The Foundation Of City Hospitals
( Originally Published 1911 )
Probably the most important work that the Popes did for medical science in the Middle Ages was their encouragement of the development of a hospital system throughout Christianity. The story of this movement is not only interesting because it represents a coordination of social effort for the relief of suffering humanity, but also because it represents the provision of opportunities for the study of disease and the skilled care of the ailing such as can come in no other way. Those who are familiar with the history of medicine, and especially of surgery, know that a great period of progress in these departments came during the thirteenth century. The next two centuries indeed represent an epoch of surgical advance such as was probably never surpassed and only equalled by the last century. This seems much to say of a medieval century 700 years ago, but our chapter on surgery will, I think, amply justify the assertion. The reasons for this great development in surgical knowledge are properly understood only when we come to realize that there was a corresponding development in hospital organization. These two features of medicine always go hand in hand. The hospitals, as might be expected, preceded the surgical development, and owed their great progress at this time mainly to the Popes.
The city hospital as we have it at the present time, that is, the public institution meant for the reception of those suffering from accidents, from acute diseases of various kinds, and also for providing shelter for those who have become ill and have no friends to take care of them, is an establishment dating from the beginning of the thirteenth century. It will doubtless be a surprise to most people to be told that the modern world owes this beneficent institution to the fatherly watchfulness, the kindly foresight, and the very practical charity of one of the greatest of the Popes, whose name is usually associated with ambitious schemes for making the Papacy a great political power in Europe, rather than as the prime mover in what was probably the most far-reaching good work of supreme social significance that was ever accomplished.
At the beginning of the thirteenth century, mainly as the result of those much abused sources of many benefits to mankind in the Middle Ages, the Crusades, the people of Europe had begun to dwell together in towns much more than before. It is closeness of population that gives rise to the social needs. While people were scattered throughout the country diseases were not so prevalent, epidemics were not likely to spread, and the charitable spirit of the rural people themselves was quite sufficient to enable them to care for the few ailing persons to be found. With the advent of even small city life, however, came the demand for hospitals in the true sense of the word, and this need did not long escape the watchful eye of Innocent III. He recognized the necessity for a city hospital in Rome, and in accordance with his very practical character and wonderful activity, at once set about its foundation.
As was to be expected from his wise foresight, he did not do so without due consideration. He consulted many visitors to Rome and many distinguished medical authorities as to what they considered to be the best conducted and most ably managed institution for the care of the sick in Europe at that time. Almost by common con-sent he was assured that the most successful hospital management was to be found at Montpelier. This French town near the shores of the Mediterranean had succeeded to the medical prestige formerly held by Salerno, and was now the favorite place of pilgrimage for the nobility and reigning sovereigns of Europe, whenever they became so ill that their ordinary medical attendants seemed to be able to do nothing for them. Pope Innocent was further told that the institution at Montpelier which was best conducted was undoubtedly the Hospital of the Fathers of the Holy Spirit.
Accordingly, the Pope extended an invitation which, under the circumstances, must have been practically a command, to Guy or Guido of Montpelier, the administrative head to whom the hospital there owed its successful organization, to come to Rome and establish a hospital of his order in the Papal capital. He provided the order with a sufficient foundation in what is now known as the Borgo, not far from the present Vatican. On this was erected, at the beginning of the thirteenth century, a hospital of the Holy Spirit, which still exists there, though, of course, the building has been many times renewed since the original foundation. This hospital of the Holy Spirit soon attained a world-wide reputation for careful nursing and medical' attendance and for the discretion with which its surgical cases were treated. It was understood that all the ailing picked up on the streets should be brought to the hospital, and that all the wounded and injured would be welcomed there. Besides, certain of the attendants of the hospital went out every day to look for any patients who might be neglected or be without sufficient care, especially in the poorer quarters of the city, and these were also transported to the hospital. This old Santo-Spirito. hospital then was exactly the model of our modern city hospitals.
Pope Innocent's idea, however, was not to establish a hospital at Rome alone, but his fatherly solicitude went out to every city in Christendom. In accordance with this pre-determined plan, by personal persuasion, by the display of an interest in hospital work, and by official Papal encouragement he succeeded in having, during his own pontificate, a number of hospitals established in all parts of the then civilized world on the model of this hospital of the Holy Ghost at Rome. The initiative thus given proved lasting, and even after the Pontiff's death hospitals of the Holy Ghost continued to multiply in various parts of Europe, until scarcely a city of any importance was without one.
