Chapter XIV: Introduction (9)

That there was no change of Papal policy in the next century can be gathered from an interesting phase of Papal interest in science which, though not directly concerned with medicine, eventually resulted in important theoretic advances in medical science. This was the encouragement of Father Kircher's work at Rome. Father Kircher was the Jesuit who made the first scientific museum. As the result of his general interest in things scientific he wrote a little book on the pest. In this book he stated in very clear terms the modern doctrine of the origin of disease from little living things, which he called corpuscles. Because of this Tyndall attributes to Father Kircher the first realization of the role that bacteria play in disease. Even more wonderful than this, however, was Father Kircher's anticipation of modern ideas with regard to the conveyance of disease. He insisted that contagious diseases, as a rule, were not carried, as had been thought, by the air, but {239} were conveyed from one person to another, either directly, or by the intermediation of some living thing. He considered that cats and dogs were surely active in conveying diseases, and he even reached the conclusion that insects were also important in this matter. His expressions with regard to this are not of the indefinite character which one often encounters in the supposed anticipation of important principles in medicine, but are very precise and definite. Father Kircher is quoted by Dr. Howard Kelly, of Baltimore, in his life of Major Walter Reed, whose work in showing that yellow fever is transmitted by mosquitoes is well known, as saying in one place, "Flies carry the plague," and in another place, "There can be no doubt that flies feed on the internal secretions of the diseased dying, then flying away they deposit their excretions on the food in neighboring dwellings, and persons who eat it are thus infected." It is interesting to find that the Professor of the Practice of Medicine in the Papal University at Rome when this book was published, far from resenting, as many professors of medicine might, the excursion of an outsider into his science, said Father Kircher's book "not only contains an excellent resume of all that is known about the pest or plague, but also many valuable hints and suggestions on the regional spread of the disease which had never before been made." He did not hesitate to add that it was marvelous for a man, not educated as a physician, to have reached such surprising conclusions, which seemed worthy of general acceptance. All this, it may be said in passing, was within a few years after the trial of Galileo. In this next century the Popes continued their special efforts to secure the greatest teachers of anatomy and physiology for their Roman medical school. One of the {240} results was the appointment of Malpighi, whose name has deservedly become attached to more structures in the human body because of tissues which he first studied in detail, than any other man in the history of medicine. Malpighi represents the beginning of most of the comparative biological sciences, and his original observations upon plants, upon the lower animals, on fishes and then on the anatomical structure of man and the higher animals, stamp him as an investigating genius of the highest order. He was the personal friend of Innocent XI., who wished to have him near him at Rome as his own medical adviser, and besides desired the prestige of his fame and the stimulating example of his investigating spirit for the students of the medical school of the Sapienza. The closing years of Malpighi's life were rendered happier, and his wonderful researches were as well rewarded as such work can be, by the estimation in which he was held at Rome.

Malpighi was succeeded as Papal Physician and Professor in Rome by Tozzi, who is distinguished in the history of medicine for his commentaries on the ancients rather than for original observation, but who was looked upon in his time as one of the most prominent physicians in Italy. Tozzi had been the Professor of Medicine and Mathematics at the University of Naples, where he became famous. From here he received a flattering invitation to the chair of physic at Padua. In order that he might not desert Naples, his salary was raised and he was given the post of Protomedicus or Chief Physician to the Court. It was after this that the death of Malpighi left an important chair vacant in Rome, and there being no one apparently more worthy than this man for whom other important universities were contending, he {241} was offered the chair on such excellent conditions that he accepted it. It is another case of the Popes being not only willing and even anxious, but also able because of their position, to secure the best talent available for their medical school at the Roman University.

Undoubtedly one of the greatest members of the faculty that the Papal Medical School ever had is Lancisi, one of the supreme medical teachers of history, who is usually considered one of the founders of modern clinical medicine. When at the beginning of the eighteenth century Boerhaave attracted the attention of the world by his bedside teaching of medicine at Leyden, there were two occupants of thrones in Europe who proved to have particular interest in this new departure. They were perhaps the last two who might ordinarily be expected to have much use for such improvements in medical education. One of them was the Empress Maria Theresa, of Austria, whose patronage of Boerhaave 's pupil, Van Swieten, secured the establishment of that system of clinical teaching which has since made the Vienna Medical School famous. The other was the Pope. With his approbation Lancisi established clinical teaching at Rome, and thus did much to maintain at Rome a great center of medical progress during the eighteenth century.

Lancisi was graduated at the Sapienza, the Roman University, at the early age of eighteen. When only twenty-two he became assistant physician at the Santo Spirito Hospital and began to show the first hint of the brilliant genius he was to display later in life.

