History of the

Hospitals have become the primary theaters of modern medical practice. The early history of these institutions dates from about 400 to 1600, and includes these developments: (1) the origins of hospitals; (2) their development in the Byzantine and Islamic worlds; (3) their history in medieval western Europe; and (4) their flowering in Renaissance Italy. For purposes of this discussion, the term hospital refers to an institution that focused on caring for patients and, if possible, curing them. Hospice describes an institution that offered food and shelter to the poor, travelers, and the homeless sick but did not maintain specific services, such as the attentions of physicians, to treat those who were ill.

Hospital Origins

Several early cultures developed institutions to care for the sick. Ancient Indian sources describe centers that dispensed medicines and engaged specially trained personnel to care for the ill. Classical Greek society produced the asklepieia, the temples of the god of medicine, where the sick sought divine and natural cures. The Roman Empire supported valetudinaria (infirmaries) providing medical care to legionaries stationed on the barbarous northern frontier. None of these institutions, however, was strong enough to survive the upheavals that destroyed much of ancient civilization in Eurasia between 200 and 600. Modern hospitals trace their origins, and even their name, not to Indian treatment centers, Greek asklepieia, or Roman valetudinaria but to the hospices and hospitals established by the Christian church during the late Roman Empire.

From its earliest days, Christianity demanded that its adherents aid sick and needy people. Christians believed that on the Last Day, God would judge according to the love one had shown those in need. Had one fed the hungry, sheltered the homeless, visited the sick (Matt. 25:31-46)? By the early second century, bishops such as Polykarp of Smyrna expected Christian clergy to take care of the sick, orphans, and widows.

Local Christian clergy assisted the unfortunate without any formal charitable institutions until the fourth century. Thereafter, in the eastern Greek-speaking provinces of the Roman Empire, the demand for charity became so great, especially in the larger cities, that specialized institutions called xenodocheia (hospices) appeared. By the 320s the church in Antioch operated a hospice to feed and shelter the poor of Syria. By the mid-fourth century, the pagan emperor Julian referred to hospices as common Christian institutions.

Before 360, Christian hospices did not focus attention on the sick; but during the 370s Basil, bishop of Caesarea in Asia Minor, opened an institution where physicians and nurses treated patients. Two decades later, Bishop John Chrysostom supervised hospitals in Constantinople where doctors tended the sick. By about 410, the monk Neilos of Ankyra considered the hospital physician a common figure in the Greek Christian world. These early hospitals thus evolved from simpler hospices by expanding their services to include free medical care for needy guests.

Christian bishops built hospices during the fourth century and subsequently created more specialized hospitals for the sick, not only because they wished to follow Christ's command to practice charity but also because they sought support for the new religion among the urban lower classes. During the fourth century the cities of the Eastern provinces experienced an influx of rural poor who migrated to towns in search of food and employment. Classical civic institutions could not feed, house, and care for these new residents. The local bishops used the expanding resources of the Christian church to build hospices and hospitals for these migrants, and thereby won support both from the many poor and from the urban aristocrats. When Emperor Julian (361-363) tried to halt the spread of Christianity, he emphasized that the "Galilaeans" had succeeded in part because of their charitable institutions.

Early hospitals met their expenses from the revenue of lands that local bishops had donated. Subsequently, wealthy aristocrats and the emperors augmented these resources. As Christianity expanded it destroyed some aspects of classical civilization, but others it simply reoriented. For example, Christianity wholeheartedly accepted the classical obligation of aristocrats to benefit local cities, but the Christian church

HOSPITAL, MEDIEVAL AND RENAISSANCE HISTORY OF THE •-

encouraged donors to endow institutions such as hospitals rather than traditional theaters, baths, and ornamental colonnades. By supporting hospitals a Christian aristocrat not only acted charitably but also fulfilled the classical duty toward the city. Moreover, such benefactions cemented local political support. This same combination of Christian morality, classical traditionalism, and political realism motivated emperors in their benefactions (Miller, 1985).