It is no less a person than Virchow, the greatest of modern medical scientists, who has traced the origins of the modern German city hospitals back to Innocent and given us a list of those which were established during the century following his pontificate. Here are the names of those towns from Virchow's list in which hospitals were founded during the thirteenth century in Germany alone, which will show very convincingly how widespread the hospital establishment movement was : Zurich, St. Gallen, Bern, Basel, Constanz, Villingen, Pfullendorf, Freiburg, Breisch, Stephansfelden, Oppenheim, Mainz, Speyer, Coblenz (an der Leer), Cologne, Crefeld, Ulm, Biberach, Rothenburg, Kirchheim, Mergentheim, Wimpfen, Reutlingen, Memmingen, Augsburg, Rothenburg a. Tauber, München, Frankfort a. M., Hoxter, Dortmund, Brandenburg, Spandau, Salzwedel, Stendal, Berlin, Perleberg, Pritzwalk, Halberstadt, Halle, Quedlinburg, Helmstedt, Magdeburg, Sangerhauson, Eisenach, Naumburg, Hanover, Gottingen, Northeim, Bremen, Hamburg, Lübeck, Parchim, Wismar, Rostock, Schwerin, Mollen, Oldeslo, Ratzelburg, Ribnitz, Stettin, Stralsund, Greifswald, Demmin, Anclam, Breslau, Bunzlau, Gorlitz, Brieg, Glatz, Sagan, Steinau, Glogau, Inowraclaw, Wien, Meran, Brixen, Sterzing, Elbing, Thorn, Königsberg, Danzig, Marienburg, Riga.
Many of these towns were comparatively small. In fact, there were no cities that we moderns would call large in the thirteenth century. London had probably not more than some twenty thousand ; Paris, even at the most flourishing period of the university, under fifty thousand. Most of the German towns had less than ten thousand, and of these which are the sites of hospital foundations mentioned by Virchow, probably not more than a dozen, if that many, had more than five thousand inhabitants. Since the movement spread even to such small towns, it can be readily understood how far-reaching in its effects was the policy initiated by Innocent III. and how thoroughly he laid the secure foundations of a great Christian hospital system.
Since the Papal example and recommendations produced so much effect upon Germany, which was not so closely united to the Holy See as were the Latin nations, it is easy to understand what an impetus to the hospital movement must have been given in the southern countries, even though we have not had the advantage of so patient a collector of information as Virchow to give us all the details. In the larger cities hospitals were already in existence, and these took on a new life because of the hospital movement. In Paris, for instance, the Hotel Dieu, which had been in existence for some time, be-came so cramped for room in its original location, just beyond the Petit Pont, that at this time it had to be transferred to its present commodious quarters next to the Cathedral, on the square of Notre Dame. The hospital became a city hospital in the genuine sense of the word, and the citizens became interested in it to a note-worthy degree. It began to be the subject of bequests and benefactions of all kinds on the part of the clergy and laity, and many interesting details of these benefactions are still at hand in documents contained in the hospital archives of Paris.'
There are some curious historical details in these old documents, since they serve to show the method in use for designating houses at that time when, it must be re-called, street numbers had not as yet been invented. Most of the houses had on their facades some image or figure by which they were known. The Hotel Dieu, for instance, acquired during the thirteenth century the houses with the image of St. Louis, with the sign of the golden lion of Flanders, with the image of the butterfly with that of the wolf, with the images of the three monkeys, with the image of the iron lion, with the cross of gold, with the three chimneys, etc. A certain amount for the support of the hospital was allowed out of the city revenues, and a favorite method was to permit, in times of special stress upon the hospital, the collection of a tax on all of a certain commodity that came into the city. For a time, for instance, during an epidemic or other period of necessity, a hospital would obtain permission to collect a tax on all the salt, or, occasionally, on all the wheat that entered Paris. This serves to show the renewed interest in city hospital affairs that had arisen mainly as the result of Papal initiative and encouragement.
In the smaller towns in France there was the same hospital movement as characterized the situation in Germany. In the south, the closeness of Montpelier made the example of the hospital of the Holy Ghost of that city especially forceful. In other portions of France it is well known that the Sisters of the Holy Ghost very early established separate hospitals from those founded by the Brothers of the Holy Ghost. There are records of such separate hospitals entirely under the control of Sisters in Bar-Sur-Aube, in Neuf-Chateau, and, according to Virchow, at many other places. At the same time, however, there still continued to be hospitals of the Holy Ghost as at Besançon, where the Brothers and Sisters of the Holy Ghost had their institutions in common, though there was a distinct separation of the communities and allotment of tasks. The Brothers cared rather for the surgical cases, while the care of the children and the pregnant women was confided to the Sisters. This of itself was rather an advantage, since the separation of the women and the children from the ordinary hospital patients, must have proved an important preventive of infection and an ameliorating factor as regards that hospital atmosphere especially likely to be unfavorable to these delicate, sensitive cases. We know now what hospitalisrn means for them.
That the influence of the movement initiated by Innocent III. was felt even in distant England is very clear, from the fact that practically all of the famous old British hospitals date their existence as institutions for the care of the ailing from the thirteenth century. The famous St. Bartholomew's Hospital in London had been a priory founded at the beginning of the twelfth century, which took care of the poor and the destitute sick, but at the beginning of the thirteenth century it became, in imitation of the Hospital of the Holy Spirit at Rome, frankly a hospital in the modern sense of the word. St. Thomas's Hospital, which continues to be down to the present time one of the great medical institutions of London, was founded by Richard, Prior of Bermondsey, in 1213. Bethlehem, or as the name was softened in the English speech of the people, Bedlam, was founded about the middle of the thirteenth century. Originally it was a general hospital for the care of the sick of all kinds, though in later times it became, as its name has come to signify in modern English, a place exclusively for the care of the insane. Bedlam, in the fourteenth century, and probably also in the later years of the thir teenth, made provision for a certain number of the insane in addition to other patients, so that it presented the accomplishment of that desideratum for which we are striving in the twentieth century a city general hospital with psychopathic wards. This arrangement, as we have said in the chapter on the Church and the Mentally Afflicted, has many advantages over the special hospital for the insane, entrance to which, as a rule, re-quires tedious formalities.
