HOSPITALS, NURSING AND CARE FOR THE INSANE
An excellent criterion of the social status of any period in history
is the genuine humanitarian purpose that animates it, and how
seriously it takes the duty of caring for those who most need care is
to be found in the character of its hospital buildings and their
maintenance. Tried by this standard, Columbus' Century proves to be
one of the greatest of the centuries of history. This will seem very
surprising to most people, because the general impression has been
that until our generation hospitals were rather ugly buildings of
institutional type, with small windows, sordid surroundings and very
unsuitable internal arrangements for the ailing. There is no doubt at
all that hospital buildings just before our generation--and some of
them unfortunately remain over as living witnesses--were all that has
been thus suggested and if possible worse. Indeed, some of the
hospital buildings of two generations ago were about as unsuitable for
their purpose as could well be imagined. The general feeling with
regard to this fact, however, is not so much one of blame as of pity.
Most people assume that the older generations did not know how to
build good hospitals. They did as well as they could, but until the
development of modern knowledge of hygiene and sanitation, as well as
the demand made on hospital administration by modern surgery,
hospitals could scarcely be expected to be anything but the sordid
piles of buildings they usually were, thought proper if they but
furnished a protection from the weather and sustenance for the sick
poor.
Anyone who will consult the real history of hospitals, however, will
be surprised to find that the worst hospitals in the world's history
were built in the first half of the nineteenth century. The usual
impression is that, if the hospitals of a {193} century ago were so
bad, those of the century preceding that must have been much worse and
so on progressively more unsuitable until in the Middle Ages they must
have been unspeakable. As a matter of fact, the hospitals of the
thirteenth and fourteenth centuries were beautiful buildings as a
rule, quite as charming structures for their purposes as all the other
architecture of that time--churches, monasteries, abbeys, castles,
town halls and the rest. They had at this time a period of wonderful
surgical practice, of which we have learned from the republication of
their text-books of surgery only in recent years, and there is a
definite, direct ratio between surgery and proper hospital
organization. Whenever there is good surgery there are good hospitals,
and whenever there are good hospitals, surgery will be found occupying
a prominent, progressive place in the history of medicine.
It is hard to understand the periods of decadence in hospital
construction and maintenance and in nursing care and training, but not
more difficult than to understand the ups and downs of surgery. That
anaesthesia and antiseptic practice should obtain for a while and then
gradually be lost is no harder to understand than that hospitals
should gradually "sink to an almost indescribable level of
degradation." Miss Nutting and Miss Dock, in their "History of
Nursing," have described the century from 1750 to 1850 as "The Dark
Period of Nursing."
They quote Jacobsohn, the well-known German writer about care for the
ailing, who says "that it is a remarkable fact that attention to the
well-being of the sick, improvements in hospitals and institutions
generally and to details of nursing care, had a period of complete and
lasting stagnation after the middle of the seventeenth century, or
from the close of the Thirty Years' War. Neither officials nor
physicians took any interest in the elevation of the nursing or in
improving the conditions of hospitals. During the first two-thirds of
the eighteenth century he proceeds to say nothing was done to bring
either construction or nursing to a better state. Solely among the
religious orders did nursing remain an interest and some remnants of
technique survive. The result was that in this period the general
level of nursing fell far below that of earlier {194} periods. The
hospitals of cities were like prisons, with bare, undecorated walls
and little dark rooms, small windows where no sun could enter, and
dismal wards where fifty or one hundred patients were crowded
together, deprived of all comforts and even of necessities. In the
municipal and state institutions of this period, the beautiful
gardens, roomy halls and springs of water of the old cloister hospital
of the Middle Ages were not heard of, still less the comforts of their
friendly interiors."
It so happens that just about the beginning of Columbus' Century there
was a great new development of hospital building. This was only what
might have been expected, for a wonderful new period of architecture
was just beginning and buildings of all kinds were being erected with
a magnificence that has made them the admiration of the world ever
since. Handsome basilicas, Renaissance palaces, town halls were being
executed by the architects of the time so as to make them precious
monuments for future generations. Hospitals came in for their share of
this renewal of architectural interest, and a series of really
beautiful hospital buildings were erected which we have come to admire
very much since we ourselves have wakened up to the duty of building
fine hospitals. The old municipalities felt that buildings erected for
the poorer citizens must not be planned with the idea that anything
was good enough for the poor, but must be suitable to the dignity of
the city.
