HOSPITALLERS AND HOSPITAL SISTERS

These are general terms used to describe the various nursing orders whose chief duty was serving medieval hospitals.

Origins. Although by 800 every important city of the Muslim world had its medical hospitals with trained physicians and substantial endowments, western Europe did not come near to matching that achievement until about 1200. A distinction was drawn between the hospice, a house for permanent occupation by the poor, the insane, and the incurable, and the hospital, a place where the sick were temporarily accommodated for medical treatment, though the same foundation could be both hospice and hospital, and guests, especially pilgrims, were often cared for in both. In many instances the hospital developed from the hospice, and a majority of hospitals came to be administered by a community vowed to the religious life. Some were staffed only by men, others only by women, others still—e.g., scores of Maisons-Dieu and Hôtels-Dieu (see hÔtel-dieu de paris)—by both sexes. Even the patients might be bound by a form of religious profession. A monastery could itself be a hospital, as were certain English gilbertine houses. Conversely, some hospitals developed into monasteries, and even lost their eleemosynary character. St. Bartholomew's, London, was both a monastery and a hospital, each division having its own organization, seals, and income. Many a hospital, without being integrated into a particular order, observed the Rule of St. augustine (the most popular), or the benedictine rule, or that of the franciscans, or the Knights Hospitallers of St. John of Jerusalem (see knights of malta). Even so, the diocesan bishop was often called upon to compile hospital statutes. During the 13th and 14th centuries in Germany and Italy the control of many of these independent hospitals passed to the municipalities. In every century the solicitude of the popes for the hospitallers expressed itself in innumerable bulls granting them chapels, cemeteries, exemptions, and indulgences. Lay patronage had a significant share in the distribution of wardenships, hospital offices, and corodies. The master was sometimes a layman, more often a religious; generally he lived in a separate house, and he might also be a physician. The professed brothers and sisters, who often paid entry fees, might live in a corody house and carry out only honorary duties; but for the most part they were nurses of the sick, and in the larger hospitals

they were assisted in worship and work by clerks in minor orders and lay servants.

The Nursing Orders. The 11th and 12th centuries were an age of momentous increase in the number of hospitals. In medieval England, for instance, 980 hospitals have been identified, their number reaching its maximum in the 13th century, and diminishing after 1350. In every generation, old hospitals, usually un-endowed, disappeared and new ones were founded. The pattern was similar in all Catholic countries, and by the 14th century such great cities as Rome and Florence had 30 hospitals each. This hospital expansion must be associated with the development of orders specifically devoted to nursing, of which the history of the antonines may be taken as characteristic. About 1100, a nobleman, Gaston de Dauphiné, founded the hospital of saint-antoine-de-viennois as a dependency of the monastery of the same name, establishing an almonry house with a separate hospital for poor persons suffering from the diseases (including erysipelas and ergotism) known collectively as "St. Anthony's Fire." During the 12th and 13th centuries Antonine hospitals were founded in most of the larger towns of France, Italy, Spain, and Germany and at Constantinople and Acre. The chief officers of the order and the heads of its houses were priests, though the majority of the members in the early years were lay brothers and lay sisters. In 1231 statutes were drawn up under papal supervision, and the order was freed from subjection to the Benedictines and put under the government of an elective master and an annual chapter-general of all the commanders. In 1247 the order adopted the Rule of St. Augustine, and in 1301 Pope boniface viii converted it to an order of Augustinian Canons and exempted it from episcopal jurisdiction. The Antonines wore a black habit with the blue St. Anthony's cross (the tau ). Included among their patients were the sick of the papal household.

Mention should be made also of the work of the Order of the holy spirit, founded at Montpellier in 1145, and confirmed by Pope innocent iii in 1198. By 1250 its houses were to be found in every important town in western Europe. The Order of St. William of the Desert (see saint-guilhem-du-dÉsert, abbey of), the Knights of Malta, the bethlehemites, and the hospital sisters of the Order of St. Catherine all made significant contributions to the development of the movement. The influence of the mendicant orders is illustrated by the work of St. elizabeth of hungary, Landgravine of Thuringia, who, after founding a hospital with 28 beds near Eisenach in 1226, and attending 900 poor daily, became a Franciscan tertiary in 1228 and built a second hospital for the sick at Marburg; or by the hospital of poor clares that her great-niece St. elizabeth of portugal established at Coimbra.