Bridewell and Christ's Hospital, the other two of the institutions long known as the five royal hospitals of London, were either actually founded or received a great stimulus and a thorough reorganization during the thirteenth century. In the succeeding centuries Bridewell ceased to be a hospital and became a prison, while Christ's Hospital, though retaining its name, became a school. With some of these institutions the name of Edward VI. has become associated, but, as pointed out by Gairdner, the English historical writer, without any due warrant. Gairdner says in his History of the English Church in the Sixteenth Century, " Edward has left a name in connection with charities and education which critical scholars find to be little justified by fact." The supposed foundation of St. Thomas's Hospital, as he points out, was only the re-establishment of this institution, "and even when it was granted by Edward to the citizens of London, it was not without their paying for it." Many institutions, charitable and educational, had been destroyed by Henry VIII., and the crying need for them became so. great under Edward's reign that the government was compelled to provide for their re-establishment.
It is no wonder, with all this activity of the hospital foundation movement, that Virchow should have been unstinted in his praise of the Pontiff and of the Church responsible for the great charity. He said : "It may be recognized and admitted that it was reserved for the Roman Catholic Church, and above all for Innocent III., not only to open the bourse of Christian charity and mercy in all its fulness, but also to guide the life-giving stream into every branch of human life in an ordered manner. For this reason alone the interest in this man and in this time will never die out."
Even this was not all that he felt bound to say, and in his admiration he quite forgot the constant opposition he manifested toward the Papacy on all other occasions. This happened to be the one feature of Papal influence and endeavor that he had investigated most thoroughly, and one is tempted to wonder if like investigation in other directions would not have shown him the error of prejudiced views he harbored with regard to other phases of the beneficent influence of the Popes in history. More knowledge is all that is needed, as a rule, to overcome all the anti-Papal prejudices founded on supposed historical grounds.
Indeed, Virchow's tribute to Pope Innocent III. as the initiator of all this humanitarian work is so frank and outspoken that, coming as it does from a man whose sympathies with the Papacy were well known to be the slightest, it deserves to be recalled in its completeness, in order that another factor for the vindication of Innocent's character may be better known. The great pathologist said : " The beginning of the history of all of 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 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."
The quotation from Virchow gives a good and quite comprehensive idea of the scope of these institutions. The ailing of all kinds were received beneath their hospitable roof. In many cases the regulations for the reception of pregnant women and for the care of the foundlings are still extant, besides the hospital rules for the care of the various kinds of patients. The department set aside for the foundlings was in most places rather an allied institution than an integral part of the hospital itself. While these were called findel or found-ling houses in Germany, in Italy this harsh name was not used, but the institutions were termed hospitals for the innocents, thus emphasizing the most pitiable feature of the cases of the little patients, and not branding them for life with a name that suggested their having been abandoned by those who should have cared for them.
The regulations for the admission and care of patients are interesting as showing how much these medieval institutions tried to fulfill the ideal of hospital work. The people of the Middle Ages had not as yet suffered all the disillusionments that come from the abuse of charity at the hands of those who least deserve help, and besides, the attendants at the hospitals were expected to do their work for its own sake and from the highest motives of Christian benevolence rather than for any lesser reward. At the beginning, at least, there seems to be no doubt that this lofty purpose was accomplished very satisfactorily ; but men and women are only human, and after a time there was deterioration. Even Virchow, however, was so struck by the ideal conditions that existed in these early hospitals that he discussed the necessity for having in modern times hospital attendants with as unselfish motives as those of the medieval period. It seems worth while then to give some of the details of this supremely Christian management of hospital work.
In an article on the medieval hospitals in the Dublin Review for October, 1903, Elizabeth Speakman quotes from the statutes of various hospitals sufficient to show how the internal government of these charitable institutions was regulated. There was always a porter at the main door, usually one of the Brothers or Sisters, who had the power to receive patients applying for admission. At certain places, however, it seems to have been necessary to inform the superior ; and the statutes of the French Hospital at Angers say, that the prioress is to go herself without delay to receive patients or to send one of the Sisters for that purpose, " not severe or hard, but kind of countenance." At the same place the statutes say, " the number of the sick is not to be defined, for the house is theirs, and so all indifferently shall be received as far as the resources of the house allow."
From many of the hospitals members of the community were sent out from day to day to find out if there were any lying sick who needed care and who should be sent to the hospital. They were expected also to pick up any of the infirm whom they might find along the streets and bring them to the hospital. The attitude which the religious attendants at the hospitals were to assume toward the patients upon whom they wait is clearly stated. In nearly all of the French hospitals of the thirteenth century, at least, the statutes in this matter do not differ much from this specimen :
" When the patient arrives he shall be received thus : First, having confessed his sins to the priest, he shall be communicated religiously and afterward be carried to bed and treated there as our Lord, according to the resources of the house ; each clay, before the repast of the brethren, he shall be given food with charity, and each Sunday the epistle and gospel shall be read and aspersion with holy water made with procession."
