HOSPITALS, NURSING AND CARE FOR THE INSANE

An excellent criterion of the social status of any period in history is the genuine humanitarian purpose that animates it, and how seriously it takes the duty of caring for those who most need care is to be found in the character of its hospital buildings and their maintenance. Tried by this standard, Columbus’ Century proves to be one of the greatest of the centuries of history. This will seem very surprising to most people, because the general impression has been that until our generation hospitals were rather ugly buildings of institutional type, with small windows, sordid surroundings and very unsuitable internal arrangements for the ailing. There is no doubt at all that hospital buildings just before our generation and some of them unfortunately remain over as living witnesses were all that has been thus suggested and if possible worse. Indeed, some of the hospital buildings of two generations ago were about as unsuitable for their purpose as could well be imagined. The general feeling with regard to this fact, however, is not so much one of blame as of pity. Most people assume that the older generations did not know how to build good hospitals. They did as well as they could, but until the development of modern knowledge of hygiene and sanitation, as well as the demand made on hospital administration by modern surgery, hospitals could scarcely be expected to be anything but the sordid piles of buildings they usually were, thought proper if they but furnished a protection from the weather and sustenance for the sick poor.

Anyone who will consult the real history of hospitals, however, will be surprised to find that the worst hospitals in the world’s history were built in the first half of the nineteenth century. The usual impression is that, if the hospitals of a century ago were so bad, those of the century preceding that must have been much worse and so on progressively more unsuitable until in the Middle Ages they must have been unspeakable. As a matter of fact, the hospitals of the thirteenth and fourteenth centuries were beautiful buildings as a rule, quite as charming structures for their purposes as all the other architecture of that time churches, monasteries, abbeys, castles, town halls and the rest. They had at this time a period of wonderful surgical practice, of which we have learned from the republication of their text-books of surgery only in recent years, and there is a definite, direct ratio between surgery and proper hospital organization. Whenever there is good surgery there are good hospitals, and whenever there are good hospitals, surgery will be found occupying a prominent, progressive place in the history of medicine.

It is hard to understand the periods of decadence in hospital construction and maintenance and in nursing care and training, but not more difficult than to understand the ups and downs of surgery. That anæsthesia and antiseptic practice should obtain for a while and then gradually be lost is no harder to understand than that hospitals should gradually “sink to an almost indescribable level of degradation.” Miss Nutting and Miss Dock, in their “History of Nursing,” have described the century from 1750 to 1850 as “The Dark Period of Nursing.”

They quote Jacobsohn, the well-known German writer about care for the ailing, who says “that it is a remarkable fact that attention to the well-being of the sick, improvements in hospitals and institutions generally and to details of nursing care, had a period of complete and lasting stagnation after the middle of the seventeenth century, or from the close of the Thirty Years’ War. Neither officials nor physicians took any interest in the elevation of the nursing or in improving the conditions of hospitals. During the first two-thirds of the eighteenth century he proceeds to say nothing was done to bring either construction or nursing to a better state. Solely among the religious orders did nursing remain an interest and some remnants of technique survive. The result was that in this period the general level of nursing fell far below that of earlier periods. The hospitals of cities were like prisons, with bare, undecorated walls and little dark rooms, small windows where no sun could enter, and dismal wards where fifty or one hundred patients were crowded together, deprived of all comforts and even of necessities. In the municipal and state institutions of this period, the beautiful gardens, roomy halls and springs of water of the old cloister hospital of the Middle Ages were not heard of, still less the comforts of their friendly interiors.”

It so happens that just about the beginning of Columbus’ Century there was a great new development of hospital building. This was only what might have been expected, for a wonderful new period of architecture was just beginning and buildings of all kinds were being erected with a magnificence that has made them the admiration of the world ever since. Handsome basílicas, Renaissance palaces, town halls were being executed by the architects of the time so as to make them precious monuments for future generations. Hospitals came in for their share of this renewal of architectural interest, and a series of really beautiful hospital buildings were erected which we have come to admire very much since we ourselves have wakened up to the duty of building fine hospitals. The old municipalities felt that buildings erected for the poorer citizens must not be planned with the idea that anything was good enough for the poor, but must be suitable to the dignity of the city.

