Byzantine

Any hospitalist will tell you that the hospital is an increasingly complex environment. Between Medicare policy, Joint Commission surveys, credentialing hurdles, and payment models, hospitalists might shake their heads sadly and bemoan the lost lack of simplicity of the halcyon (the bucolic, not the benzo) days of medicine.

Sometimes these labyrinthine and seemingly unnecessary regulations and policies seem to be a modern phenomenon. However, like most things, history repeats itself. Whether it's ancient Persian credentialing, colonial American utilization review, or medieval admission criteria, the things that drive us mad today did the same to our distant medical forbearers. If we want to examine a truly complex and highly regulated medical system, we have only one choice: Let's get Byzantine.

In 1136, the monastery of Christ Savior Pantokrator was founded by Emperor John II Komnenos (also known as John the Beautiful). Included in his design was a charitable institution designed to heal the sick of Constantinople, called the Pantokrator Xenon (meaning “house of strangers,” not the noble gas).

The goal of the institution was to provide a clean bed, medical and nursing care, and nutrition in a facility with a well-developed set of regulations for administration, supply chain management, and staff organization. All this was laid out in the constitutional document, the Typikon, for the people of Constantinople. A Gerokomeion, a proto-nursing home for the infirm elderly, was also established as part of the design.

The Xenon had fifty beds, arranged in five sets similar to what we might consider wards or units. The first was 10 beds for wounds and fractures, or what we might call the ortho-trauma unit. The second ward was for ophthalmology or gastrointestinal illness. (It's hard not to make an “eyes too big for the stomach” joke here, but I'll resist.) The third unit had 12 beds for women, and the last two units of 10 beds each were for general cases. The beds, with only one patient each, came with a mattress, a pillow, and sheets. Specialty beds for patients who had diarrhea or were incapacitated were equipped with drainage holes through the mattress in case patients were unable to get up and use the latrines, of which there was one for men and one for women.

Each patient who could eat was provided a standard vegetarian diet. They received a fixed portion of bread, two vegetable dishes, and two onions, estimated at 3,300 calories per day. They were also given an allotment of money daily (a nomisma, as in numismatic) to buy extra food or wine.

The medical team would seem quite familiar. Two physicians, called iatroi (from which we derive the term iatrogenic), were assigned to each ward. There were three medical assistants, two junior assistants, and two servants. On the female ward there was an additional female physician, four medical assistants, two juniors, and two servants. (The design is reminiscent of our academic services, with residents and interns, though that might mean medical students are our servants?) There were also several physicians assigned to cover outpatient care, both surgical and medical.

There was a strict hierarchy among the physicians, and advancement occurred up this professional ladder. At the top were two physicians who oversaw all activities and reviewed treatment plans. Think of them as the chief medical officers. Next in line were the two specialists in ocular and GI disease, followed by the ortho-trauma surgeons. Then came the general ward doctors (the hospitalists), followed by the female doctors. At the bottom were the outpatient physicians. The doctors worked in shifts of a month (the old 30 on/30 off) and rounded once a day in the winter and twice a day during summer months.

The ancillary staff was also very well defined. There were six pharmacists of various ranks. For dietary services there were a kettle-keeper, a miller, two bakers, and two cooks. For environmental services, there were five laundresses and a latrine keeper. And for spiritual needs, there were two priests, two lectors, and four pallbearers.

What hospital would be complete without an administration? The monastery had a board of directors, one of whom was responsible for Xenon affairs, making sure there was adequate funding and supplies. However, for day-to-day management, there needed to be an administrator who managed daily operations. This was the nosokomos. With an assistant, the nosokomos (think nosocomial) ran the facility, ensuring that supplies, medications, and staff were available, independent of the board of directors.

The Typikon describes the structure of the hospital and its supplies and staff but doesn't really address the treatments given. Based on the specified supplies, however, we know there were frequent baths (at least twice a week), phlebotomy, bladder catheterization, and dental pliers. Spiritual treatment was part of every therapy.

And so here we sit, almost nine centuries after the formation of this early hospital, with distinct regulations, an administrative hierarchy, a variety of physicians and ancillary staff, and specialist- and unit-based services. Next time a colleague complains about the complexity of current practice, just smile at them and let them know it's Byzantine.

Editor's Note: “The Birth of the Hospital in the Byzantine Empire,” by Timothy S. Miller (Baltimore: Johns Hopkins University Press; 1985), served as reference material for this column.