One of the most beautiful hospitals of this time is the famous
_Ospedale Santa Maria degli Innocenti,_ which has been called the
finest and most interesting foundling asylum in the world. It was
built under the patronage of the guild of silk merchants in the early
part of the fifteenth century, being completed in 1451, and is a model
of charming architecture, decorated with fine paintings and adorned
with the well-known della Robbia blue medallions. The Italians did
not, however, call it--as in our ruder Northern ways is our custom--a
foundling asylum, thus stamping the tragedy of their existence on the
children, but the Home of Innocents. Surely they were the innocent
victims of the conditions which had brought about their abandonment by
their parents. The {195} children were kept until the age of seven,
and then they were placed about with families who promised to treat
them as their own children. The boys were taught trades; the girls,
trained in all domestic occupations, were, when married, given dowries
by the hospital or the foster parents, or received into convents if
they so wished. As showing how the spirit that organized it in
Columbus' Century lives on, we may quote what Miss Nutting and Miss
Dock say with regard to the hospital in their "History of Nursing" (p.
243):
[Illustration: BRAMANTE, GREAT COURT OF HOSPITAL (MILAN)]
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"To-day this richly historic house is in charge of the Sisters of
St. Vincent de Paul, under the direction of a highly scientific and
progressive council chiefly consisting of medical men, and is one of
the most perfectly kept and well managed institutions of the kind in
existence, its union of mediaeval charm with modern science being a
congenial and happy one."
Other hospitals in Florence are scarcely less interesting. The
hospital where Romola went to nurse her patients is still in
existence, but is no longer a hospital. It is now the very interesting
Accademia dei Belli Arti. One of the beautiful hospitals erected at
this time which may serve as a type of the buildings erected for
hospital purposes is the great Ospedale Maggiore of Milan. Important
portions of this were finished during Columbus' Century. One of its
courts is so beautiful that it has been attributed to Michelangelo,
though it seems more probable that it was due to that almost equally
great architectural genius, Bramante. The famous Santo Spirito
Hospital in the Borgo at Rome was rebuilt by Sixtus IV in the first
half of Columbus' Century and had many of the characteristics of the
best architecture of the time. Practically every city in Italy did
some really fine hospital building at this time. Naples and Venice
added to their beautiful mediaeval hospitals and everywhere there was
high development of humanitarian purpose in this regard.
Italy, however, was not the only country of Europe to have fine
hospitals. Indeed, every country had a share in this, and wherever
there was a flourishing period of architectural evolution hospitals
came in for their share of the development. In the Low Countries and
Northeastern France, where a series of beautiful cathedrals and
churches were being rebuilt or newly erected, and above all where the
magnificent town halls that have been such a subject for admiration
ever since were being erected, hospitals received great attention. Not
only were fine buildings erected, but a magnificent organization of
nursing and care for the ailing occurred. There was great prosperity
among the people, they were doing the trade of the world, they were
democratic in their ideas and they felt that the dignity of the
municipalities required worthy care for the citizens no matter how
poor they might be.
[Illustration: MEMLING, MARTYRDOM OF ST. URSULA
(BRUGES. HOSPITAL OF ST. JEAN)]
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Above all, some of our own ideas in hospitals developed among them and
many of the wealthy came to realize that they could be better cared
for in the efficient hands of trained attendants in properly arranged
hospital quarters than in their own homes. There was not that dread of
hospitals which develops whenever they are exclusively for the
poor--and deservedly, because the patients are inevitably the subject
of many abuses.
That picturesque Belgian community, the Beguines, had charge of a
number of hospitals at this time which became famous for their
thorough organization and maintenance on a high level of efficiency.
One of these was founded at Beaune by Nicolas Rolin, chancellor of the
Duke of Burgundy, just about the beginning of Columbus' Century. Miss
Nutting and Miss Dock, in their "History of Nursing," have given a
description (p. 269) of this, as well as some of the details of the
nursing and management mainly taken from Helyot's "History of the
Religious Orders":
"It was built with much magnificence, with long wards extending into
a chapel, so that the sick could hear the services, and opening into
square courts with galleries above and below. Patients of both sexes
and of all ranks and degrees were received, both rich and poor.
There was one ward for those most seriously ill, and back of all a
building for the dead, with 'many lavatories and stone tables.' In
the upper galleries were suites of apartments for wealthy patients,
and the gentlefolk came from leagues around. The suites consisted of
a bedroom, dressing-room, anteroom and cabinet. They were richly
furnished, and each patient had three beds, that he might move from
one to another. Each apartment had its own linen, utensils and
furniture, 'and borrowed nothing from any other.' The suites and
wards were named after the King, royal family, dukes of Burgundy,
and other prominent personages. In the middle wards patients of the
middle class were received, and in the lower galleries the poor. The
rich patients had their own food and wine sent to them, and paid for
their medicines, but the rooms and the sisters' services were free.