One of the most beautiful hospitals of this time is the famous Ospedale Santa Maria degli Innocenti, which has been called the finest and most interesting foundling asylum in the world. It was built under the patronage of the guild of silk merchants in the early part of the fifteenth century, being completed in 1451, and is a model of charming architecture, decorated with fine paintings and adorned with the well-known della Robbia blue medallions. The Italians did not, however, call it as in our ruder Northern ways is our custom a foundling asylum, thus stamping the tragedy of their existence on the children, but the Home of Innocents. Surely they were the innocent victims of the conditions which had brought about their abandonment by their parents. The children were kept until the age of seven, and then they were placed about with families who promised to treat them as their own children. The boys were taught trades; the girls, trained in all domestic occupations, were, when married, given dowries by the hospital or the foster parents, or received into convents if they so wished. As showing how the spirit that organized it in Columbus’ Century lives on, we may quote what Miss Nutting and Miss Dock say with regard to the hospital in their “History of Nursing” :

“To-day this richly historic house is in charge of the Sisters of St. Vincent de Paul, under the direction of a highly scientific and progressive council chiefly consisting of medical men, and is one of the most perfectly kept and well managed institutions of the kind in existence, its union of mediaeval charm with modern science being a congenial and happy one.”

Other hospitals in Florence are scarcely less interesting. The hospital where Romola went to nurse her patients is still in existence, but is no longer a hospital. It is now the very interesting Accademia dei Belli Arti. One of the beautiful hospitals erected at this time which may serve as a type of the buildings erected for hospital purposes is the great Ospedale Maggiore of Milan. Important portions of this were finished during Columbus’ Century. One of its courts is so beautiful that it has been attributed to Michelangelo, though it seems more probable that it was due to that almost equally great architectural genius, Bramante. The famous Santo Spirito Hospital in the Borgo at Rome was rebuilt by Sixtus IV in the first half of Columbus’ Century and had many of the characteristics of the best architecture of the time. Practically every city in Italy did some really fine hospital building at this time. Naples and Venice added to their beautiful mediaeval hospitals and everywhere there was high development of humanitarian purpose in this regard.

Italy, however, was not the only country of Europe to have fine hospitals. Indeed, every country had a share in this, and wherever there was a flourishing period of architectural evolution hospitals came in for their share of the development. In the Low Countries and Northeastern France, where a series of beautiful cathedrals and churches were being rebuilt or newly erected, and above all where the magnificent town halls that have been such a subject for admiration ever since were being erected, hospitals received great attention. Not only were fine buildings erected, but a magnificent organization of nursing and care for the ailing occurred. There was great prosperity among the people, they were doing the trade of the world, they were democratic in their ideas and they felt that the dignity of the municipalities required worthy care for the citizens no matter how poor they might be.

Above all, some of our own ideas in hospitals developed among them and many of the wealthy came to realize that they could be better cared for in the efficient hands of trained attendants in properly arranged hospital quarters than in their own homes. There was not that dread of hospitals which develops whenever they are exclusively for the poor and deservedly, because the patients are inevitably the subject of many abuses.

That picturesque Belgian community, the Beguines, had charge of a number of hospitals at this time which became famous for their thorough organization and maintenance on a high level of efficiency. One of these was founded at Beaune by Nicolas Rolin, chancellor of the Duke of Burgundy, just about the beginning of Columbus’ Century. Miss Nutting and Miss Dock, in their “History of Nursing,” have given a description of this, as well as some of the details of the nursing and management mainly taken from Helyot’s “History of the Religious Orders”:

“It was built with much magnificence, with long wards extending into a chapel, so that the sick could hear the services, and opening into square courts with galleries above and below. Patients of both sexes and of all ranks and degrees were received, both rich and poor. There was one ward for those most seriously ill, and back of all a building for the dead, with ‘many lavatories and stone tables.’ In the upper galleries were suites of apartments for wealthy patients, and the gentlefolk came from leagues around. The suites consisted of a bedroom, dressing-room, anteroom and cabinet. They were richly furnished, and each patient had three beds, that he might move from one to another. Each apartment had its own linen, utensils and furniture, ‘and borrowed nothing from any other.’ The suites and wards were named after the King, royal family, dukes of Burgundy, and other prominent personages. In the middle wards patients of the middle class were received, and in the lower galleries the poor. The rich patients had their own food and wine sent to them, and paid for their medicines, but the rooms and the sisters’ services were free. Few, however, left without bestowing a gift. The poor were cared for without any cost, but if they wanted anything special they had to buy it. A little river ran through the court and was carried in canals past the different departments for drainage. It was noted that the hospital had no bad odors, such as were found in so many others, but was sweet and clean.”