As is noted by Miss Speakman, all through the hospital statutes of these times the name of Masters or Lords is applied to the patients. The expression in Old French is Les Seignors Malades. The ordinary name for hospital was Maison Dieu, which has been well translated "God's Hostelry." It is evident, then, though the origin of the phrase " Our Lords the Poor," as applied to hospital patients, has been said to be obscure, that it is only a re-echo of the scriptural expression, " Whatsoever ye shall do, even to the least of these, be-hold ye do it unto Me." A quotation which was emphasized in the old rule of St. Benedict, promulgated for the treatment of those received into the hospitality of the Benedictine monasteries, "All guests shall be received as Christ, who Himself has said, ` I was a stranger and ye took Me in.' "
In modern times, the necessity for providing for patients whatever within reason they may long for has often been insisted on. It is curiously interesting to find a striking anticipation of this very modern rule in the customs of these old-time hospitals. As a result of the attitude of supreme good will toward patients, there is an injunction in many hospital statutes, that whatever the patient may desire, if it can be obtained and is not bad for him, shall be given to him until he is restored to health. The Knights Hospitalers of St. John of Jerusalem followed the injunction so carefully and endeavored to satisfy even whims of their patients that might seem unreasonable to such an extent, that their conduct in the matter became proverbial and gave rise to at least one pretty legend, the hero of which is no less a personage than the famous Eastern Sultan of the later Crusade period.
" Saladin desiring to prove for himself this reputed indulgence of the knights to their patients, disguised himself as a pilgrim and was received among the sick in the hospital in Jerusalem. He refused all food, declaring that there was only one thing that he fancied, and that he knew they would not give him. On being pressed, he confessed that it was one of the feet of the horse of the Grand Master. The latter, on being acquainted with this fact, ordered that the noble animal should be killed and the sick stranger's desire satisfied. Saladin at this point, thinking the experiment had gone far enough, declared himself taken with a repugnance to it, so the animal was spared."
Virchow studied very faithfully the management of these medieval hospitals, and was evidently quite impressed with the success with which difficulties had been met and overcome. None knew better than he all the difficulties there were in hospital management, for during nearly fifty years he had been identified with many hospitals, from city charity institutions to the various kinds needed for war and those erected in connection with universities for teaching purposes. He had very little patience with religious formule, and was indeed a typical agnostic. Notwithstanding this, he has been perfectly frank in confessing how much is accomplished by the religious management of the hospitals, and even did not hesitate to declare that if hospitals for the poor particularly, are to be successfully managed, there must be a change in the view-point of those who take up the work of hospital nursing, and the attendants must come from better social classes than is at present the custom. (This is of course for Germany.)
The question as to whether secular or religious management of hospitals shall prevail has not been as yet absolutely decided, and this adds to the value of Virchow's opinion. No one knew better than he of the many sacrifices required if the patients are to be properly cared for. Himself, as I have said, utterly without religion, it is curious to see how he recognizes the benefit that religious motives confer upon the management of a hospital, and how much better the work is likely to be done by those who give themselves up to the care of the sick as a Christian duty. He says :
"The general hospital is the real purpose of our time, and anyone who takes up service in it must give himself up to it from the purest of humanitarian motives. The hospital attendant must, at least morally and spiritually, see in the patient only the helpless and suffering man, his brother and his neighbor ; and in order to be able to do this he must have a warm heart, an earnest devotion, and a true sense of duty. There is in reality scarcely any human occupation that brings so immediately with it its own reward, or in which the feeling of personal contentment comes from thorough accomplishment of purpose.
" But so far as the accomplishment of the task set one is concerned, the attendant in the hospital has ever and anon new demands made upon him and a new task imposed. One patient lies next the other, and when one departs another comes in his place.
"From day to day, from week to week, from year to year, always the same work, over and over again, only forever for new patients. This tires out the hospital attendant. Then the custom of seeing suffering weakens the enthusiasm and lessens the sense of duty. There is need of a special stimulus in order to reawaken the old sympathy. Whence shall this be obtained from religion or from some temporal reward ? In trying to solve this problem we are standing before the most difficult problem of modern hospital management. Before us lie the paths of religious and simple care for the sick. We may say at once that the proper solution has not yet been found.
" It may be easy, from an impartial but one-sided view of the subject, to say that the feeling of duty, of devotion, even of sacrifice, is by no means necessarily de-pendent on the hope of religious reward, nor the expectation of material remuneration. Such a point of view, however, I may say at once, such a freedom of good will, such a warmth of sympathy from purely human motives as would be expected in these conditions, are only to be found in very unaccustomed goodness of disposition, or an extent of ethical education such as cannot be found in most of those who give themselves at the present time to the services of the sick in the hospitals. If pure humanity is to be a motive, then other circles of society must be induced to take part in the care of the sick. Our training schools for nurses must teach very differently to what they do at present, if the care of the sick in municipal hospitals shall compare favorably with that given them in religious institutions. Our hospitals must become transformed into true humanitarian institutions."