Few, however, left without bestowing a gift. The poor were cared for
without any cost, but if they wanted {198} anything special they had
to buy it. A little river ran through the court and was carried in
canals past the different departments for drainage. It was noted
that the hospital had no bad odors, such as were found in so many
others, but was sweet and clean."
The conditions in these hospitals of Columbus' Century were so much
better than we have had any idea of until recent historical studies
revealed them to us, and so many people have somehow become persuaded
that hospitals of the olden time were without proper provision for the
care of the sick, such as we have elaborated again in our time, that
descriptions of other hospitals seem necessary to make the hospital
organization of the time clear. Miss Nutting and Miss Dock declare
that "the hospital at Chalons sur Saone was also very magnificent, and
there, too, there were no bad odors, but in winter delicate perfumes
and in summer baskets of growing plants hung from the ceiling. It had
a large garden with a stream running through it with little bridges
over it." It is easy to understand what a charming place for
convalescents and what a pleasant view for patients could be made out
of such surroundings. There is no doubt that they were well taken
advantage of, for this is the time of the beautiful Renaissance
gardens, when everywhere natural beauty was cultivated to a good
purpose.
Helyot, in his _"Les Ordres Monastiques."_ describes the beautiful
drug rooms in these hospitals, where the various medicaments were
prepared, many of them being grown in the hospital garden, and also
the other rooms of the hospital, the quarters for the nursing sisters,
and says that "the patients were nursed with all the skill and
goodness of heart and refinement that might be expected from the
conditions surrounding them." He appreciated very well that proper
quarters for patients and nurses make strongly for such nursing
conditions as are sure to be of the greatest possible help in the care
of diseases.
A special nursing order of Beguines was formed at this time, and as
these religious women were recruited as a rule from the better classes
of the population, bringing in with them such dowries as would enable
them to support {199} themselves in whatever work they might
undertake, it is easy to understand on what a high plane the nursing
must have been. It would remind one of the conditions in the early
days of the trained nurse in modern times, when so many of the
applicants for nursing positions were prepared by their family life at
home for devotion to a liberal profession rather than merely the
taking up of an occupation necessary for livelihood.
How their efforts were appreciated by patients will be very well
understood from what may still be seen at the hospital of St. Jean at
Bruges. The great painter Memling was for a time a patient in the
hospital. He felt that he owed his life to the good sisters who had
done so much for him, and so he painted a great altar-piece for them
and decorated the famous Shrine of St. Ursula. The pictures were
painted just about the time that Columbus discovered America. They are
among the most beautiful examples of religious painting ever made. The
decorations of the shrine particularly are among the world's great
works of art. They are almost miniatures and contain large numbers of
faces, beautifully executed, but every detail has been worked out by
the great painter, evidently as a labor of love. The texture of some
of the garments as he reproduces them has proved a source of wonder to
artist visitors ever since. Many thousands of visitors find their way
to the hospital every year, and even the small sum of money (twenty
cents) which is charged for admission to see them constitutes in the
annual aggregate an income of thousands of dollars. The hospital,
which is very spacious and has large gardens with the canal winding
alongside of it, is enabled to carry on its work much better as a
consequence of this notable addition to its revenues due to the
gratitude of a patient of over four hundred years ago.
Many of these hospitals had beautiful decorations. They understood
very well at that time that patients' minds must be occupied if they
are to be saved from the depressing effect of too much thinking about
themselves, and they felt that staring at bare walls was not conducive
to diversion of mind. In many of these hospitals then there were
beautifully {200} decorated walls and great pictures in the corridors.
As these were painted directly on the wall, as a rule they did not
collect dust nor present opportunities for dirt to gather.
Helyot has insisted on the ample water supply that they made it a rule
to secure for these old-time hospitals. It was felt that the plentiful
use of water was absolutely essential for maintaining healthy
conditions in hospital work. In our modern time we have come more and
more to realize that, while antiseptics are of great value once
infection has taken place and dirt has found an entrance, soap and hot
water are the best possible materials, especially when frequently
applied, to maintain sanitary conditions.