From early in the 13th century the beguines, an association of women in the Low Countries started by the priest Lambert le Bègue (d. 1177), frequently supported themselves by nursing the sick, especially at Liège, Malines, Brussels, Louvain, and Bruges. The Beguines were devoted to a life of religion and sometimes organized into semiconventual communities and later even into houses of Dominican, Franciscan, or Augustinian tertiaries. The similar male communities of Beghards, first appearing at Louvain in 1220, also nursed the sick, but hospital nursing was never the major preoccupation of the Beguines and Beghards. In contrast, the alexian brothers, whose patron was St. Alexius of Edessa, arose in Malines in the early 15th century under the layman Tobias to succor plague victims and bury those who died (hence their other name of Cellites, from cella, a grave). The Alexians spread through Flanders, Brabant, and Germany; they are still active in hospital work today.

The Knights of St. John of Jerusalem (more widely known as the Knights of Malta) were founded not later than 1108 to nurse the sick and tend pilgrims in the Holy Land. They soon became a military order, but they always laid special emphasis on medical work, founding and managing hundreds of hospitals and hospices in Catholic Europe and the Levant. Unlike their rivals, the templars, they affiliated hospitaller sisters to their order, many of them with the duty of ministering to patients (chiefly women). Such were the Johnannines St. Toscana at Verona (d. 1338) and St. Ubaldesca at Pisa (d. 1206). The order's principal hospital, at Jerusalem from 1108 to 1187, was governed under the rules drawn up by the Grand Masters Raymond du Puy (d. c. 1160) and Roger des Moulins (d. 1187) and accommodated 2,000 patients. In their later Convent (or headquarters) of Rhodes (1306–1523), the Knights of St. John sheltered pilgrims in the Hospice of St. Catherine and also built a commodious infirmary exclusively for the sick and wounded, which was administered by their Hospitalarius (always a French knight), two prud'hommes, and a lay staff of physicians (some of them Jews), surgeons, apothecaries, and male nurses. The infirmary in Malta, where the Convent was located from 1530 to 1798, was completed in 1578; it had a great ward 503 feet long, 35 feet wide, and 30 feet high, one of Europe's largest interiors, free from draughts and sun-glare, and equipped with the unusual luxury of 300 single beds. After Malta was lost, the order eventually reestablished its headquarters in Rome (1834), and its medical role has since then vastly expanded.

No medieval hospitallers had greater influence on medical progress than those who served leper-houses. In the ancient world there had been no consistent understanding of the spread of infection by contact. In the Middle Ages the group of diseases today termed leprosy was treated by regarding it as contagious (although not all such medieval diseases were properly leprosy) and sternly excluding it by confining all known lepers to leper-houses. Leprosy appeared in Catholic Europe about 500, reached its apogee in the 13th century, was in decline by 1350, and was extremely rare by 1500. The success of isolation (helped by leprosy's low infectivity) led to the realization that other diseases were infectious: e.g., erysipelas, scabies, conjunctivitis, phthisis, fevers with rashes, and bubonic plague; and medieval governments began to enforce rigorous measures against the spread of epidemics. The leper-house was a group of individual houses clustered around a chapel, standing well out of town in the open country, sometimes close to a healing spring, e.g., the famous wells at a house near Nantwich, England. The master would be a priest presiding over a community of nursing brothers and sisters, often 13 in number, who might well be lepers themselves, and who would include a capellanus and a clerk to collect rent and alms. Usually their patients were also regarded as brothers and sisters of the house. By the 13th century the comprehensive attack on leprosy had produced 2,000 leper-houses in France alone, and hundreds in every other country of Europe. Most houses were autonomous, not belonging to any congregation. A great house such as Saint-Lazare at Paris was dependent on the local bishop, though after 1200 many municipalities took over control of their lazar-houses. The hospitallers of st. lazarus, founded to treat leprosy in 12th-century Jerusalem, acquired many houses and endowments in the West, but their work is only part of a story that has been deemed "a great social and hygienic movement."

Hospital Facilities Hospitals other than leperhouses were usually located at a town, preferably on a site outside the walls to counter the spread of disease (e.g., S. Spirito, Florence), and if possible on a river bank (e.g., St. Francis, Prague). The early form was that of a church, with the aisled hall opening at the east end into a chapel. Later there was developed a plan resembling that of a monastery or college. King henry ii of England built the hospital of Saint-Jean at Angers with three wings, and in many hospitals the hall ranged around three or four sides of a quadrangle. It must be emphasized, however, that most medieval hospitals had fewer than 30 beds, although every country had its great infirmaries. Margaret of Burgundy built one at Tonnerre with a hall 260 feet long, 60 feet wide; the main ward of S. Spirito, Rome, was 409 feet long, 40 feet wide, and that of the Holy Ghost, Lübeck, 300 feet long with 140 beds in four rows of cubicles. The lavishly staffed St. Leonard's, York, could accommodate 224 sick and poor. At Milan between 1445 and 1500 the Visconti and the sforza built the finest hospital of the Middle Ages. Toward the end of the period the great new foundations, such as Santa Cruz, Toledo (1504–14), were often given a cruciform plan, with four wards meeting at a central altar. An alternative, late-medieval design was the row of almshouses, each with its own fireplace and offices. The hospital hall or ward had a tiled floor and large windows, the lower parts of which could be opened, and it was sometimes divided into private cubicles, each patient being expected, if well enough, to join in evening prayers at his cubicle door.