While some of this striking opinion of Virchow's was derived from personal experience with hospitals managed by religious, it must not be forgotten that such hospitals are rarer in Germany, at least in the north, than almost anywhere else in the world. His opportunities then were limited, and undoubtedly much of his favorable persuasions in this regard was founded on his investigation of conditions as he had learned to know them in the old-time hospitals of the later Middle Ages. The traditions as to the treatment of patients in these early times are such as to make us believe that hospital attendants did take their work seriously from a very lofty motive, and that while medicine and surgery were much less effective than in more modern times, the ten-der care of patients did as much as was possible to make inevitable suffering more bearable, and to keep the sight of painfully approaching death from being a source of discouragement and even of despair.
We have the best evidence, that of a contemporary, as to the conditions which obtained in these medieval hospitals, and the dispositions of the attendants as regards their religious duties would seem to be an unmistakable index as to their willingness to sacrifice their own comfort for the sake of the patients. The well known Jacques de Vitry, who had been Bishop of Acre and afterwards Cardinal, and whose wide travel had given him many opportunities to judge for himself, said :
"There are innumerable congregations, both of men and women, renouncing the world and living regularly in leper houses and hospitals of the poor, humbly and devoutly ministering to the poor and the infirm. They live according to the rule of St. Augustine, without property and in community and under obedience to one above them ; and having assumed the regular habit, they promise to God perpetual continence. The men and women, with all reverence and chastity, eat and sleep apart. The canonical hours, as far as hospitality and the care of the poor of Christ allow, by day and night they at-tend. In houses where there is a large congregation of brethren and sisters, they congregate frequently in chapter for the correction of faults and other causes. Readings from Holy Scriptures are frequently made during meals, and silence is maintained during meals in the refectory and other fixed places and at certain times. . . . . Their chaplains, ministering in spiritual matters with all humility and devotion to the infirm, instruct the ignorant in the word of divine preaching, console the faint-hearted and weak, and exhort them to patience and to correspond to the action of grace. They celebrate divine office in the common chapel assiduously by day and night, so that the sick can hear from their beds. Confession and extreme unction and the other sacraments they administer diligently and solicitously to the sick, and to the dead they give due burial. These ministers of Christ, sober and sparing to themselves and very strict and severe to their bodies, overflowing with charity to the poor and infirm and ministering with ten-der heart to their necessities according to their powers, are all the more lowly in the House of God as they were of high rank in the world. They bear for Christ's sake such unclean and almost intolerable things, that I do not think any other can be compared to this martyrdom, holy and precious in the sight of God."
It might perhaps be thought that these hospitals of the Middle Ages would be of very little interest to the modern student of things social and medical except for the fact, surprising enough in itself at this time of sup-posed neglect of social duties, when the paternal spirit of the municipality is presumed. scarcely to have developed as yet, that such institutions were provided. It would ordinarily be assumed that they were, in accordance with the lack of knowledge of the time as regards the influence of light and air on the ailing, dingy and unventilated, lacking most of the qualities that distinguish our modern hospital. As a matter of fact, how-ever, just as our architects go back to the Middle Ages to get models for our churches and municipal buildings, and even our millionaires' palaces and public institutions, they also find that in the matter of hospitals much valuable guidance is to be obtained from what was accomplished by these people of the Middle Ages, of whom we ordinarily think so little. Mr. Arthur Dillon, an architect, writing in the " Mail and Express " for May 7th, 1904, described the hospital founded by Marguerite of Bourgogne, the sister of St. Louis, at Tanierre in France in 1293. It consisted of a ward, a building attached to it by a covered passage in which Marguerite herself lived for many years, and separate buildings for kitchens, for storage of provisions and for the lodging of the twenty monks and nuns who had charge of the sick. A feature that perhaps we would not admire very much, was that adjacent to the buildings there was a cemetery. They were not so fearful about death in the Middle Ages, however, as we are apt to be ; and who shall say that the contemplation of it did not often give that restful sense of submission to whatever would come, that sometimes means so much in serious illness, and keeps the patient from still further exhausting vitality by worrying as to the outcome ? The medicine was stronger than our de-generate generation might be able to bear, but then all their medicines were apt to be stronger in that time.
The situation of the hospital might well be thought ideal. The princess had gardens about her lodging, and the whole property was surrounded by a high wall, along which flowed the branches of a small stream, which doubtless tempered the atmosphere and served as a carrier off of much undesirable material. The hospital ward itself was 55 feet wide and 270 feet long and had a high arched ceiling of wood. It was lighted by large pointed windows high up in the walls. At the level of the window-sills, some twelve feet from the floor, a narrow gallery ran along the wall, from which the ventilation through the windows might be readily regulated and on which convalescent patients might walk or be seated in the sunshine. The beds were placed each in a little room formed by low partitions. Privacy was thus secured much better than in the modern hospital wards, and as there were only forty beds, the ventilation was abundant.