Many of the habits worn by the religious who were devoted to nursing
had certain features that made them much more hygienic for patients
than ordinary feminine dress. As a rule, they were very simple, often
made of washable materials, the head was always covered and spotless
white was worn around the shoulders and at the wrist. This was
sufficient of itself to keep constantly in mind the necessity for
scrupulous cleanliness. Dirt showed very readily. When the nurses, or
at least those who had the main duties to perform, came of refined
families and wore these habits there could have been no neglect of
cleanliness.
The best possible evidence for the proper appreciation of the place of
hospitals in life at this time is to be found in Sir Thomas More's
account of the hospitals in Utopia. It must not be forgotten that he
was travelling in Flanders when he wrote it. He pictures the people of
his ideal republic as possessed of fine large hospital buildings,
providing ample accommodations so that even in times of epidemic there
need be no danger of contagion and abundantly supplied with all that
is necessary for the care of the ailing. The standard was not what was
good enough for the ailing poor, but what was worthy of the dignity of
the city caring for its citizens. The proof of the completeness of
their arrangements for the care of patients is to be found in the
added declaration that practically everyone who was sick preferred to
go to the hospital rather than to be cared for at home. This is the
condition of affairs which is now developing among us again, {201}
after a long interval, during which hospitals were the dread of the
poor and the detestation of those who had to go to them. The whole
passage is extremely interesting for this reason:
"But they take more care of their sick than of any others; these are
lodged and provided for in public hospitals. They have belonging to
every town four hospitals, that are built without their walls and
are so large that they may pass for little towns; by this means, if
they had ever such a number of sick persons, they could lodge them
conveniently, and at such a distance that such of them as are sick
from infectious diseases may be kept so far from the rest that there
can be no danger of contagion. The hospitals are furnished and
stored with all things that are convenient for the ease and recovery
of the sick; and those that are put in them are looked after with
such tender and watchful care, and are so constantly attended by
their skilful physicians, that as none is sent to them against their
will, so there is scarce one in a whole town that, if he should fall
ill, would not choose rather to go thither than lie sick at home."
The spirit of the century and its power of organization of charity and
good works is well expressed by the foundation of the Brothers of
Mercy in Spain, in 1538, by a Portuguese soldier who had been wounded
in battle, as was not infrequent in those days, and vowed to devote
his life to God if he recovered. He rented a small house in Granada,
where he gathered together a number of sick people and nursed them
with the greatest care. In order to support them he went through the
streets in the evening with a basket begging for his patients. After a
time others came and joined him in his good work. Alms boxes were
placed here and there through the city to remind people of the help
that was needed. Gradually the scope of their work increased, they
were given charge of hospitals, they visited the sick at their homes
and the order spread not only over Europe but throughout the
Spanish-American countries on this continent. Within a hundred years
after the foundation the annual number of patients under their care
was said to have been some two hundred thousand. A number of houses of
the order was {202} founded in Italy, and over their alms boxes down
there the sign was, _Fate bene, fratelli_, (Do good, little brothers).
From this sign they came to be known as the _Fate Bene Fratelli_, the
Do Good Little Brothers.
The proper care of the insane is usually looked upon as a very modern
phase of humanitarian evolution. Most people think that until the last
hundred years the insane have been hideously neglected, when not
treated with absolute barbarity, and that the rule has been simply to
put them away so that they could not injure themselves or others,
confining, manacling, and otherwise hampering their activities,
regardless of their health or the mental effect on them. In this once
more, as in most of the historical ideas with regard to humanitarian
development, the erroneous notions are due to the fact that the care
for the insane was at its lowest point during the eighteenth and the
early part of the nineteenth century, and that there has been a
magnificent improvement since, though it must not be forgotten that
there has not been a single generation since when there have not been
very serious complaints deservedly uttered of awful neglect of the
insane in some part of the civilized world. We have had revelations
with regard to the care of the insane in the country districts of even
our Eastern States which have been almost incredible. The conditions
that we have come to learn as existing in the South in the care of the
insane, which have been brought to light by the recent investigation
of pellagra, have been of a similar character. The epithet mediaeval
which is applied so often to these conditions is absolutely
unwarranted by our present knowledge of old-time care of the insane.
It has been concluded that, since care for the insane was so neglected
in the eighteenth century, it must have been almost infinitely worse
in preceding centuries. The same fallacy lies at the root of a great
many false impressions with regard to mediaeval and Renaissance
history. The eighteenth was the lowest of centuries in art,
literature, education, and humanitarian purpose. The preceding
centuries exhibit some very interesting developments of care for the
insane, some of which anticipate our most modern ideas. At Gheel in
{203} Belgium, from the earlier Middle Ages, they cared for defectives
on the village plan. Similar institutions were not infrequent. They
developed the "open door" system of caring for the insane and insane
institutions were mainly in connection with monasteries, well out in
the country, and under good conditions, since they were never crowded.
