The Emergence of Hospitals in the Middle East, Constantinople, and Europe During the Tenth through Twelfth Centuries

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The Emergence of Hospitals in the Middle East, Constantinople, and Europe During the Tenth through Twelfth Centuries

Overview

During the tenth century, hospitals began to emerge along the routes taken by European crusaders to the Middle East, as their travels were accompanied by microorganisms, discord, and holy wars. The Crusades, a series of military campaigns from 1096 to 1291, were undertaken by Christian groups to take back the Holy Land from the Muslims. Trauma, either due to injuries, war, or poor living conditions, was a constant companion to those who traveled.

Then, as now, a stable, adequate diet, availability of clean water, and sanitary lodging were necessary for the maintenance of health. In the past pestilence and disease were frequently more lethal than actual warfare. The first hospitals were military institutions built along the well-worn routes of traders and the crusaders. Later, as populations increased, both Christians and Muslims found the need to build hospitals, and their respective motivations were both charitable and noble.

Background

The Latin word for the place where a guest was received is "hospitium," and the word "hospice" was used to mean places for permanent occupation by the poor, infirm, incurable, or insane. "Hospitalis," the adjective, came into use to describe a temporary place for occupation by the sick. "Hospital" then started to be used both in the sense of a permanent retreat for the disenfranchised and a temporary place for sick people; it later came to take the second meaning exclusively.

Prior to the Middle Ages, many hospitals had been built at the time of Emperor Constantine's conversion to Christianity in 325. Roman military valetudinaria served a similar purpose. Early Christian hostels, built to shelter pilgrims, were more like inns or hotels than institutions for study or teaching. However, they also cared for the sick and infirm. At the time, medicine was considered a work of charity, and helping the sick a duty.

In Persia, the city Jundishapur became the cross-cultural center for exchange of information among Greeks, Indians, Jews, and Nestorians. The hospital there is said to have been more like a medical school than a hostel. It was associated with a university where scholars translated Hippocrates (460-377 b.c.) and Galen (130-200), the mainstays of medical knowledge, from Greek into Arabic.

The Muslims, followers of the religious prophet Muhammad (570-632), became prime movers in the spread of culture and medical information throughout Asia, Persia, Egypt, North Africa, and Spain. Wherever Muslims went, so did Arab medicine. Although there were no hospitals during Muhammad's lifetime, a multiplicity of educational institutions was established as part of Islamic culture. One of the most significant achievements of the Golden Age of Islamic medicine was the development of hospitals and hospital-based clinical training of medical practitioners. By the end of the ninth century, more than 30 hospitals had been built.

Impact

Hospitals in the Islamic World

The first true Islamic hospital was built, in the style of Jundishapur, during the reign of Caliph Harun-ul Rashid (786-809) in Baghdad. The next hospital was the Audidi, built under the direction of ar-Razi (865-923), or Rhazes as he was known in the West. One story recounts that, to select the site, Rhazes hung pieces of meat around the city to determine which took the longest to rot. The site where the meat became least putrefied was chosen for the Audidi. Audidi had a staff of 24 physicians, including bone setters, surgeons, oculists, and physiologists.

As Islam grew, the Muslims conquered west Asia, Egypt, North Africa, and Spain. The resulting medical system drew the best medical knowledge from these cultures. When hospitals were built, they were large complexes, employing 25 physicians and divided into specialized wards. They served as teaching hospitals as well, giving instruction to physicians.

Thirty-four of these early hospitals were in Muslim cities. It is believed that the elaborate hospitals were reconstructed palaces, the best known being the Mansuri in Cairo, built in 1283. This model hospital had male and female nurses in addition to physicians, and special wards for women, fever cases, eye diseases, and mental patients. Its water supply came from the Tigris River and it had the capacity to take care of 8,000 patients. It was endowed and had a pharmacy, library, and lecture hall.

However, the splendor of the environment was not matched by the professionalism of the staff. Standards had not been developed for the type of knowledge and skills necessary to work in a hospital and there were not formal examinations for membership. Many lay healers, magicians, and mountebanks plied their trades within those walls. Unfortunately, women, many of whom learned medicine from physicians in their family, were put in the same category as quacks and prohibited to practice; they could be nurses and midwives only.

