Hospitals today are places where medical treatment is provided, but also places where major life events, such as birth and death, occur. Yet, their history is relatively short; they were born, together with modern medicine, some two hundred years ago in the revolutionary Paris (1,2). Around 1790, large hospitals and pioneering research blossomed throughout Europe, replacing the Hippocratic model of disease with the localizationist paradigm. The rise of the modern hospital began in Paris when the social change brought about by the French Revolution provided the momentum for the transformation. For the first time in history, cure of the body and care for the soul were separated, and physicians, rather than the church and rich lay patrons, took charge of medical institutions. Medical treatment was no longer a privilege of the rich (at home) or charity for the poor (in hospital), but an indispensable human right. This article discusses the influence of social changes on the history of the pre-modern hospitals between the late Antiquity and early modern period. Using examples from Southern Croatia, it illuminates the subtle differences in socio-political organization, which shaped the history of hospitals.
While institutions providing some form of medical treatment existed in ancient Greece and Rome, neither of these cultures organized community care for the sick, poor, and needy (3). A radical change occurred in the late Antiquity, with the rise of Christianity, which embraced charity as one of its basic doctrines. The first hospitals were founded when Christianity became the state religion of the Roman Empire (3). Hospital tradition in Byzantium continued into the Middle Ages, but the West experienced a centuries-long break. At the end of the early Middle Ages, the Benedictine monks revived the hospital institution. Hospitals flourished in the crusades, with the rise of orders specialized for that service, such as Hospitaller Knights. But, by the thirteenth century, growing urban communities had taken over the leading cultural role from monasteries (3). While monastic hospitals and hospital orders, such as the energetic Sisters of Mercy, continued to develop, hospitals physically and administratively moved to the cities.
Italian merchant urban communes, such as Florence, Padua, and Venice, spearheaded urbanization and partial secularization of hospitals, which were being increasingly established by local governments, confraternities, and rich individuals (4). Hospitals guarded the social order and enabled uninterrupted running of commerce and manufacture in cities. Considered as institutions of social prevention, they simultaneously protected marginal social strata from homelessness and hunger, and the society from the marginal social layers. They brought under the same roof all those who could not afford better accommodation – abandoned children, travelers, the sick, and the poor. In contrast to monastic institutions, they employed university-educated medical practitioners. This was the period when early-medieval type of religiousness, marked by asceticism, withdrawal from the worldly life, and contemplation, was replaced by the late-medieval “secular” type, which emphasized the need to act socially and charitably. Thus, the number of hospitals was often higher than what the population size required. The representatives of the secular type of religiousness were confraternities (5). These associations of citizens practicing the same craft or inhabiting the same area performed religious and social activities, organized processions to honor protector saints, and ensured financial and other support to its members and the wider community.
In this period, hospitals preserved both the symbolic and material link to the Church and religion, based on the idea that the body and the soul were closely connected and mutually influenced. Physicians refused to treat patients who had not made a confession, as the sacrament of confession purified the soul from sins. Hospitals frequently emulated monasteries. Patients were occasionally required to follow the monastic rules and some hospitals admitted 12 male patients in an obvious reference to 12 apostles. Even the hospital architecture was supposed to inspire religious devotion—the leading European hospital, the Florentine Santa Maria della Nuova, had a cross-shaped ground-plan, with the long axis serving as the male and the short as the female ward (6). The monastery-like hospital interior included frescoes with Biblical motives and altars adorned with Christian iconography.
However, the influence of the secular sphere in hospitals was growing stronger. Urban communities at the Dalmatian Coast are a good example of how political and economic circumstances shaped the development of hospitals. In contrast to much larger and wealthier Italian cities, Dalmatian hospitals were small, situated in residential houses of rich citizens rather than in purpose-built institutions, and usually admitted no more than 30 patients. None of the hospital buildings survived to the present day: they either fell into disrepair or were rebuilt beyond recognition. Written sources, however, indicate that they were similar to Italian hospitals, although less luxurious (7). Domus Christi in Dubrovnik, possibly the most important late medieval and early modern hospital of the Eastern Adriatic, had a richly decorated altar in the main patient room, with a wooden cross, a painting, and two chandeliers. Unfortunately, very little is known about the everyday life, medical practice, and religious services in these hospitals.
Although the hospitals of Venetian Dalmatia and the independent Dubrovnik shared many similarities, they were also profoundly different. In Dalmatia under Venetian rule (1420–1797), the lack of strong and interested central administration had a negative impact on hospitals. In the relatively large and economically important Split and Trogir, urban hospitals were founded and financed by the powerful confraternity of Holy Spirit (Santo Spirito) (8). The confraternity of Holy Spirit was founded in Rome with the specific goal of establishing and running hospitals, yet there is no evidence of direct links between the center in Rome and Dalmatian institutions. The hospital in Trogir was founded in 1357 and the hospital in Split in the first half of the fifteenth century. While these institutions practically functioned as communal hospitals, they were not financially supported by the commune. Indeed, in the seventeenth-century wars, the hospital was confiscated for the military needs, in spite of the confraternity protests.