The conditions in these hospitals of Columbus’ Century were so much better than we have had any idea of until recent historical studies revealed them to us, and so many people have somehow become persuaded that hospitals of the olden time were without proper provision for the care of the sick, such as we have elaborated again in our time, that descriptions of other hospitals seem necessary to make the hospital organization of the time clear. Miss Nutting and Miss Dock declare that “the hospital at Chalons sur Saône was also very magnificent, and there, too, there were no bad odors, but in winter delicate perfumes and in summer baskets of growing plants hung from the ceiling. It had a large garden with a stream running through it with little bridges over it.” It is easy to understand what a charming place for convalescents and what a pleasant view for patients could be made out of such surroundings. There is no doubt that they were well taken advantage of, for this is the time of the beautiful Renaissance gardens, when everywhere natural beauty was cultivated to a good purpose.

Helyot, in his "Les Ordres Monastiques." describes the beautiful drug rooms in these hospitals, where the various medicaments were prepared, many of them being grown in the hospital garden, and also the other rooms of the hospital, the quarters for the nursing sisters, and says that “the patients were nursed with all the skill and goodness of heart and refinement that might be expected from the conditions surrounding them.” He appreciated very well that proper quarters for patients and nurses make strongly for such nursing conditions as are sure to be of the greatest possible help in the care of diseases.

A special nursing order of Beguines was formed at this time, and as these religious women were recruited as a rule from the better classes of the population, bringing in with them such dowries as would enable them to support themselves in whatever work they might undertake, it is easy to understand on what a high plane the nursing must have been. It would remind one of the conditions in the early days of the trained nurse in modern times, when so many of the applicants for nursing positions were prepared by their family life at home for devotion to a liberal profession rather than merely the taking up of an occupation necessary for livelihood.

How their efforts were appreciated by patients will be very well understood from what may still be seen at the hospital of St. Jean at Bruges. The great painter Memling was for a time a patient in the hospital. He felt that he owed his life to the good sisters who had done so much for him, and so he painted a great altar-piece for them and decorated the famous Shrine of St. Ursula. The pictures were painted just about the time that Columbus discovered America. They are among the most beautiful examples of religious painting ever made. The decorations of the shrine particularly are among the world’s great works of art. They are almost miniatures and contain large numbers of faces, beautifully executed, but every detail has been worked out by the great painter, evidently as a labor of love. The texture of some of the garments as he reproduces them has proved a source of wonder to artist visitors ever since. Many thousands of visitors find their way to the hospital every year, and even the small sum of money (twenty cents) which is charged for admission to see them constitutes in the annual aggregate an income of thousands of dollars. The hospital, which is very spacious and has large gardens with the canal winding alongside of it, is enabled to carry on its work much better as a consequence of this notable addition to its revenues due to the gratitude of a patient of over four hundred years ago.

Many of these hospitals had beautiful decorations. They understood very well at that time that patients’ minds must be occupied if they are to be saved from the depressing effect of too much thinking about themselves, and they felt that staring at bare walls was not conducive to diversion of mind. In many of these hospitals then there were beautifully decorated walls and great pictures in the corridors. As these were painted directly on the wall, as a rule they did not collect dust nor present opportunities for dirt to gather.

Helyot has insisted on the ample water supply that they made it a rule to secure for these old-time hospitals. It was felt that the plentiful use of water was absolutely essential for maintaining healthy conditions in hospital work. In our modern time we have come more and more to realize that, while antiseptics are of great value once infection has taken place and dirt has found an entrance, soap and hot water are the best possible materials, especially when frequently applied, to maintain sanitary conditions.

Many of the habits worn by the religious who were devoted to nursing had certain features that made them much more hygienic for patients than ordinary feminine dress. As a rule, they were very simple, often made of washable materials, the head was always covered and spotless white was worn around the shoulders and at the wrist. This was sufficient of itself to keep constantly in mind the necessity for scrupulous cleanliness. Dirt showed very readily. When the nurses, or at least those who had the main duties to perform, came of refined families and wore these habits there could have been no neglect of cleanliness.