Some ten years later, as the result of a competitive examination which still further demonstrated his talents, he was chosen Professor of Anatomy in his Alma Mater, {242} the Sapienza. He was only thirty-three at the time, and the fact that he should be chosen shows that the Papal University was ready to take advantage of talent wherever it found it and did not allow itself to be won only by notoriety at a distance. The excellence of the choice was demonstrated before long by Lancisi's brilliant career as a teacher and an original investigator. Some of the most distinguished medical men from all over the world came to listen to his lectures (according to Hirsch's Biographical Lexicon of the Most Prominent Physicians of All Times and Peoples), and even Malpighi and Tozzi, the Papal physicians during the time, were among his auditors. [Footnote 29]

[Footnote 29: Most of these details are taken from Hirsch's Biographisches Lexicon der hervorragenden Aertzte aller Zeiten und Voelker. Wien und Leipzig, 1886.]

After the departure of Tozzi from Rome Lancisi became the Papal physician. He continued to be the medical adviser of Popes Innocent XI. and XII. and of Clement XI. until his death in 1720. It was under Clement that he had the new clinic built, in which teaching after the manner of Boerhaave was to be established. At his death Lancisi left his fortune and his library to Santo Spirito Hospital, on condition that a new portion of the hospital should be erected for women. There is no doubt that he belongs among the most distinguished of contributors to medical science, and Hirsch declares that anatomy, practical medicine, and hygiene are indebted to him for notable achievements. His books are still classics. The one on Sudden Death worked a revolution in the medical diseases of the brain and heart. His work _De Motu Cordis et Aneurysmatibus_ has been pronounced epoch-making, and his suggestion of percussion over the sternum in order to {243} determine the presence of an aneurysm, made him almost an anticipator of Auenbrugger and prompted Morgagni's famous book _De Sedibus et Causis Morborum_, which appeared after his death. Lancisi's work on Aneurysms was not published until after his death.

Two others of his books deserve mention because they show how broad were the interests of the man in many phases of progress in medicine. Their titles are Diseases and Infections of Domestic Animals and The Climate of Rome.

The next great name in Italian medicine is that of Morgagni. He was not a regular Papal physician, nor a member of the faculty of the Papal Medical School, but he was often consulted, as we told in the chapter on Papal Physicians, both as to the health of the Popes and the methods of teaching at the Roman Medical School. His life brings us down almost to the nineteenth century, and the cordial relations of the Popes to him, far from being an exception in the history of medicine, are only typical of the attitude of the Roman Pontiffs to medical and all other scientists from the dawn of the history of science in modern times.

While the Papal Medical School at Rome, attached to the university of the city and directly under the control of the Papal Curia, more especially deserves the name thus given it, it must not be forgotten that there was in the Papal States a series of medical schools in various cities. One of these, at Perugia, founded by a bull of Pope John XXII., has come under consideration in the chapter on A Papal Patron of Medical Education. Another medical school, that of Ferrara, which also was in the Papal States, had considerable prestige. Some distinguished professors taught there before going to {244} Padua or Bologna. At the beginning of the sixteenth century, Bologna, after having been during the preceding three centuries under the domination of one powerful family or another, from the Pepoli to the Bentivogli, and then to the Visconti and back again to the Bentivogli, was incorporated in the Papal States under Pope Julius II. At this time the Medical School of Bologna was at the height of its reputation and was one of the two greatest medical schools in Italy. Padua was its only rival. Shortly after this Rome became a serious competitor in medical education. Practically, then, this was a second Papal medical school, almost as directly under the control of the Popes as the Roman Medical School. Far from there being any diminution in the glory or the efficiency of the Bolognese Medical School, its reputation even became enhanced after the city came under the control of the Popes.

This is all the more surprising because, as we have shown, just about this time the Popes began the work of making their Medical School at Rome the most important center for medical education, especially in the scientific phases of medicine--anatomy, physiology, and comparative anatomy--that there was at that time in the world. In spite of this rivalry, however, nothing was done directly to hurt the prestige of the school of Bologna, and indeed the rivalry seems to have been more of an encouraging competition than in any sense a destructive struggle for existence. When the Popes took possession of Bologna, Alexander Achillini was professor of anatomy and medicine in the Bolognese school, and his discoveries and methods of investigation attracted the attention of students from all over the world. His assistant for many years and his successor in the {245} post was Berengar of Carpi, of whom we have already said much in the chapter Anatomy Down to the Renaissance. For some time Vesalius lectured on medicine and anatomy at Bologna, and one of Berengar's most distinguished successors in the sixteenth century was Aranzi, who occupied the post of anatomical professor for thirty-two years and who corrected a number of errors in anatomical detail that had been made by Vesalius and others of the preceding generation. He confirmed Columbus's discoveries at Rome with regard to the course which the blood follows in passing from the right to the left side of the heart, and made many important additions to the knowledge of the anatomical relations of the cavities of the heart, the valves, and the great blood vessels. There are a number of important structures in the brain which owe their names to him, and his descriptions of them are better, according to Prof. Turner, than those of other anatomists for a century after his time.