Zadar, the capital of Venetian Dalmatia, had many hospitals (9). They were financed with lay money and managed either by priests or by laymen under the bishop’s supervision. In 1295, the rich nobleman Cosa Saladin founded a hospital as part of a monastery for eight Franciscans with a chapel, garden, and pharmacy. Similarly, the hospital founded by Teodor de Prandino accommodated Franciscan third-order nuns whose duty was to take care of the poor. The list of founders comprised many well-known families, but the hospital founded by the rich merchant Grgur Mrganić in the mid-fifteenth century in the immediate proximity of the church of St. Anastasia was especially famous. In his will, Mrganić specified the number and characteristics of the poor that should be admitted to the institution: 13 poor patients, Zadar citizens or foreigners, but no patients with plague. Although Zadar with its central administrative position and greater economic power had more and larger hospitals than either Split or Trogir, it was still subject to the vagaries of Venetian politics. As in Split, the naval wars of the seventeenth century caused the conversion of the city hospital of St. Mark into a military hospital.
In Dubrovnik, the local aristocracy firmly held power in their hands (10). Local confraternities were supervised and subjected to restrictive regulations, and the relationship with the Church was frequently strained. In this context, the commune and rich aristocrats were the chief founders and administrators of hospitals. The first hospital, following earlier monastic establishments, was founded by the city in the period immediately after the outbreak of Black Death in 1348 (11). The (h)ospedal del comun was located beneath the city walls, near the monastery of St. Claire. It accommodated diverse inmates: the old, sick, and poor. Travelers stayed at the hospitium near Sponza. The next two hundred years saw the foundation of several other hospitals by rich local aristocrats. The hospital of St. Jacob, (also known as de puteis, because it was located near the city fountain) was founded in 1387 with the bequest by Sir Jacob de Sorgo. The hospital of St. Peter (also called Clobucich de Castello after a nearby church) was founded by Sir Marin de Bodazia in 1406, while the hospital of St. Nicholas was founded by Sir Johannes de Volzo in 1451. In 1432, the city established an orphanage in the immediate proximity of the main street, Stradun. The window of the orphanage was equipped with a stone turntable (ruota), where unwed mothers could place the unwanted child, ring the bell, and disappear into anonymity of the night.
In mid-sixteenth century, the municipal authorities made a crucial decision that would transform the city hospital into a medical institution. The old (h)ospedal del comun was renovated. A decree from 1540 regulated that it could admit exclusively poor men suffering from curable diseases. They were required to leave the hospital immediately after they had been cured. Those who did not fit this description were transferred to other institutions. It is probably no coincidence that it was in 1543 that Sir Marino de Gozze established a hospital for old and/or sick women, which, under the name of St. Theodor, would remain in service for centuries.
Unlike Santa Maria della Nuova, which had had medical practitioners on the payroll as early as the fourteenth century, Domus Christi did not employ physicians and surgeons. The low patient numbers of around 30 did not allow for such an expense. The hospital did, however, have its own barber and lower medical personnel. Importantly, the decree from 1540 required the medical practitioners in the service of the commune to make hospital rounds twice a day, in the morning and the evening. The admission of patients was still, however, in the hands of hospital administrators, city aristocrats who selected patients worthy of treatment.
With the exception of the military hospitals under Venetian rule, Domus Christi was for a long time the only exclusively medical hospital on the Croatian territory. Other hospitals remained a mix of retirement homes, poorhouses, and clinics until the late eighteenth century, when the first medical institutions were founded, inspired by the ideals of the Enlightenment or under French administration. The Split hospital, financed by Ercegovac brothers, was only erected in 1797 – the last year of the Venetian rule (12).
Modern hospital was thus born with the secular state and medical reform in the French revolution. The norms and values of the new revolutionary society were built into the foundations of this institution and in modern medicine. This short overview of the history of the “pre-modern hospital,” which appeared with Christianity in the late Antiquity, showed that many questions we grapple with today had also been tackled by our medieval ancestors. These were, for instance: what is the role of religion (or “spiritual treatment”) in the care for the body? Should medical care be part of general welfare or should it be independent? Who should pay for it—the community/state, like in Dubrovnik, or citizens themselves, like in Trogir and Split? Different models coexisted at the same time in towns only a few hundred kilometers apart, but under very different regimes and economic circumstances, reminding us how deeply the history of medicine/medical treatment is embedded in social history.
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