Mr. Dillon, from the standpoint of the architect, says of it :
" It was an admirable hospital in every way, and it is doubtful if we today surpass it. It was isolated, the ward was separated from the other buildings, it had the advantage 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 ; is 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 colored glass. Altogether, it was one of the best examples of the best period of Gothic architecture."
Probably the most interesting feature of the early his-tory of the hospital movement is the spirit of evolution to meet growing needs and developing ideals which it manifested. In spite of the judicious consideration de-voted to the establishment of the original hospital of the Holy Ghost at Rome, it was not long before it proved inadequate for its purpose. One of the eminently note-worthy things that constantly repeat themselves in history is that where a social need is discovered and a remedy found for it, it is not long before the need in-creases to such a degree as to outstrip the original remedy. Before half a century had passed Innocent's successors declared in unmistakable terms that the original hospital was entirely too cramped and crowded. Accordingly, a much larger and handsomer building was erected. Visitors to Rome admired the new building, and it proved an incentive for larger plans for hospitals in other important cities. At the end of the thirteenth and the beginning of the fourteenth centuries some really imposing edifices were erected as hospitals, especially in towns of Italy. It was at this time that the artistic Italian mind seems to have realized the truth, which has only come to be recognized again in quite re-cent times, that a hospital building should be as fine a structure as the finances of a city will permit. It was felt that nothing was too good for the ailing citizens and that the city honored itself by making its public buildings a monument of artistic purpose. The earliest ex-ample of how well this was accomplished is to be found at Siena, whose hospital continues to be down to the present time one of the most interesting objects of admiration for the visitor. Portions of this Siena hospital as it now exists were built as early as the last decade of the thirteenth and the first decade of the fourteenth century. It was during the first half of the fourteenth century that it was resolved to make the building as beautiful in the interior by means of great artistic decoration and frescoes as it was imposing on the exterior. It was not for a century and a half later that Milan's magnificent hospital took on its modern shape, though the city had been always famous for its care of the sick. The hospital movement of the thirteenth century, how-ever, culminated in monuments as famous and as architecturally beautiful as any that have been built in recent years.
To take, for example, that of Siena, a good description of which may be found in The Story of Siena, by G. Gardner. (Dent, London, 1902.) The buildings occupy the whole side of the Piazzo del Duomo, directly opposite the facade. They constitute almost as striking a bit of architecture as any edifice of the period, and contain a magnificent set of frescoes, some of them of the fourteenth century, many others of later centuries. The Siena school of painting in the fourteenth century was doing some of the best art work of the time, and as a consequence the hospital has been of perennial inter-est. Artists and amateurs and dilettante visitors have gladly spent time in studying and admiring its artistic treasures at nearly all times, but more especially in re-cent years. The sympathetic admiration for its art has led to a better appreciation of the motives of the generation that built it, than even the sublime humanitarian purpose which dictated it or the work for suffering humanity which it accomplished.
It is typical of the times in many ways. We have only just begun again in very modern times, as we have al-ready said, to consider that some of the best of our buildings in any large city should be those intended for the sick and the poor of the community. The city must respond nobly to its civic duties. The idea, however, came so naturally to the medieval mind that apparently there was no question about it. Only in very recent years has come the additional thought that these buildings must be appropriately decorated, and that the work of the greatest artists of the time can have no better place for its display than the walls of a hospital or a great charitable institution. Bartolo's` frescoes, on the walls of the hospital at Siena, tell the story of the work that was done for foundlings and pilgrims as well as for the sick in the early days of its establishment, The first picture of the series represents the baptism of the children that had been picked up and brought to the hospital.
It is characteristic of the times, too, that one of the greatest pictures on the hospital walls is not something that makes for the glory of the trustees or the founders, nor that is some fancy of the painter, some study of myth or landscape, in which he might have been especially interested Probably the masterpiece of the old painters is the Scala del Paradiso (the stairs to heaven), by Vecchietta. The picture was evidently painted for the department of the foundlings, and its subject is the ascent of these little children to heaven and their welcome by the angels and saints and by the Heavenly Father. A more inspiring vision to be impressed upon the minds of these growing children who had been abandoned by their own, and who must have felt all of their loneliness in spite of their favorable surroundings, could scarcely have been imagined.
The dedication of the hospital is expressed in terms very typical of the Middle Ages, or as they might better be called, "The Ages of Faith." It reminds one of the formal terms of wills, as they used to be worded in olden times : "In the Name of God, Amen. To the honor, praise and reverence of God and of His Mother, Madonna, Holy Mary Virgin, and of all the saints of God, and to the honor and exaltation of Holy Mother Church and of the Commune and of the people of the city of Siena, and to its good and pacific state, and to the increase of the Hospital of Madonna, Holy Mary Virgin, of Siena, which is placed in front of the chief church of the city, and to the recreation of the sick and the foundlings of the said hospital." This dedication is to be found at the beginning of the statutes of the hospital as they were formulated in 1305.