It is always crowding that brings serious abuses with it and leads to
what seems to be barbarity, but is really an inability to cope with
the large problem with inadequate means.
It so happened that just before the beginning of Columbus' Century
there was a special development of care for the insane and the opening
of a series of hospitals that represent an epoch in the history of
care for these poor people. The most important part of this
development of the fifteenth century occurred in Spain. Asylums were
founded at Valencia, Saragossa, Seville, Valladolid and Toledo. This
movement has sometimes been attributed to Moorish or Mohammedan
influence, but even Lecky, in his "History of European Morals," has
rejected these assertions which are absolutely without proof. Spain
continued to be the country in which lunatics were best cared for in
Europe down to the beginning of the nineteenth century. Pinel, the
great French psychiatrist who struck the manacles from the insane of
France, declared Spain to be the country in which lunatics were
treated with most wisdom and most humanity. In his book on "Mental
Alienation" he gives some details of the treatment which show a very
modern recognition of the need to be gentle and careful of the insane
rather than harsh and forceful.
In England a rather important development of care for the insane
occurred during this century in connection with Bedlam Hospital,
London. This, originally founded as a home for the suffering poor, as
its name Bethlehem (house of bread) implies, whether they had any
specific ailment or not, came after a time to be a hospital, and then
as a further development confined its care to the insane. Tyndale is
the first to use the word Bedlam as meaning a madhouse or a madman, so
that the conversion had evidently taken place in his time. One very
interesting custom developed which serves to show the mode of
treatment practised. A "bedlam" came to {204} signify one who had been
discharged from this hospital with the license to beg. After recovery
from their acute conditions the insane were allowed to go out on
condition, if there was no one to care for them, that they wore a tin
plate on their arms as a badge to indicate that they had been for a
time in the asylum. This tin plate aroused the sympathy of those they
met and they were helped in various ways by the people of the time.
Besides, it served as a warning that, since such people had been for a
time in the asylum, they were not to be irritated nor treated quite as
other folk, but on the contrary to be cared for. They were known as
bedlamers, bedlamites or bedlam beggars. They were treated so well
that tramps and other beggars of various descriptions obtained
possession of badges and abused the confidence of the public.
After Henry VIII's time Bedlam, which had been a religious
institution, passed under the care of the state, and from this time on
the story of abuses of all kinds is repeated at successive
investigations in every other generation. Evelyn, in his "Diary of
1656," notes that he saw several poor creatures in Bedlam in chains.
In the eighteenth century it became the custom for those seeking
diversion and entertainment to visit Bedlam and observe the antics of
the insane patients as a mode of amusement. This was done particularly
by the nobility and their friends. A penny was charged for admission
into the hospital, and there is a tradition that at one time an annual
income of L400 accrued from this source. This would mean that one
hundred thousand people had visited the hospital in the course of a
year. Some of Hogarth's pictures show the hospital being visited in
this way by fashionable ladies.
In Rome the Popes, recognizing the superiority of the care for the
insane as practised in Spain and in Navarre, opened a Pazzarella at
Rome in the sixteenth century under the care of three Navarrese. This
hospital for the insane "received crazed persons of whatever nation
they be and care is taken to restore them to their right mind; but if
the madness prove incurable they are kept during life and have food
and raiment necessary to the condition they are in." Evidently they
{205} looked for improvement in many cases and expected to allow the
patients to leave the asylum at least for a time, though if their
alienation continued they were kept. Just about the end of Columbus'
Century a Venetian lady of wealth, evidently attracted by the kind of
care given the insane, "was moved to such great pity of these poor
creatures upon sight of them that she left them heirs to her whole
estate. This enabled the management with the approbation of Pope Pius
IV to open a new house."
It is after the sixteenth century that decadence in the care of the
insane becomes very marked. This reached its climax, as might well be
expected, just about the same time that hospitals and care for the
ailing reached their lowest ebb of efficiency. Burdett, in his
"Hospitals and Asylums of the World," London, 1901, gives his third
chapter the title, "The Period of Brutal Suppression in Treatment and
Cruelty, 1750 to 1850." This decadence was largely due to the fact
that institutions for the care of the insane became State asylums,
with hired attendants, whose only interest after a time was the
drawing of their salary and having as little trouble as possible with
the care of the insane. In the previous centuries they had been under
the care of the religious orders.
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