The tradition of great teachers thus carried on during the first century after the absorption of Bologna into the Papal States, continued uninterruptedly in the next century, when we find on the list of professors at Bologna such names as those of Malpighi, the greatest mind in the medical sciences of the seventeenth century, and his colleague Fracassati, who, though over-shrouded by Malpighi, still claims a prominent place in the history of medicine. Bologna has a special feature of medical development to its credit which, because of its importance for science in general as well as for medicine, deserves to be mentioned here. During the century after the Popes became the rulers of the city scientific societies were founded here, and as the professors and {246} students of the medical school were also the most interested in science in general, the membership of these societies was largely made up of individuals connected with the medical school. A special society for the cultivation of anatomical knowledge, the first of its kind ever founded, was established in Bologna scarcely more than a century after the city came under the Papal dominion. It was called the Coro Anatomico, or anatomical choir, and had at first only nine members. Among these, however, were such distinguished men as Malpighi, Fracassati, Capponi, and Massari, to the last of whom the initiative of the foundation of the society is said to have been due. Bologna was noted during the sixteenth and seventeenth centuries for the number of foreign students of medicine who were attracted to its hospitable medical school and who carried the tradition of science for its own sake, so characteristic of this Papal Medical School, to all parts of the world.

After this consideration of the relation of the Popes to medical science during many centuries when medicine practically included all the physical sciences, it may seem utterly inexplicable to any fair-minded person that the tradition of the opposition of the Popes to science and scientific educational development should have apparently become a commonplace in history. This will not be a surprise, however, to those who know how perversive and influential has been the Protestant tradition which from the beginning of the sixteenth century has devoted itself to blackening the reputation of the Church, the Popes, and Catholic ecclesiastics generally. Nowhere is this more true than in history as written for English-speaking people. Those who left the old Church and their immediate descendants, justified their {247} withdrawal to themselves as well as others, by taking every possible excuse and inventing every possible pretext, to show how unworthy of their continued allegiance the old Church had been. The point of view thus assumed was taken quite seriously by succeeding generations, until at length a whole body of historical traditions, utterly unfounded in fact, accumulated, especially in England, where it must be remembered that for several centuries Catholics were not in a position to impugn and eradicate it. This unfortunate state of affairs, and not real opposition on the part of the Popes to science, is the source of the tradition with regard to the supposed opposition between the Church and science.

{248}

THE FOUNDATION OF CITY HOSPITALS.

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 {249} 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 {250} and most ably managed institution for the care of the sick in Europe at that time. Almost by common consent 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 {251} 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, Muenchen, Frankfort a. M., {252} Hoxter, Dortmund, Brandenburg, Spandau, Salzwedel, Stendal, Berlin, Perleberg, Pritzwalk, Halberstadt, Halle, Quedlinburg, Helmstedt, Magdeburg, Sangerhauson, Eisenach, Naumburg, Hanover, Gottingen, Northeim, Bremen, Hamburg, Luebeck, 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, Koenigsberg, 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 {253} hospital movement. In Paris, for instance, the Hotel Dieu, which had been in existence for some time, became 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 noteworthy 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. [Footnote 30]

[Footnote 30: Bordier, Archives Hospitalieres De Paris, Paris; Champion, Publications for the Society of the History of Paris, 1877.]

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 recalled, 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 {254} 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 Besancon, 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 hospitalism 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 {255} 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 thirteenth, 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, requires 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 {256} 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 {257} 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 {258} 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." [Footnote 31]

[Footnote 31: Virchow's article on the German hospitals is to be found in the second volume of his collection of essays on Public Medicine and the History of Epidemics, which is, unfortunately, not translated into English, so far as I know, but will have to be consulted in the original Gesammelte Abhandlungen aus dem Gebiete der Oeffentlichen Medicin und der Seuchenlehre von Rudolf Virchow, Berlin, 1879. August Hirschwald.]

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 foundling 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 {259} 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 {260} 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 day, 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, behold 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.'"

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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 {262} 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 formulas, 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 {263} 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 dependent 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 {264} 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 tender 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 {265} 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 attend. 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 {266}
very strict and severe to their bodies, overflowing with charity to
the poor and infirm and ministering with tender 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 supposed 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, however, 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 {267} 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 degenerate 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:

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"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 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 history 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 devoted 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 noteworthy 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 increases 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.

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