National Library of Medicine V ~V _# w »* ■♦ *• of '»' r EUROPE, 1200 - 1981 ,- Itt^diiKt of photographs by GRACE GOLDIN- * -j- J**. - ' -»-___._:_____tLS____________._______:__________,__:____m___. •-■», - . .•fe*1 -r-'^j -%*r ^W^ A Note on the Exhibit The principal part of this exhibit, the photographs and accompanying text material, has been loaned to the National Library of Medicine through the courtesy of its owner, Mrs. Grace Goldin. Mrs. Goldin, who is well-known as a poet and photog- rapher, has also written and lectured extensively on the history of hospitals. She is best known in this connection as the co-author (with John D. Thompson) of the volume, The Hospital: A Social and Architectural History (New Haven, 1975). She resides in Swarthmore, Pennsylvania. Mrs. Goldin photographed a great many of the oldest surviving European hospitals during a series of trips over a period of nearly twenty years. Some of the photographs were used to illustrate The Hospital, and were subsequently shown in slide presen- tations to various groups around the country. Many of the photographs, however, have been reserved for this highly personal exhibit, one which displays an appreci- ation for the combined historical, visual, social, and human aspects of the hospital as an institution. This part of the exhibit was originally displayed in 1983, in virtually the same format, at the Wangensteen Library of the University of Minnesota. The staff of the National Library of Medicine is indebted to Professor Leonard G. Wilson of that institution for bringing the exhibit to our attention and for arranging for its ship- ment to Bethesda at no cost to the taxpayers. The exhibit was prepared for show- ing at NLM by Daniel Carangi and James Cassedy, with the assistance of Grace Goldin. The remainder of the exhibit represents a selection of the historical works pertaining to European hospitals that are in the NLM collection. HISTORIC HOSPITALS of EUROPE, 1200-1981 by GRACE GOLDIN Hospital history involves the history of half a dozen other special fields. Today, a hospital is thought of as the place where the most advanced medicine and surgery are effectively practiced. But the history of hospitals is not merely the history of medicine and surgery. For centuries the hospital was not even primarily medical. Until very recent- ly, in or out of the hospital, medicine could not do much to cure, while surgery frequently fatally in- fected. Nursing, on the other hand, was useful for making the patient simply more comfortable, and often, in the past as today, has made the difference between death and recovery. Nursing care in the old hospitals often compared, in fact, most favora- bly in its devotion and concern with the best of ours; note two late-eighteenth century nursing sis- ters of St. John's Hospital, Bruges, lifting a patient into bed. [Illus. No. 1] Other aspects of the hospital across the ages are also of much significance. Every hospital performed its functions in some kind of building, and not a few of these were of considerable architectural in- terest. Often the hospital had its own pharmacy, since medications of various kinds were constant- ly being tried, whether or not they worked. Over the centuries, moreover, technological innovations were introduced in the various hospitals, from the varied medieval provisions for latrines to modern instruments and electrical communications. Con- sider, for instance, the impact of the invention ot elevators on structures previously limited to three or four stories Hospital history is obviously closely related to the Illus. No 1. Detail from oil painting by Johannes Beerblock, View of the Sick W.ncl of St. John's Hospital" (Bruges), 1778 Nurses lifting patient into bed. 1 t.ambt -jl Illus. No. 2. Engraving by Philippe Thomassin, "The Fourth Work of Mercy is to Visit the Sick," end of 16th century (Fry Collection, Yale University). 2 21 social, economic, and even military history of any given community. It is also an integral part of an age's art history. Records of how hospitals ran in a given century are to be found in numerous sur- viving prints and paintings. To interpret these cor- rectly, one must take into account how artists of the time saw things outside as well as inside the hospital. The component of hospital history that is least expected nowadays was, until the end of the 18th century, the most important one: religion. Consider a print by Philippe Thomassin of a late 16th cen- tury interior, probably not of any particular hospital. [Illus. No. 2] About the only similarity with our modern idea of a hospital is that there are patients in bed. Food and drink are being served. Most pa- tients lie naked, save for turbans on the heads of the women, to the left. In large open halls, divi- sion was regularly made between sexes. In this idyllic scene, patients lie singly in beds big enough for two. Often they lay double, in beds we would think fit for one. There are medical touches, soon told. In the sec- ond bed on the left, a woman is being bled. Medi- cation is probably being brought to the woman be- hind her and to the man in the right rear bed. The dominating feature of the scene however is an altar, with a patient praying at it. From the little we see of medical treatment here, what other hope was there? Behind the altar is a painting of the Good Samaritan, specifically pointed out by a figure left rear. The title of the print is entirely religious: "The Fourth Work of Mercy is to Visit the Sick." This was a charity hospital. The patients you see are paupers. Until the last quarter of the nineteenth century, rich folk were nursed at home. But. as St. Chrysostom had told them, "If there were no poor, the