The hospital did excellent service, and most of the original building has remained down to our own day. It has seen many times of trial for the citizens of Siena, and has proved its usefulness. Twice during the fourteenth century it saw the coming of the Black Death, and its wards and corridors and every room were filled with the dead and the dying. During the fourteenth century St. Catherine of Siena spent much of her time in the hospital, and it was her work here that gave her the glorious prestige that came so unlooked for. The special confraternity with which she was associated met in one of the smaller rooms of the hospital. Attached to the hospital there was a special house for lepers, and this was one of the favorite places for St. Catherine's visitations. It is not surprising to find that she was, at the beginning at least, very much opposed by her family in her choice of such an occupation as this personal devotion to the poor and the sick. In reading the story, one is reminded of the opposition that is sometimes evoked at the present time when young women feel the necessity for some occupation other than so-called social duties, and take to slum visiting, or the care of the cancer poor, or some other form of practical aid for the needy, apart from the giving of money, or of doing a little sewing in a Lenten class, supposed to be the limit of their charitable work in their special social circle.
It is of curious interest, though not surprising, to find that in the midst of the organization of new hospitals and reorganization of old hospital foundations in the thirteenth century, attempts were made to correct abuses which still continue to be some of the thorny problems of hospital management. For instance, the danger was recognized of having the expenses of ad-ministration outrun those of the hospital proper, and of having the number of attendants, or at least of persons living upon the hospital revenues, greater than was absolutely needed for the care of patients. There are various Papal decrees and decisions of diocesan synods in this matter. Pope Honorius III., who occupied the Papal See from 1216 to 1227, and must be considered as a very worthy successor of the first great Pope of the century, Innocent III., in approving the union of two hospital foundations at Ghent, required that only a certain limited number of Brothers and Sisters for nursing purposes should be received, in order that the community expenses proper might not impair to too great a degree the resources of the hospital for its real purpose of taking care of patients. Previously, he had insisted by a decree that the number of Brothers and Sisters in the hospital community at Louvain should not exceed the proportion of more than one to nine of the patients. Synodal decrees in various bishoprics allowed only board and clothing, but nothing more, to attendants in hospitals. In the thirteenth century the personal satisfaction of accomplishing a charitable work in attendance upon the sick was expected to make up for any further remuneration. '
The other serious problem of hospital management was to keep those not really suffering from serious disease, malingerers of various kinds, from occupying beds and claiming attention, to the deprivation of those who were genuinely ill. Various regulations were made looking to the careful examinations of such persons, though in most places with the affirmation of a standing rule, that all those complaining of illness were to be received into the hospital for at least one day, until their cases could be examined with sufficient care to decide how much of reality and how much of simulation there might be in their pretended symptoms. The tramp, of course, has always been in the world, and probably always will be, and so what are called the sturdy vagrants (validi vagrantes) received the special attention of those wishing to eliminate hospital abuses, and various decrees were made in order to prevent them from receiving sustenance from the hospitals, or in any other way abusing the privileges of these charitable institutions.
A hospital movement, quite distinct from that of Innocent III., which attracted so much attention shortly after the general hospital became common as to deserve particular consideration, was the erection of the leproseries or special institutions for the care of lepers. Leprosy had become quite common in Europe during the Middle Ages, and the continued contact of the West with the East during the crusades had brought about a notable increase of the disease. It is not definitely known how much of what was called leprosy at that time, really belonged to the specific disease now known as lepra. There is no doubt that many affections, which have since come to be considered as quite harmless and non-contagious, were included under the designation leprosy by the populace and even physicians incapable as yet of making a proper differential diagnosis. Probably severe cases of eczema and other chronic skin diseases, especially when complicated by the results of wrongly directed treatment or of lack of cleansing, were not infrequently pronounced to be true leprosy.
There is no doubt at all, however, of the occurrence of real leprosy in many of the towns of the West from the twelfth to the fifteenth centuries, and the erection of these hospitals proved the best possible prophylatic against the further spread of the disease: Leprosy is contagious, but only mildly so. Years of intimate association with a leper may, and usually do, bring about the communication of the disease to those around them, especially if they do not exercise rather carefully, certain precise precautions as to cleanliness after personal contact or after the handling of things which have previously been in the leper's possession. As the result of the existence of these houses of segregation, leprosy disappeared during the course of the next three centuries, and thus a great hygienic triumph was obtained by sanitary regulation.
This successful sanitary and hygienic work, which brought about practically the complete obliteration of leprosy in the Middle Ages, furnished the first example of the possibility of eradicating a disease that has once become a serious scourge to mankind. That this should have been accomplished by a movement that had its greatest source in the thirteenth century is all the more surprising, since we are usually accustomed to think of the people of the times as sadly lacking in any interest in sanitary matters. The role of the Popes in the mat-ter is another striking feature well worthy of note. The significance of the success of this segregation method was lost upon men down almost to our own time. This was unfortunately because it was considered that most of the epidemic diseases were conveyed by the air. They were thought infectious and due to a climatic condition rather than contagious, that is, conveyed by actual contact with the person having the disease or something that had touched him, which is the view now held. With the beginning of the crusade against tuberculosis in the later nineteenth century, however, the most encouraging factor for those engaged in it was the history of the success of segregation methods and careful prevention of the spread of the disease, which had been pursued against leprosy. In a word, the lessons in sanitation and prophylaxis of the thirteenth century are only now bearing fruit because the intervening centuries did not have sufficient knowledge to realize their import and take advantage of them.
