MEDIEVAL HOSPITALS

Our recent experience makes it easy to understand that such magnificent advance in surgery as has been described in the preceding chapters would have been quite impossible unless there were excellent hospitals in the medieval period. Good surgery demands good hospitals, and indeed inevitably creates them. Whenever hospitals are in a state of neglect, surgery is hopeless. We have, however, abundant evidence of the existence of fine hospitals in the Middle Ages, quite apart from this assumption of them, because of the surprising surgery of the period. Historical traditions from the earlier as well as the later medieval times demonstrate a magnificent development of hospital organization. While there had been military hospitals and a few civic institutions for the care of citizens in Roman times, and some hospital traditions in the East and in connection with the temples in Egypt, hospital organization as we know it is Christian in origin; and particularly the erection of institutions for the care of the ailing poor came to be looked upon very early as a special duty of Christians. Even the Roman Emperor, Julian the Apostate, declared that the old Olympian religion would inevitably lose its hold on the people, unless somehow it could show such care for others in need as the Christians exhibited wherever they obtained a foothold. It was not, however, until nearly the beginning of the Middle Ages that the Christians were in sufficient numbers in the cities, and were free enough from interference by government, to take up seriously the problem of public hospital organization. The rapidity of the development, once external obstacles were removed, shows clearly how close to the heart of Christianity was the subject of care for the ailing poor. St. Basil’s magnificent foundation at CÆsarea in Cappadocia, called the Basilias, which took on the dimensions of a city (termed Newtown) with regular streets, buildings for different classes of patients, dwellings for physicians and nurses and for the convalescent, and apparently even workshops and industrial schools for the care and instruction of foundlings and of children that had been under the care of the monastery, as well as for what we would now call reconstruction work, shows how far hospital organization, even in the latter part of the fourth century, had developed.About the year 400 Fabiola at Rome, according to St. Jerome, “established a Nosocomium to gather in the sick from the streets, and to nurse the wretched sufferers wasted from poverty and disease.” A little later Pammachius, a Roman Senator, founded a Xenodochium for the care of strangers which St. Jerome praises in one of his letters. At the end of the fifth century Pope Symmachus built hospitals in connection with the three most important churches of Rome, St. Peter’s, St. Paul’s, and St. Lawrence’s. During the Pontificate of Vigilius, Belisarius founded a Xenodochium in the Via Lata at Rome, shortly after the middle of the sixth century. Christian hospitals were early established in the cities of France; and not long after the conversion of England, in that country.

In connection with these hospitals, it is rather easy to understand the fine development of surgery by early Christian physicians which we have traced. The later medieval period of hospital building, however, is of particular interest in the history of medicine, because we have such details of it as show its excellent adaptation to medical and surgical needs. According to Virchow, in his article on the History of German Hospitals, which is to be found in the second volume of his collected “Essays on Public Medicine and the History of Epidemics,”[14] the story of the foundation of these hospitals of the Middle Ages, even those of Germany, centres around the name of one man, Pope Innocent III. Virchow was not at all a papistically inclined writer, so that his tribute to the great Pope who solved so finely the medico-social problems of his time undoubtedly represents a merited recognition of a great social development in history.

“The beginning of the history of all these German hospitals is connected with the name of that Pope who made the boldest and farthest-reaching attempt to gather the sum of human interests into the organization of the Catholic Church. The hospitals of the Holy Ghost were one of the many means by which Innocent III. thought to hold humanity to the Holy See. And surely it was one of the most effective. Was it not calculated to create the most profound impression to see how the mighty Pope, who humbled emperors and deposed kings, who was the unrelenting adversary of the Albigenses, turned his eyes sympathetically upon the poor and the sick, sought the helpless and the neglected upon the streets, and saved the illegitimate children from death in the waters! There is something at once conciliating and fascinating in the fact that, at the very time when the fourth crusade was inaugurated through his influence, the thought of founding a great organization of an essentially humane character, which was eventually to extend throughout all Christendom, was also taking form in his soul; and that in the same year (1204) in which the new Latin Empire was founded in Constantinople, the newly erected hospital of the Holy Spirit, by the old bridge on the other side of the Tiber, was blessed and dedicated as the future centre of this organization.”

According to tradition, just about the beginning of the thirteenth century Pope Innocent resolved to build a hospital in Rome. On inquiry, he found that probably the best man to put in charge of hospital organization was Guy or Guido of Montpellier, of the Brothers of the Holy Ghost, who had founded a hospital at Montpellier which became famous throughout Europe for its thorough organization. Accordingly he summoned Guido to Rome, and gave into his hands the organization of the new hospital, which was erected on the other side of Tiber in the Borgo not far from St. Peter’s. Indeed, Santo Spirito Hospital, as it came to be called, was probably the direct successor of the hospital which Pope Symmachus (488-514) had had built in connection with St. Peter’s not long after the beginning of the Middle Ages. It is easy to understand that at the time when magnificent municipal structures, cathedrals, town halls, abbeys, and educational institutions of various kinds were being erected, with exemplary devotion to art and use, the Hospital of Santo Spirito under the special patronage of the Pope was not unworthy of its time.[15] We know very little, however, about the actual structure.