The best possible evidence for the proper appreciation of the place of hospitals in life at this time is to be found in Sir Thomas More’s account of the hospitals in Utopia. It must not be forgotten that he was travelling in Flanders when he wrote it. He pictures the people of his ideal republic as possessed of fine large hospital buildings, providing ample accommodations so that even in times of epidemic there need be no danger of contagion and abundantly supplied with all that is necessary for the care of the ailing. The standard was not what was good enough for the ailing poor, but what was worthy of the dignity of the city caring for its citizens. The proof of the completeness of their arrangements for the care of patients is to be found in the added declaration that practically everyone who was sick preferred to go to the hospital rather than to be cared for at home. This is the condition of affairs which is now developing among us again, after a long interval, during which hospitals were the dread of the poor and the detestation of those who had to go to them. The whole passage is extremely interesting for this reason:

“But they take more care of their sick than of any others; these are lodged and provided for in public hospitals. They have belonging to every town four hospitals, that are built without their walls and are so large that they may pass for little towns; by this means, if they had ever such a number of sick persons, they could lodge them conveniently, and at such a distance that such of them as are sick from infectious diseases may be kept so far from the rest that there can be no danger of contagion. The hospitals are furnished and stored with all things that are convenient for the ease and recovery of the sick; and those that are put in them are looked after with such tender and watchful care, and are so constantly attended by their skilful physicians, that as none is sent to them against their will, so there is scarce one in a whole town that, if he should fall ill, would not choose rather to go thither than lie sick at home.”

The spirit of the century and its power of organization of charity and good works is well expressed by the foundation of the Brothers of Mercy in Spain, in 1538, by a Portuguese soldier who had been wounded in battle, as was not infrequent in those days, and vowed to devote his life to God if he recovered. He rented a small house in Granada, where he gathered together a number of sick people and nursed them with the greatest care. In order to support them he went through the streets in the evening with a basket begging for his patients. After a time others came and joined him in his good work. Alms boxes were placed here and there through the city to remind people of the help that was needed. Gradually the scope of their work increased, they were given charge of hospitals, they visited the sick at their homes and the order spread not only over Europe but throughout the Spanish-American countries on this continent. Within a hundred years after the foundation the annual number of patients under their care was said to have been some two hundred thousand. A number of houses of the order was founded in Italy, and over their alms boxes down there the sign was, Fate bene, fratelli, (Do good, little brothers). From this sign they came to be known as the Fate Bene Fratelli, the Do Good Little Brothers.

The proper care of the insane is usually looked upon as a very modern phase of humanitarian evolution. Most people think that until the last hundred years the insane have been hideously neglected, when not treated with absolute barbarity, and that the rule has been simply to put them away so that they could not injure themselves or others, confining, manacling, and otherwise hampering their activities, regardless of their health or the mental effect on them. In this once more, as in most of the historical ideas with regard to humanitarian development, the erroneous notions are due to the fact that the care for the insane was at its lowest point during the eighteenth and the early part of the nineteenth century, and that there has been a magnificent improvement since, though it must not be forgotten that there has not been a single generation since when there have not been very serious complaints deservedly uttered of awful neglect of the insane in some part of the civilized world. We have had revelations with regard to the care of the insane in the country districts of even our Eastern States which have been almost incredible. The conditions that we have come to learn as existing in the South in the care of the insane, which have been brought to light by the recent investigation of pellagra, have been of a similar character. The epithet mediaeval which is applied so often to these conditions is absolutely unwarranted by our present knowledge of old-time care of the insane.

It has been concluded that, since care for the insane was so neglected in the eighteenth century, it must have been almost infinitely worse in preceding centuries. The same fallacy lies at the root of a great many false impressions with regard to mediaeval and Renaissance history. The eighteenth was the lowest of centuries in art, literature, education, and humanitarian purpose. The preceding centuries exhibit some very interesting developments of care for the insane, some of which anticipate our most modern ideas. At Gheel in Belgium, from the earlier Middle Ages, they cared for defectives on the village plan. Similar institutions were not infrequent. They developed the “open door” system of caring for the insane and insane institutions were mainly in connection with monasteries, well out in the country, and under good conditions, since they were never crowded. It is always crowding that brings serious abuses with it and leads to what seems to be barbarity, but is really an inability to cope with the large problem with inadequate means.