Pope Innocent III. was not the only occupant of the Papal throne whose name deserves to be remembered with benedictions in connection with the hospital movement of the thirteenth century. His successor took up the work of encouragement where Innocent had left it at his death, and did much to bring about the successful accomplishment of his intentions in the ever wider spheres. Honorius III. is distinguished by having made into an order the Antonine Congregation of Vienna, which was especially devoted to the care of patients suffering from the "holy fire" and from various mutilations. The disease known as the holy fire seems to have been what is called in modern times erysipelas. During the Middle Ages it received various titles, such as St. Anthony's fire, St. Francis's fire, and the like, the latter part of the designation evidently being due to the striking redness which characterizes the disease, and which can be compared to nothing better than the intense erythema consequent upon a rather severe burn. This affection was much more common in the Middle Ages than in later times, though it must not be forgotten that its disappearance has come mainly in the last twenty-five years. It is now known to be a contagious disease, and indeed, as Oliver Wendell Holmes pointed out over half a century ago, may readily be carried from place to place by the physician in attendance. It does not al-ways manifest itself as erysipelas when thus carried, however, and the merit of Dr. Holmes's work was in pointing out the fact that physicians who attended patients suffering from erysipelas and then waited on obstetrical cases, were especially likely to carry the affection, which manifested itself as puerperal fever. A number of cases of this kind were reported and discussed by him, and there is no doubt that his warning served to save many precious lives.
Of course nothing of this was known in the thirteenth century ; yet the encouragement given to this religious order which devoted itself practically exclusively to the care in special hospitals of erysipelas, must have had no little effect in bringing about a limitation of the spread of the disease. In such hospitals patients were not likely to come in contact with many persons, and consequently the contagion-radius of the disease was limited. In our own time, immediate segregation of cases when discovered has practically eradicated it, so that many a young physician, even though ten years in practice, has never seen a case of it. It was so common during the Civil War and for half a century before that here in America, that there were frequent epidemics of it in hospitals, and it was generally recognized that the disease was so contagious, that when it once gained a foothold in a hospital ward nearly every patient suffering from an open wound was likely to be affected by it.
It is interesting then to learn that these people of the Middle Ages attempted to control the disease by erecting special hospitals for it, though unfortunately we are not in a position to know just how much was accomplished by these means. A congregation devoted to the special care of the disease had been organized, as we have said, early in the thirteenth century. At the end of this century this was given the full weight of his amplest approval by Pope Boniface VIII., who conferred on it the privilege of having priests among its members It will be remembered that Pope Boniface VIII. is said to have issued the bull which forbade the practice of dissection. That bull only regulated, as I have shown, the abuse which had sprung up of dismembering bodies and boiling them in order to be able to carry them to a distance for burial, which was in itself an excellent hygienic measure. His encouragement of the special religious order for the care of erysipelas must be set down to his credit as another sanitary benefit conferred on his generation.
Many orders for the care of special needs of humanity were established during the thirteenth century. It is from this period that most of the religious habits worn by women originate. They used to be considered rather cumbersome for such a serious work as the nursing and care of the sick, but in recent years quite a different view has been taken. The covering of the head, for instance, and the shearing of the hair must have been of distinct value in preventing the communication of contagious diseases. There has been a curious assimilation in the last few years of the dress required to be worn by nurses in operating rooms to that worn by most of the religious communities. The head must be completely covered and the garments worn are of material that can be washed.
It will be recalled that the head-dress of religious being, as a rule, of white, on which the slightest speck shows, must be renewed frequently, and therefore must be kept in a condition of what is practically surgical cleanliness. While this was not at all the intention of those who adopted the particular style of head-dress worn by religious, yet their choice has proved, in what may well be considered a Providential way, an excellent protective for the patients on whom they waited, against certain dangers that would inevitably have been present, if their dress had been the ordinary one of the women of their class, during these many centuries of hospital nursing by religious women.
In a word, then, all the features which characterize our modern hospitals, found a place in the old-time institutions for the care of the ailing, which we owe to the initiative of the Church and religious orders, and above all, the Popes. While we are accustomed to hear these old-time institutions spoken of slightingly, that is because our knowledge of them was not as detailed as it should be, until the recent interest in things medieval revealed many details previously misunderstood. The hospitals of the thirteenth, fourteenth and fifteenth centuries were much better than those of subsequent centuries down practically to our own time. The reason for this decadence is rather complex, but it evidently occurred in spite of the Church and the Popes. Much of it was due to the fact that, particularly in the sixteenth and seventeenth centuries, the political governments interfered in the work of charity and hospital management, and always to the detriment of it. The greatest triumph of the Church during the earlier centuries is to be found in the magnificent organization of the hospital system and the anticipation of so many things in the organization of hospital work, the care of patients and even the prevention of contagious disease, that we are apt to think of as essentially modern.