THIRTEENTH-CENTURY HOSPITAL INTERIOR (TONERRE)

From “The Thirteenth: Greatest of Centuries,” by J. J. Walsh

Then, as now, Bishops made regular visits at intervals ad limina—that is, to the Pope as Chief Bishop of the Church; and according to tradition Pope Innocent called their attention particularly to this hospital of Santo Spirito, one of his favourite institutions, and suggested that every diocese in Christendom ought to have such a refuge for the ailing poor. The consequence was the erection of hospitals everywhere throughout Europe. Virchow has told the story of these hospital foundations of the Holy Ghost, as they were called, and makes it very clear that probably every town of 5,000 inhabitants everywhere throughout Europe at this time had a hospital. The traditions with regard to France are quite as complete as those that concern Germany and the great hospitals of London—St. Thomas’s; St. Bartholomew’s, which had been a priory with a house for the care of the poor, but was now turned into a hospital; Bethlehem, afterwards Bedlam; Bridewell, and Christ’s Hospital, the first of which afterwards became a prison, while Christ’s Hospital, though retaining its name, became a school. The Five Royal Hospitals, as they were called, were either founded, or received a great stimulus and thorough reorganization, during the thirteenth century.

It would be easy to suppose these hospitals were rather rude structures, inexpertly built, poorly arranged, and above all badly lighted and ventilated. They might be expected to furnish protection from the elements for the poor, but scarcely more, and probably became in the course of time hotbeds of infection because of their lack of air and uncleanness. As a matter of fact, they were almost exactly the opposite of any such supposition. Those in the larger towns at least were model hospitals in many ways, and ever so much better than many hospital structures erected in post-medieval centuries. Indeed, the ordinary impression as to the medieval hospitals, and their lack of suitability to their purpose, would apply perfectly to the hospitals of the latter half of the eighteenth and the early nineteenth centuries. It is because our generation still has the memory of these hospitals of the past generation, and assumes that if these were so bad, the hospitals of an earlier time must have been worse and the hospitals of the medieval period must have been intolerable, that the derogatory tradition with regard to medieval hospitals and many other medical subjects maintained itself until the coming of real information with regard to them.The ecclesiastical architecture of the later Middle Ages was not only beautiful, but it was eminently suitable for its purpose, and above all provided light and air. The churches, the town halls, the monasteries and abbeys, were models in their kind, and it would have been quite surprising if the hospitals alone had been unworthy products of that great architectural period. As abundant remains serve to show even to the present time, they were not. The hospitals built in the thirteenth century particularly usually were of one story, had high ceilings with large windows, often were built near the water in order that there might be abundance of water for cleansing purposes, and also so that the sewage of the hospital might be carried off, had tiled floors that facilitated thorough cleansing, and many other provisions that the architects of our time are reintroducing into hospital construction. They were a complete contrast to the barrack-like hospitals with small windows, narrow corridors, cell-like rooms, which were built even two generations ago, and which represented the lowest period in hospital building for seven centuries.

LEPER HOSPITAL OF ST. BARTHOLOMEW, OXFORD

From “Medieval Hospitals,” by Miss R. M. Clay

Viollet le Duc, in his “Dictionary of Architecture,” has given a picture of the interior of one of these medieval hospitals, that of Tonnerre in France, erected by Marguerite of Bourgogne, the sister of St. Louis, in 1293, which we reproduce here. Mr. Arthur Dillon, discussing this hospital from the standpoint of an architect, says:

The hospital ward itself was 55 feet wide and 270 feet long and had a high arched ceiling of wood. The Princess herself lived in a separate building, connected with the hospital by a covered passage. The kitchen and storehouse for provisions were also in separate buildings. The whole hospital plant was placed between the branches of a small stream conducted around it, which served to temper the atmosphere, and was a source of water supply at one end of the grounds and helped in the disposal of sewage from the other end.

A hospital of the Holy Ghost which may be taken as the type of such structures is still standing at LÜbeck in Germany, and was, like the hospital at Tonnerre, also built during the thirteenth century. It was erected as the result of the movement initiated by Pope Innocent’s foundation of the Santo Spirito at Rome. The picture of this, in my “Thirteenth Century,” will serve to show what Holy Ghost hospitals in important cities at least were like. LÜbeck was one of the rich Hansa towns in the thirteenth century, but there were many others of equal importance, or very nearly so, and all of these towns were rivals in the architectural adornment of their municipalities, and particularly in the erection of cathedrals, town halls, guild halls, and other buildings for the use of citizens.