It so happened that just before the beginning of Columbus’ Century there was a special development of care for the insane and the opening of a series of hospitals that represent an epoch in the history of care for these poor people. The most important part of this development of the fifteenth century occurred in Spain. Asylums were founded at Valencia, Saragossa, Seville, Valladolid and Toledo. This movement has sometimes been attributed to Moorish or Mohammedan influence, but even Lecky, in his “History of European Morals,” has rejected these assertions which are absolutely without proof. Spain continued to be the country in which lunatics were best cared for in Europe down to the beginning of the nineteenth century. Pinel, the great French psychiatrist who struck the manacles from the insane of France, declared Spain to be the country in which lunatics were treated with most wisdom and most humanity. In his book on “Mental Alienation” he gives some details of the treatment which show a very modern recognition of the need to be gentle and careful of the insane rather than harsh and forceful.

In England a rather important development of care for the insane occurred during this century in connection with Bedlam Hospital, London. This, originally founded as a home for the suffering poor, as its name Bethlehem (house of bread) implies, whether they had any specific ailment or not, came after a time to be a hospital, and then as a further development confined its care to the insane. Tyndale is the first to use the word Bedlam as meaning a madhouse or a madman, so that the conversion had evidently taken place in his time. One very interesting custom developed which serves to show the mode of treatment practised. A “bedlam” came to signify one who had been discharged from this hospital with the license to beg. After recovery from their acute conditions the insane were allowed to go out on condition, if there was no one to care for them, that they wore a tin plate on their arms as a badge to indicate that they had been for a time in the asylum. This tin plate aroused the sympathy of those they met and they were helped in various ways by the people of the time. Besides, it served as a warning that, since such people had been for a time in the asylum, they were not to be irritated nor treated quite as other folk, but on the contrary to be cared for. They were known as bedlamers, bedlamites or bedlam beggars. They were treated so well that tramps and other beggars of various descriptions obtained possession of badges and abused the confidence of the public.

After Henry VIII’s time Bedlam, which had been a religious institution, passed under the care of the state, and from this time on the story of abuses of all kinds is repeated at successive investigations in every other generation. Evelyn, in his “Diary of 1656,” notes that he saw several poor creatures in Bedlam in chains. In the eighteenth century it became the custom for those seeking diversion and entertainment to visit Bedlam and observe the antics of the insane patients as a mode of amusement. This was done particularly by the nobility and their friends. A penny was charged for admission into the hospital, and there is a tradition that at one time an annual income of L400 accrued from this source. This would mean that one hundred thousand people had visited the hospital in the course of a year. Some of Hogarth’s pictures show the hospital being visited in this way by fashionable ladies.

In Rome the Popes, recognizing the superiority of the care for the insane as practised in Spain and in Navarre, opened a Pazzarella at Rome in the sixteenth century under the care of three Navarrese. This hospital for the insane “received crazed persons of whatever nation they be and care is taken to restore them to their right mind; but if the madness prove incurable they are kept during life and have food and raiment necessary to the condition they are in.” Evidently they looked for improvement in many cases and expected to allow the patients to leave the asylum at least for a time, though if their alienation continued they were kept. Just about the end of Columbus’ Century a Venetian lady of wealth, evidently attracted by the kind of care given the insane, “was moved to such great pity of these poor creatures upon sight of them that she left them heirs to her whole estate. This enabled the management with the approbation of Pope Pius IV to open a new house.”

It is after the sixteenth century that decadence in the care of the insane becomes very marked. This reached its climax, as might well be expected, just about the same time that hospitals and care for the ailing reached their lowest ebb of efficiency. Burdett, in his “Hospitals and Asylums of the World,” London, 1901, gives his third chapter the title, “The Period of Brutal Suppression in Treatment and Cruelty, 1750 to 1850.” This decadence was largely due to the fact that institutions for the care of the insane became State asylums, with hired attendants, whose only interest after a time was the drawing of their salary and having as little trouble as possible with the care of the insane. In the previous centuries they had been under the care of the religious orders.