to these physicians since they neither demand fees for themselves, nor do they drive you into financial duress for the medicines that they prepare save almsgiving.”141
This clarion call for universal philanthropy materialized itself in the Christian charitable hospitals and poorhouses which tended to the infirm unable to bear physicians’ high fees.142 The development of these institutions (so well documented by Demetrios Constantelos, Timothy Miller, and most recently Andrew Crislip) drew much of its vigor from the haranguing echoes of Christian preachers calling on their congregations to empty their pocketbooks. At a torrential speed their wealth flowed into charitable institutions like Fabiola's sick-house (nosokomeion) and Basil of Caesarea's ptōchotropheia, likely a poorhouse for lepers.143 To clerics like Basil these hospitals were “new cities” for elite euergetism, a new “common treasury of the wealthy in which their excesses are stored” for the benefit of the poor.144 Two generations later, when Rabbula, bishop of Edessa, established a multi-ward hospital, he did so knowing that hospitals provided “an opportunity for many to leave riches and property to the hospital in their wills, so that, from them, a thousand denarii might be the total income for the hospital in one year. Thus, there was relief for the weak and benefits for the healthy through the provision of His word. ”145 The hospital mediated a new reciprocal healthcare economy, in which almsgivers treated the diseases of their souls by provisioning the care of the physically sick.
The author of Rabbula's life provides a vivid description of how these purgative funds were spent, boasting of the cleanliness of the facilities, the quality of its linens and beds, and the virtue of the attendant deacons.146 Absent from the hospitals described amenities were “professional,” that is, paid, physicians. Similarly, Jerome's description of the Christian hospitals in Italy does not mention physicians. The same observation can be made about Basil of Caesarea's description of his ptōchotropheia. Basil never specified that physicians are present at the institution that would take his name, the Basileias, but rather he wrote of “men who nurse” (tous nosokomountas) and “those who give medical care” (tous iatreuontas).147 As Oswei Temkin and others have rightly inferred from this distinction, there were likely no physicians in Basil's compound and instead the ill and the lame were treated by clerics, monks, and volunteers who may have had varying degrees of medical knowledge.148 As Peregrine Horden has recently concluded, late Rome and Byzantium were likely not nearly as “medicalized” as more optimistic historians would like to believe. Deacons, monks, and members of pious confraternities likely represented the majority of caretakers at late antique hospitals not “professional” physicians. It is simply unclear how many trained physicians offered medical care at the hundreds of Christian charitable institutions that emerged between the fourth and seventh century. The presence of paid “professional” physicians might have been limited only to affluent institutions in major cities.149 The first attestation of physicians at charitable hospitals may be from Palladius, an ally and biographer of John Chrysostom, who stated that the patriarch “erected more hospitals on account of the need of treatment, over which he appointed two devout priests, as well as doctors, cooks, and workers from among his celibates for their assistance, so that strangers coming to the city, and there falling ill, could obtain care…150 Does each hospital receive two physicians or are there two for all the hospitals of the diocese? Slightly later Neilos of Ankyra (d. ca. 430) in two letters references a physician making the rounds at his monastic hospital on the Sinai Peninsula. This physician, he explained, served paralytics, the weak, and the injured, giving each an appropriate treatment and a daily bedside visit.151 As with Rome's 14 official archiatroi, the ratio of doctors to patients seems steep and understandably so. From the scant evidence that we have on doctors assigned to monastic and ecclesiastical hospitals, it is obvious that they were paid for their services, which would have placed constraints on the number of physicians that individual institutions could support.152
As Horden and others have underscored, we should not draw too large a distinction between “professional” physicians and other caretakers with pharmacological resources and some medical training. Christian communities no doubt relied on these dedicated clerics, ascetics, and pious laypersons to supplement “professional” physicians. This is not to say, however, that Christian communities did not find ways to bring “professional” physicians into service of their community. From the fourth century onwards an increasing number of physicians who took on holy orders, either as clerics or monks, appear in the historical record across a wide range of evidence. These were men such as “Phlorentios… who setup his own home as an apostolic hospital [and] who paid reverence to God as a reader and an abbot” in fifth-century Bulgaria, and “Phlorentios, who for forty years saw in the temple of the holy his eternal dwelling place, who setup his own home as an apostolic hospital, who paid reverence to God as a reader and an abbot, and [who] found his peace here on the day before the Kalends of March in the seventh indiction.”153 Christian Schulze in his 2005 study of Christian medicine in Late Antiquity identified over 30 clerics and monks who also labored as physicians—though his catalogue is not exhaustive.154 Given the very limited amount of knowledge we have about most clerics’ prior professional or occupational training, the number of trained physicians is indicative of the desirability of physicians for ordination.155 “Above all in the case of deacons entrusted with the Church's charity, men with medical training were sought-out candidates.”156 Other physicians obtained the priesthood such as the legendary Sampson so-called xenodochos who, after having distributed his wealth became a priest at Constantinople offering charitable healthcare. Justinian named the great hospital (xenon) at Constantinople after him. The structure continued to serve the impoverished and the sick until 1204.157 Several bishops reached the episcopacy such as Bishop Gerontios of Nicomedia who ran afoul of Ambrose of Milan, Gregory of Nyssa, and John Chrysostom.158 When, during his brief tenure as patriarch, Chrysostom tried to oust Gerontios and replace him with a candidate he favored, the populace of Nicomedia rioted. “They enumerated publicly and privately his beneficence,” lauding “the liberal advantage derived from his science, its generous utility for the rich and poor alike.”159 The inhabitants of Nicomedia cited Gerontios’ free medical care before any of his personal or spiritual attributes. Whether as monks receiving mere sustenance and shelter or as clerics receiving stipends, physicians of the cloth served at the remunerated leisure of their ecclesiastical communities. Physicians in urban areas would have earned clerical stipends on par with the incomes of urban professionals such as physicians. In this way the ordination of physicians, who were likely already of a charitable nature, encouraged the provision of free care since fees would be less of a requirement for the physicians’ incomes.