Medical Knowledge of the Hospitallers. By 1200 the medieval hospitaller worked under physicians trained at Salerno, Montpellier, and other universities (compared with which the monastic orders contributed little to the progress of medical science). These men, though their pathology was still that of the four humors and their knowledge of drugs empirical, could refer to the consilia of such writers as Taddeo Alderotti (d. 1295) with their careful and perceptive descriptions of symptoms and treatments. There was, for example, a rich variety of mercurial recipes for the nurse to apply against a large group of chronic skin infections, some probably syphilitic. Guglielmo di Saliceto (d. 1276) had challenged the Arab view that pus-formation was good for wounds and had recommended dressings to heal "by first intention," though his new principle was to be painfully slow in acceptance; he had also pointed to the connection between dropsy and nephritis, prescribing draughts of oxymel and barley water. The nurse needed an understanding of the use of traction in the treatment of fractures; of uroscopy; of the use of the instep of the naked foot as a clinical thermometer; and of the anesthetic sponge, impregnated with opium and mandragora, and soused in hot water, to produce fumes for the patient to inhale. The miniatures that illuminate some of the Salernitan codices show the wide range and enterprising techniques of medieval surgery. The hospitaller attended on operations for piles, fistula, stricture, nasal polyps, rupture, and cataract, as well as on venesection, cupping, and trephining. Thousands of foundation charters, statutes, and ordinances testify to the well-regulated character of medieval nursing: the prohibition on leaving the sick unattended, the confinement of the very sick to private wards (some Italian hospitals having separate wards— pazzerie —for the delirious), and the emphasis on the care of women in childbirth and for 3 weeks thereafter as a major duty. Above all, in hospitals following a rule, the canonical hours had to be strictly observed, and even patients were often enjoined, under vows, to perform their religious exercises.

See Also: hospitals, history of, 1.

Bibliography: p. hÉlyot, Histoire des ordres monastiques, 8 v. (Paris 1714–19). m. a. nutting and l. l. dock, A History of Nursing, 4 v. (New York 1907–12). Knowles-Hadcock. w. g. wylie, Hospitals: Their History, Organization, and Construction (New York 1877). r. m. clay, The Mediaeval Hospitals of England (London 1909). r. graham, "The Order of St. Antoine de Viennois and Its English Commandery, St. Anthony's, Threadneedle Street," Archaeological Journal NS 34 (1927) 341–406. h. pirenne, Histoire de Belgique, v.1 (Brussels 1903) 337–340, for Beguines and Beghards. p. ferrand, Précis historique des Ordres de Saint-Lazare et de Saint-Maurice (Lyons 1860). c. a. mercier, Leper Houses and Mediaeval Hospitals (London 1915). c. j. singer and e. a. underwood, A Short History of Medicine (2d ed. New York 1962). a. castiglioni, A History of Medicine, ed. and tr. e.b. krumbhaar (2d ed. New York 1947). f. h. garrison, Introduction to the History of Medicine (4th ed. Philadelphia 1929). l. thorndike, A History of Magic and Experimental Science, 8 v. (New York 1923–58). v.1 and 2. l. c. mackinney, Early Medieval Medicine, with Special Reference to Paris and Chartres (Baltimore 1937); Medical Illustrations in Medieval Manuscripts (Berkeley 1965). d. riesman, The Story of Medicine in the Middle Ages (New York 1935). p. diepgen, Geschichte der Medizin, 2 v. (Berlin 1949–55). k. sudhoff, ed., Studien zur Geschichte der Medizin, 23v. (Leipzig 1907–37); Beiträge zur Geschichte der Chirurgie im Mittelalter, 2 v. (Leipzig 1914–18); Aus der Frühgeschichte der syphilis (Leipzig 1912). p. giacosa, ed., Magistri Salernitani nondum editi (Turin 1901), 1 v. and atlas. e. e. hume, Medical Work of the Knights Hospitallers of St. John of Jerusalem (Baltimore 1940).

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