greater part of your sins would not be reme- died; they are the healers of your wounds." Before him, word had come down from Jesus himself: "What you have done for the least of mine you have done for me" — a text responsible for the founding and funding of most medieval hospitals. The charity institution was shaped in a most literal sense by the Biblical seven works of mercy, which were: to feed the hungry, give drink to the thirsty, clothe the naked, visit the sick, shelter the home- less, ransom the captive, and bury the dead. Only the sixth was irrelevant to hospital work. In early prints of hospital interiors, it is hard to tell where personification of the Works of Mercy leaves off and a realistic transcript begins (another task for the art historian). A sixteenth century Dutch interior by Johannes van Straaten is probably more literal than most: at left a woman rises from her bed to visit the necessarium, and the nurse runs with the communal cape to cover her nakedness. [Illus. No 3] Even the child is not out of place in a chari- ty hospital, for the Works of Mercy led to hurly- burly admittance of the homeless and starving, the acutely and chronically ill, the crippled, the aged, the blind, the insane, and helpless orphans. All of humanity, in fact, was admitted, save those recog- nized as contagious — lepers and the plague-rid- den __ who were isolated in their own institutions. Even a vagabond passing by was entitled to one night's food and lodging. I*- lus. No. 3. Sixteenth century hospital ward. Engraving bv Dutch artist. Johannes van Straaten. 3 Ilus. No. 4. "Death of a Virtuous Woman" — Wall picture in colored tiles (1635 A. D.), in Hospital de la Santa Cruz, Barcelona, Spain. The medical aim of the hospital was to save lives if possible — it always was. But in a setup where so many died, and even came to die, the religious aim was to save souls. A scene in colored tiles from a hospital in Barcelona, most likely on the wall of a room for the dying, pictures the ideal: the dying patient clasping the crucifix, her huge good angel rising triumphant with a long list of her good deeds, while a tiny devil, with his brief budget of sins, leaps defeated back to hellfire. Over the door is shown her reception into heaven. [Illus. No. 4] As preparation for death must include remission of sins, it requires confession and the Mass. Open wards of the medieval hospital were thus built in two sections: a bright, churchlike area with altar for the religious service, a large dark space for beds, like that at the Second Hospital of the Knights of St. John at Rhodes (1489). [Illus. No. 5] Ecclesiasti- cal building forms were used for the chapel area and a secular form for the ward. What was essen- tial v\ as that patients be able to see, or at least hear, the Mass. In 15th century Italy, the principle of ef- ficiency led to the cross-shaped open ward, with chapel at the crossing and four halls in which four times as many patients could see and hear the Mass. Often gigantic, sometimes quite compact, the cross-shaped hospital was declared by John How- ard in the late 18th century to be the dominant form of hospital construction. For evident reasons, single rooms were used for the agitated insane and often though not always for those in leprosaria and plague-houses. A timeworn architectural formula for institutions for the aged (whether sick or not, and perpetuated in modern condominiums for the same population) was single units attached one to another in a row or around a court. Everywhere they bespeak their country of origin: for example, an obviously Netherlandish Old Age Home in Ghent (14th century), [Illus. No. 6] and a very British foundation for pensioners, St. Cross of Winchester (15th century) [Illus. No. 7]. The building idea may be that of a hospital, but the dress put on is always that of country of origin and century of construction. How quintessential^ Span- ish is the Caridad (Charity) Hospital of Seville (mid-17th century)! [Illus. No. 8] 4 The photograph of the nurse dipping water from the fountain at the Caridad, for the use of old men in two long wards behind her, was taken in 1969. The act itself harks back a couple of centuries. Such glimpses are becoming rarer. Fifteen years go Spain was more impoverished than it is today. With funds and a spirit of progress, hospitals are the first in- stitutions to be improved. Often, in Spain as in other countries, they are simply demolished and a new one built; many beautiful old structures which were still in full operation only a quarter of a century ago are no longer in existence. Some have been abandoned and vandalized, like the grand old 18th century cross-shaped hospital, the Nuncio of Toledo, fourth oldest hospital in Spain. Many of the older hospitals have intriguing and sometimes telling details, such as the clock above the front stairs of St. Nikolaus-Spital in Cues, Ger- many — an old age home for men! This institution, which was a favorite philanthropy of Cardinal Nic- olaus Cusanus (scientist, physician, philosopher), illustrated the traditional differences in facilities that patients received, depending on their rank or status. This building was designed for 33 old men. Twenty-one were poor objects of charity. \\ ho were assigned to two large dormitories. Six were priests, and six were noblemen; to them went pri\ate rooms. Then as well as today one paid extra for privacy. At a 2,000-bed state hospital, the Allgemeines Krankenhaus of Vienna, sponsored by the Emperor Joseph II of Austria, the concepts of chanh were further modified by a modern system of charging on a sliding scale: there were four categories, and what you paid determined grade of food and ser- vice. The fourth category, the true pauper, paid nothing — and he got the worst of both. This shocked people who were accustomed to the trad- itional charitable hospitals. At the other extreme, however, on payment of a stated fee, rich, illegal- ly pregnant women could take shelter in the mater- nity court for the duration. They could arrive in secret and disguise, and could buy a private room with maid's room attached. r I i Illus. No. 5. Hospital of the Knights of St. John, Rhodes .1440 1489). Shows contrasting illumination of hospital ward and small adjoining chapel. 