The older portion of the Hospital of St. Jean at Bruges also gives an excellent idea of a later medieval hospital as it was constructed in a populous commercial town. Bruges, almost needless to say, was one of the most important cities of Europe in the fourteenth century. The Hospital of St. Jean, then, was built, like the cathedral and churches and the town hall, so as to be worthy of the city’s prestige. The older part, which is now used for a storeroom, has the characteristics of the best medieval hospitals. The ward was one story in height, the windows were large, high in the walls, and the canals that flowed around the hospital made pleasant vistas for the patient, while the gardens attached were eminently suitable for convalescents. The phases of hospital building down the centuries can be studied at St. Jean, and, strange as it may seem, the oldest portion of the hospital, that of the medieval period, provided the most light and air for the patients and the best opportunity for thorough cleansing, as well as for occupation of the patients’ minds with details of the construction that were visible from any part of the ward.

The hospitals of the Middle Ages are particularly interesting, because they represent a solution of the social problems other than merely the relief of pain and suffering, or the care of the needy who have none to care for them. They represent a ready, constantly near opportunity for the better-to-do classes to exercise charity toward those who needed it most. The hospitals were always in the busiest portions of the towns, and were often visited by the citizens, both men and women. Dr. John S. Billings, in his description of “The Johns Hopkins Hospital” (Baltimore, 1890), touched upon this spirit of the hospital movement of the Middle Ages in a very appropriate way when he said:

“When the medieval priest established in each great city of France a Hotel Dieu, a place for God’s hospitality, it was in the interest of charity as he understood it, including both the helping of the sick poor, and the affording of those who were neither sick nor poor an opportunity and a stimulus to help their fellow-men; and doubtless the cause of humanity and religion was advanced more by the effect on the givers than on the receivers.”

A rather significant historical detail with regard to medieval hospitals is the foundation of a special order to take care of the hospitals in which St. Anthony’s Fire, or what we know as erysipelas, was treated. Apparently this indicated the recognition of the contagiousness of this disease by the medieval people. Pope Honorius III. approved the foundation of an order of nurses particularly devoted to the care of patients suffering from this affection. Other religious congregations for the same works seem to have been established. We did not recognize the contagiousness of the disease until the last generation. Undoubtedly these special foundations made it possible to control many of the epidemics of erysipelas that used to make surgical care in our hospitals in the modern time such a difficult matter. Even as late as our Civil War here in America, erysipelas was the special dread of the hospital surgeon. Oliver Wendell Holmes pointed out that erysipelas might readily be carried to the parturient woman with the production of child-bed fever. It is interesting to realize, then, the attempt of the medieval period to segregate the disease.

THE HARBLEDOWN HOSPITAL, NEAR CANTERBURY

From “Medieval Hospitals,” by Miss R. M. Clay

“On the outskirts of a town, seven hundred years ago, the eye of the traveller would have been caught by a well-known landmark—a group of cottages, with an adjoining chapel, clustering round a green enclosure. At a glance he would recognize it as the lazar-house, and would prepare to throw an alms to the crippled and disfigured representative of the community.”]

Besides hospitals, a series of lazarettos—that is, of buildings for the segregation of lepers—were erected in the various countries of Europe during the medieval period. Just about the end of the Crusades it was discovered that leprosy had become very common throughout Europe. It is often said that leprosy was introduced at this time, but it had evidently been in the West for many centuries before. Gregory of Tours mentions leper hospitals as early as 560, and the disease evidently continued to progress, in spite of these special hospitals, until in the thirteenth century it became clear that strenuous efforts would have to be made to wipe out the disease. Accordingly, leproseries were erected in connection with practically every town in Europe at this time. Baas estimates that there were some 19,000 of them in Europe altogether. Virchow has listed a large number of the leper hospitals of the German cities, quite enough to show that probably no organized community was without one.

As a consequence of this widespread movement of enforced segregation, leprosy gradually died out in Europe, remaining only here and there in backward localities. The disease was probably as common during the later Middle Ages as tuberculosis is among us at the present time. The recently discovered relations between the bacterial cause of the two diseases may give rise to the question as to whether we shall succeed as well with the great social and hygienic problem that confronts our generation, of lowering the death-rate from “the great white plague,” as the medieval generations did with their chronic folk-disease, leprosy. It would be “a consummation devoutly to be wished.” We are now beginning to have as many sanatoria for tuberculosis in proportion to the population as they had of leproseries. These leproseries, or lazarettos, as they were called, were not at all the dreadful places that the imagination has been wont to picture them in recent years; on the contrary they were, as a rule, beautifully situated on a side-hill to favour drainage, consisted of a series of dwellings with a chapel in their midst surrounded by trees, and encompassed by what was altogether a park effect. Miss Clay, in “Medieval Hospitals,” has given a picture of one of them, which we reproduce, because it serves to contradict the popular false notion with regard to the bare and ugly and more or less jail-like character of these institutions.