Hospitals of the Byzantine and Muslim Worlds

Hospitals developed most rapidly where they had first appeared, in the eastern half of the Roman Empire. The large cities of the eastern Mediterranean and the stable political conditions of the eastern Roman, or Byzantine, Empire fostered their hospitals' further evolution. By the late sixth century, Christian hospitals such as the Sampson Xenon (hospital) of Constantinople maintained specialized wards for surgery patients and those with eye diseases. Moreover, the premier physicians (archiatroi) of the Byzantine capital were assigned monthly shifts to treat patients in the Sampson and in other hospitals of the city. By the twelfth century the hospitals of Constantinople had evolved into relatively sophisticated medical centers. The Pantokrator Xenon maintained five specialized wards, seventeen physicians, thirty-four nurses, eleven servants, and a store of medicines supervised by six pharmacists. The Pantokrator treated outpatients as well as those who were hospitalized. Emperor John II (1118-1143), the founder of the Pantokrator, reminded the hospital's staff that the sick were God's special friends and that caring for patients was more important than maintaining buildings (Volk).

From their beginnings, the Christian hospitals of Byzantine cities were designed for the poor, but as these institutions became increasingly sophisticated medical centers served by the best physicians, some middle-class and a few wealthy patients began to use them. In this regard Byzantine practice differed markedly from the medieval West, where the bourgeoisie and nobility shunned hospitals as institutions solely for the destitute.

Medieval Islamic society maintained hospitals (in Persian, bimaristani) that equaled those of Byzantium. The first Islamic hospitals were founded in Baghdad during the reign of the caliph Harun al-Rashid (786-809). According to a governor of the caliph, Islamic hospitals had become common by the 820s; subsequently Muslims considered support of hospitals a mark of true piety.

Like Byzantine hospitals, bimaristani had evolved from earlier Christian philanthropic institutions in large cities of the Byzantine Empire. When Emperor Zeno expelled Nestorian Christians from Syria in 489, many sought refuge in Persia, where they established institutions, including hospitals, modeled on those in Byzantine cities such as Antioch. After the Muslims conquered Sassanid Persia in the seventh century, they came in contact with Nestorians. Impressed by Nestorian medical skills, they adopted many Syrian medical traditions—teaching methods, scientific texts, and hospitals—as models for shaping Islamic institutions.

Although Islamic hospitals evolved from Christian institutions, they experienced a unique development. They differed strikingly from their Byzantine counterparts by including separate sections for mental patients. Gradually these psychiatric wards became the most prominent features of bimaristani. Neither Byzantine nor medieval Western hospitals had wards for mental patients (Dols).

Medieval Western Europe

Hospitals developed more slowly in the western Roman Empire. Saint Jerome (ca. 331-420) mentioned two small hospitals near Rome about 400. During the early Middle Ages, however, social conditions retarded hospital development in western Europe. Barbarian invasions from the north and Muslim advances in Africa inhibited political, economic, and social life. Few towns of the size and complexity that could support medical centers such as the Byzantine and Muslim hospitals survived. In the domains of Charlemagne (768-814), hospitals did not evolve beyond simple hospices. As late as the thirteenth century, hospitals were rare in Europe. None of the 112 houses for the sick in medieval England provided physicians for their patients, nor did they stock any medicines (Carlin).

In the twelfth century, a new religious order, the Knights of the Hospital of Saint John of Jerusalem (known today as the Knights of Malta) reintroduced into Europe specialized medical care for the sick when they organized their renowned hospital in Jerusalem. Under Byzantine influence, the Knights' rule for this hospital mandated a permanent medical staff of four physicians and four surgeons to treat patients. Moreover, the Knights developed a unique philanthropic ethic by adapting feudal notions to the traditional Christian command to aid those in need. The Knights were to treat the sick in the Jerusalem hospital as vassals served their overlords. As the Knights expanded, they built many smaller hospitals in the towns of Europe where they introduced practices they had established in Jerusalem (Sire).

The Knights' hospital in Jerusalem inspired many similar institutions throughout western Europe. Using its

HOSPITAL, MEDIEVAL AND RENAISSANCE HISTORY OF THE -•

rule as a model, Pope Innocent III established in 1200 the famous Hospital of the Holy Spirit in Rome. In 1217 the church in Paris reorganized its ancient hospice, the Hôtel-Dieu, by drafting a new constitution based on the regulations of the Jerusalem hospital (Miller, 1978).