5 Illus. So 6. Old age home (Hospitaal der Kindren Alyns), Ghent, Belgium, 14th century. Illus. No. 7. Hospital of St. Cross, Winchester, England f 1444i. for elderly men. Shows some of retirees returning from church, 1979. At this same institution, in the mid-nineteenth century, Ignaz Semmelweis pinpointed the cause of childbed fever. However, when he criticized the obstetricians' practice of going straight from dis- sections in the mortuary to lying-in cases in the maternity wards, without washing their hands, he was ostracized. However beautiful, however chari- table the old hospitals were, however excellent the nursing care, sanitary conditions left everything to be desired. Wounds were expected to become in- fected, and were likely to lead to death from hos- pital gangrene; hospital stays, if they did not end fatally, went on for months, as secondary infections contracted in the hospital complicated matters. (During the American Revolution it was found that wounded American soldiers more freqently recov- ered when kept outdoors under the apple trees than when cared for in warm, crowded hospitals.) In Paris, in the late 18th century, conditions at the vast and ancient Hotel-Dieu became particular- ly intolerable. There were some wards of a hun- dred or more beds, each bed holding two to six patients (the six of them cross-packed into a "grand lit," with other patients piled on the canopies above in time of pestilence). These wards ran one into the other, even connecting with those for infectious dis- ease patients. Overcrowding and "vitiated air" were scandals. Just before the French Revolution the king's physicians, planners and architects drew up plans for several hospitals of limited size to replace the Hotel-Dieu. They proposed small, clas- sified building units, isolated one from the other so the bad airs would not mix. The Revolution put an end to the paperwork (and to some of the plan- ners, too) but their solution surfaced in the pavilion plan, of which the Hopital Lariboisiere (actually built in 1854) is a classic example. The plan was enthusiastically endorsed by many, including Florence Nightingale, who became a her- oine and broke her heart trying to nurse the wound- ed in a filthy converted barracks at Scutari, Turkey, during the Crimean War. That temporary hospital was even more lethal than the Hotel-Dieu, with a mortality of 42.7 percent, mostly from hospital dis- eases. At the same time, 1855, in the same geo- graphical area, among the same soldier-patients 7 lus. No. 8. Hospital de la Caridad, Seville, Spain (1664), interior court. prefabricated one-story double barracks at Renkoi (25 men to a room, 50 to a hut) had a mortality of only 3 percent. The pavilion plan went on to provide a pattern for hospitals around the world for a hundred years. In the United States, John Shaw Billings designed Baltimore's Johns Hopkins Hospital on this model. And in London, the Nightingale Wards of St. Thom- as' Hospital are still functioning beautifully. At first, pavilions were limited to three stories and spread over huge areas. In cities where land was at a prem- ium, pavilion wards ultimately were piled one upon the other to form the first skyscraper hospitals. During the last quarter of the 19th century, many major diseases were traced to their causal organisms and so controlled or prevented. These discoveries radically altered hospitalization. Im- maculate air was no longer so important in these institutions. The discovery of antisepsis reduced in- fections consequent upon surgery, and, much later, antibiotics became available to check the spread of infection in medical wards. Ultimately, bulky, expensive, and complicated machines for diagnosis and cure were invented, and these items were to be found only in a hospital. In fact, in every way, in the twentieth century, the hospital finally came to be seen as the preferred locus of medical care for the rich as well as poor. In this century, hospital administrators, with an augmented, infinitely more curable patient popula- tion, have become preoccupied with financing hos- pital services, with efficiency studies and mechan- ical aids. These concerns have virtually eclipsed the age old reliance of hospitals on religion, prayer, charity. In fact, now only the hospice among con- temporary institutions offers the solace of religion to the sick and dying along with scientific medicine. 8 wmm Front Cover: St. John's Hospital, Bruges, Belgium (Established 12th century A.D.). Side entrance, show- ing segments from various historical periods. Back Cover: St. John's Hospital, Bruges, Belgium. Interior scene, possibly painted by Johannes Beerblock around 1800. Includes depiction of the reduction of a dislocated shoulder. Rear cover detail and Illustration No. 1, Copyright A. C. L. Bruxelles. These details of Johannes Beerblock's oil painting, "View of the Sick Ward of St. John's Hospital (Bruges), 1778," are reproduced with the joint permission of the Institut Royal du Patrimoine Artistique, Brussels, and the Commissie van Open- bare Onderstand, Bruges. DEPARTMENT OF HEALTH AND HUMAN SERVICESo Public Health Serviceo National Institutes of Health