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.
[Illustration: 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.
[Illustration: 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:
"It was an admirable hospital in every way, and it is doubtful if we
to-day surpass it. It was isolated, the ward was separated from the
other buildings, it had the advantages we so often lose of being but
one story high, and more space was given to each patient than we can
now afford.
"The ventilation by the great windows and ventilators in the ceiling
was excellent; it was cheerfully lighted, and the arrangement of the
gallery shielded the patients from dazzling light and from draughts
from the windows, and afforded an easy means of supervision; while the
division by the roofless, low partitions isolated the sick, and
obviated the depression that comes from the sight of others in pain.
"It was, moreover, in great contrast to the cheerless white wards of
to-day. The vaulted ceiling was very beautiful; the woodwork was
richly carved, and the great windows over the altars were filled with
coloured glass. Altogether, it was one of the best examples of the
best period of Gothic architecture."
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.
[Illustration: 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.