Some time amid the Persian and Arab incursions into seventh-century Egypt, the nome of Hermopolis produced a tax cadastre of the region's most affluent property owners.160 Among the approximately seventy Christian institutions listed in the cadastre are seven Christian hospitals. While not an obviously exorbitant number of hospitals for a regional urban center, with only 40,000 at maximum inhabiting the city, there was one hospital for every 5,700 inhabitants. As Peter van Minnen and others have noted, this “ratio may have been lower than anywhere else at any given time before the Industrial Revolution.”161 Slightly earlier, around 570 CE, when the Visigoth Masona assumed the episcopacy of Merida, Spain on the other end of the Mediterranean, “he built a xenodocium, enriched it with large patrimonies, and appointed ministers and doctors to serve travelers and the sick.” Masona was expanding on the charitable medicine of his predecessor Paul, an eastern physician who oversaw ecclesiastical physicians as bishop and performed medical miracles himself when lay physicians failed the ill. Contemplating the hospital's posterity Masona, “ordered the doctors to ensure with the utmost care that they should receive half of all the revenues brought into the palace by all the actuaries from the entire patrimony of the church in order that they could offer it to the sick.” He also established an interest-free bank with an endowment of 3,000 gold solidi “for the need of all the miserable poor.” Anyone “pressed by urgent necessity” could request financial assistance “without delay or difficulty.”162
The artifacts of his benefaction survive to the present as a tourist landmark: the first hospital in Spain.163 A grave marker at the nearby church dedicated to St. Eulalia commemorates at least one of the healthcare workers of the xenodocium, a certain Reccardus medicus.164 The Goths Reccared and Masona in western Spain were far from the landscape of Greek-speaking aristocrats who invented the Christian hospital in fourth-century Asia Minor and Egypt. They were testaments to how much the idea of charitable medicine had been grafted onto Christian culture. Nor were these men barbarian outliers promoting affordable medicine. Visigothic kings set ceilings on the cost of procedures, ensured the free training of student-physicians, gave wronged patients the right to seek financial redress, and most importantly offered their wealth to the Church's charitable mission.165 Save for the funding of Christian charity, these were not policies out of sync with Classical mores. As Isidore of Seville asked in a perfectly Classical fashion, “Physician, extend the wealth of the powerful to paupers. Uneven conditions should be handled in an uneven fashion. If he is a rich man, let it be a just occasion for lucre. If he is a pauper, let a fair fee suffice for you.”166 Isidore even had an equally traditional word of wisdom for the patient. “Pay what you owe to the doctor, sick man, lest when sickness comes back, no one comes running back to you.”167 Traditional medical exchange, medical ethics, and medical legislation were alive and well in this post-Roman order. The key difference between medical care in Classical Antiquity and in Late Antiquity was the system of ecclesiastical hospitals and almsgiving, which had developed to ameliorate the condition of the poor overlooked by for-profit medicine. As in Merovingian Gaul, Lombard Italy, and Byzantium, the early medieval Christian communities of Visigothic Spain felt obliged to offer charitable care to the sick and the poor funded by the offerings of the rich.168 As a Christian shepherd, like Paul and Masona before him, Isidore oversaw these systems and fittingly preached to the wealthy that “almsgiving defeats avarice,” one of the many vices that sicken the soul.169 For as Isidore explained of wealth and luxurious living, “whoever serves greed and gluttony kills his body and soul.”170 What most altered the provisioning of healthcare in Late Antiquity was the linking of the healthcare economy to the economy of salvation. All Christians owed a doctor's bill to Christus medicus, and the sick of this world were the greatest beneficiaries of its payment.