The Knights of Saint John had such a wide-ranging effect not only because their rule inspired western Europeans to help the needy, especially the sick, but also because Latin Christendom was entering a new phase of urban growth. As country dwellers migrated to the towns in growing numbers, these newcomers were exposed to a wider range of diseases. Hospitals became necessary to treat the rapidly growing number of sick among the urban poor. In fact, the economic and social conditions in the expanding towns of thirteenth-century Europe were remarkably similar to those in the fourth-century Byzantine cities where hospitals had first appeared.

An examination of the rule for the Roman Hospital of the Holy Spirit, however, indicates one important difference between the new institutions of the West and the Jerusalem hospital. The Roman rule mandated many of the Knights' practices, but it omitted any reference to physicians or surgeons. The same is true of the rule for the Hôtel-Dieu of Paris. Only gradually did physicians come to serve in these hospitals. The records of the Hôtel-Dieu do not mention a permanent staff physician until 1328. As late as the eighteenth century a physician visited Saint Bartholomew's Hospital in London only once a week. That trained doctors did not assume a major role in caring for patients in Western medieval hospitals distinguishes them from Byzantine xenones and Moslem bimaristani, where doctors not only treated the sick but supervised hospital administration.

It is also clear that some of the Western medieval hospitals did not provide care on the same level as did the Eastern medical facilities. The twelfth-century hospital at Saint-Pol in northern France maintained only six nurses (or nursing sisters) for sixty patients. Iconographic evidence indicates that at the Hôtel-Dieu in Paris patients sometimes shared beds. The wards of many medieval hospitals were also poorly heated. Conditions such as these no doubt made it difficult for hospitals to heal the sick and provided some support for the charges of later Enlightenment reformers that all medieval hospitals had in fact been death traps

(Miller, 1985). Renaissance Italy

Inspired by the Jerusalem hospital, the communes of Tuscany began building hospitals during the thirteenth century. Before 1300, for example, the town of Siena built an institution that differed from the Hôtel-Dieu of Paris in that it maintained on its staff a physician, a surgeon, and a pharmacist. In 1288 Folco Portinari, the father of Dante's Beatrice, founded the Hospital of Santa Maria Nuova in Florence; by the fifteenth century, this institution had developed into an elaborate center for medical treatment. A document dated 1500, but reflecting earlier arrangements, reveals that Santa Maria paid six of the best physicians of Florence to visit patients each morning. In addition, three young interns lived permanently at the hospital. In return for room and board and a valuable opportunity to gain experience in medical practice, they served the hospital's 300 patients by monitoring their conditions and making daily reports to the senior physicians.

Santa Maria Nuova was not a death trap, as were some less well-organized hospitals, nor was it a hospice where poor sick people were simply nourished. It provided its patients access to society's best physicians and boasted an excellent rate of cure. Hospital records reveal that about 85 percent of the patients recovered from their ailments (Park; Henderson).

At Santa Maria Nuova, the interns were willing to serve patients for free not only because such service was virtuous but also because it offered them an unparalleled opportunity to observe the course of many diseases. During the sixteenth century, the medical professors of Padua (in Venetian territory) established formal clinical instruction at the Hospital of San Francesco. Many students from northern Europe came to study at Padua because of its excellent empirical training (Bylebyl).

Conclusion

Modern scholars have not been inclined to examine medieval hospitals because of the prevailing view that these were poorly equipped asylums that offered the sick only minimal medical care. Such institutions supposedly had nothing in common with today's hospitals. This view has its origins in Enlightenment skepticism concerning religious institutions. Eighteenth-century intellectuals contrasted the efficacy of science in curing human ills, including disease, with the helplessness of Christian charity, which at best provided only comfort, not true remedies.

However, hospitals in Renaissance Italy, as well as those in medieval Constantinople and Baghdad, demonstrate that philanthropic institutions were not necessarily isolated from scientific medicine. In fact, hospital service in Italy came to form a vital part of medical training, first in Florence and then at the University of Padua. In hospitals such as Santa Maria Nuova, the Christian command to aid the needy interacted with a sense of civic pride and with a concept of professional ethics on the part of physicians to create institutions that were both truly philanthropic and efficient in curing the sick.

TIMOTHY S. MILLER (1 995) BIBLIOGRAPHY REVISED

SEE ALSO: Care; Christianity, Bioethics in; Islam, Bioethics in; Medical Ethics, History of: Europe; Professional-Patient Relationship: Historical Perspectives; Public Health: History

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