Hospitals in Constantinople

In the early sixth century b.c. the Greeks founded a city called Byzantium, which was the beginning of Istanbul (now in Turkey). It was renamed Constantinople in a.d. 300. Captured by the armies of the crusaders in 1203, it remained Constantinople until 1454.

One of the most elaborate and complex hospitals in Constantinople was the Pantocrator, (which means "Christ the ruler") started by John II Comnenus, and completed in 1136. It was part of a complex of buildings that included a church, tombs, and a monastery. It had 50 rooms that were divided into five departments. Interestingly, these were divided into wards much like modern institutions, with a number of rooms designated for: surgery cases (5), acute illnesses (8), men (10), women (10), gynecological cases (12), and emergency rooms or miscellaneous (5). The hospital also trained students and had support services such as outpatient, a pharmacy, mill, and bakery.

Despite the named departments and similarity in words to our modern hospitals, the philosophy underlying the building complex was quite different. A hospital was not a primarily medical institution until the late Middle Ages. Until then, it was more like a small city where medicine was integrated with religion, healing, faith, and philosophy, rather than a distinct place of scientific care like it is now.

Hospitals in Europe

In Europe, hospitals developed near churches or as parts of them. There were also orphanages, almshouses, and residences called leprosoria and pesthouses for people with leprosy. A pesthouse was an abandoned building or structure, usually far from the living quarters, where sick people could go during epidemics with the hope of separating them from healthy people. While there was often no treatment for them, it did protect the other inhabitants of the city.

In England, the first hospital was built in York in 937, followed by others in Cherbourg, Bayeux, Caen, and Rouen in France. The oldest European hospital still standing is the Hôtel Dieu in Paris near Notre Dame. It is arranged like a large square with a courtyard in the center.

The Abbey of Saint Gall in Switzerland, built about 822, was a hospital within a monastery. Visitors were divided into groups based on their socioeconomic status. The Hospice of Pilgrims and Paupers consisted of a large dormitory without sanitary facilities. On the other hand, the House of Distinguished Guests had individual rooms and toilet facilities called "necessaria."

In the tenth century, under the patronage of Abd al-Rahman III (912-961), the Spanish town of Cordoba became a major cultural center of Europe, with no fewer than 50 hospitals. Some of the religious orders also built hospitals, including the Knights of Saint John of Jerusalem, the Knights Templar, and the Teutonic Knights.

The Influence of Religion

Religion and medicine are closely related in all cultures. However, the nature of this relationship is often very different. In certain cultures medicine, or healing, is inseparable from art or music. Sometimes it is the doctor who takes the drugs so that he or she can better perceive what is harming the patient. In Western society, influenced by the culture of Europe and the Judeo-Christian belief system, modern medicine is a distinct category of science, but not without its own spiritual legacy. Disease was originally seen to be a punishment from God. The Bible tells of plagues that were sent by the vengeful God of the Hebrews. Healing was the work of God, perhaps manifested through the acts of a physician, but most importantly through prayer.

As Christianity spread throughout Europe, the moral value of caring for the sick, the infirm, and the lonely and providing charity with regard to feeding the poor was the basis for building the earliest hospitals. According to Christian belief, if one cared for the sick, the good works would have their reward in the afterlife. However, salvation of the soul was more important than restoration of the body. It was not until the Renaissance that the philosophy of healing changed in its focus.

In Byzantium it was because of Constantine's conversion to Christianity that so many hospitals were built. In the Levant (Syria, Egypt, and the eastern Mediterranean), Jewish translators helped to bridge the gap between Arabic, Greek, Syriac, and Hebrew so that the knowledge base expanded exponentially.

Islamic ideas of charity and public welfare were probably based on the Koran, which states, "You shall not attend to virtue unless you spend for the welfare of the poor from the choicest part of your wealth." Stories about Muhammad told of his visiting the sick at home to give hope and comfort, and his mentorship encouraged these very necessary acts and deeds. They transferred easily to the value in having hospitals to care for those who needed charity and restoration of health. The Muslims, like the Christians, had conflicts concerning which values were more important—faith or health—but more with regard to the healer than the patient. The Muslims were able to rationalize their study of medicine by believing that as long as they acknowledged the primacy of faith, it was acceptable to practice medicine as a form of religious service to relieve suffering.

LANA THOMPSON