Funding and reforming medieval hospitals

Posted on December 4, 2019 by Ruth

By the late medieval period, that is, the 13th-15th centuries, the monastic and city hospitals were often large and highly developed. The largest hospital in medieval England was St. Leonard’s in York, where 200 patients and 18 orphans were supported. St. Leonard’s had the very advanced—and expensive—touch of keeping lamps burning in the wards all night. Long-term patients sometimes wore uniform robes like the monks and nuns, and they participated in maintenance chores if they were able. The orphans formed a school and support staff for the regular hospital. Monks and nuns with practical medical and herbal training made the rounds for patient care.

How was such a large establishment funded in that time? In some cities, tax money directly supported the hospitals. In others, the hospital was granted the revenue rights to something, like ferry tolls or port fees. That was generally a popular medieval way of funding quite a few things. The beneficiary had an interest in overseeing the revenue activity, so it created administration and funding at once.

Hospitals sought private donations actively and aggressively. Leper houses required lepers to beg in public, as long as they kept some distance from the patrons. But most donations came in bequests at a wealthy person’s death. Some donated beds, and others donated houses. Hospitals might receive a farm or just about any other revenue stream that an individual had owned, such as a mill or a forest. Most of these were either sold or managed as an income stream.

When the house was in a good place to expand the hospital, it was retrofitted for a new use. Manor halls with high ceilings became wards with lines of beds along both walls, while private rooms were built at the ends. The same thing was done during the First World War, though as temporary housing, so we can get a sense of what this looked like. The beds that were donated usually went straight into such wards, so probably the beds in a ward were far from uniform.

As hospitals organized in a more advanced way, bequests and endowments were managed by a board, as they are today. Or mismanaged as the case may be. In 1311, the Pope directed that cities should audit their hospitals to make sure the money was going to the right place. Some “hospitals” were caring for few if any patients, and some hospital administrators were living comfortably while the roofs of their institutions were falling in.

After the plague in 1348-50, things got worse. The plague overwhelmed a hospital system that was set up for relatively static needs like old age or blindness. Most hospitals did not distinguish between sick patients and orphans, since both needed care, but the plague exponentially increased the number of orphans. Hospital staff died off with their patients, and endowments were left with nobody to use them. Cities and orders combined failing hospitals and set up new ordinances for their purposes. Typically orphanages, almshouses (for the aging poor) and sick care were now specified. That way, no one institution would be as overwhelmed by a new visitation of the plague, since it could restrict its help to just some sectors of need.

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The growth of medieval hospitals

Posted on December 4, 2019 by Ruth

In the ancient world, care for the sick was presumed to be the domain of the family home. The hospital system developed for care of travelers, orphans, and the very poor. The words “hospital” and “hostel” are cognates, both derived from Latin “hospitium.” For a time, the medieval English word for a hospital was simply “spital.”

The first European hospitals were designated sick bays in Roman army camps. In a sense, every soldier was a traveler and an orphan (except for those whose sisters or mothers came along). If the army was to take a man from his family for years, it had to create a substitute sick care system. After the fall of the western empire, the Roman idea of dedicated houses for the sick persisted in its eastern capital, Constantinople. If you wanted to try out one of Paul of Aegina’s surgery methods, your best bet would be one of those Byzantine hospitals, where one could recover from an infection or have simple surgeries.

The next major hospital development was the growth of Benedictine monasteries in Europe. The Order of St. Benedict required rooms set aside for the sick, with a monk assigned to care for them. Monasteries grew medicinal herbs for the sick, and they also made sure that regular meals and baths were given. The sick were exempted from fasting; they could eat meat soup during Lent. (People being what they are, quite a few monks got sick during Lent.)

The monasteries primarily cared for their own sick and aged, especially the aged. Joining a monastery was a way of ensuring that you’d have nursing care in your last years. But the monasteries were also required to give care to travelers who fell sick, and to the local poor who were sick and aged. Gradually, some of the monasteries expanded their hospital functions to be more general.

A big turning point came with the Crusades, when Europeans got to see Constantinople’s hospital system. The idea of having dedicated places for the old, poor, and sick came home with Crusaders, who then supported hospitals with endowments. The first main group to bring the idea back was, of course, the Knights of the Hospital. Their original purpose was to guard pilgrims to Jerusalem by providing defensible houses with a few knights and men at arms attached. The Knights of the Hospital were a military-monastic order, so some of their number mainly fought in the Crusade wars. But others developed the function of the hostel/hospital in imitation of the Byzantine customs, and they began to spread Hospitaler houses into Europe. The first Hospitaler hospital in England began in 1128.

Other religious orders were founded specifically to care for the sick and poor, and many of them started in the Holy Land on the same model as the Hospitalers. The Order of St. Lazarus of Jerusalem cared for lepers. St. Mary of Bethlehem cared for, among others, the insane, and its institution in London became known as the infamous “Bedlam” short for Bethlehem. The Order of the Trinity administered hospitals in France, and a small order of St. Thomas the Martyr of Acon managed one large hospital in England.

Cities began to found hospitals with specific purposes. Some were for the blind, or for orphans, while others were for the aged. Most of them shunned infectious disease, since it was dangerous and there was at least enough physical frailty to keep their rooms full without it. Most of the charters included or excluded other conditions: pregnancy, leprosy, insanity. The most numerous and best city hospitals were in Italy, where each city-commune organized fairly efficiently at a time when the rest of Europe was primarily feudal. Guilds, too, founded hospitals for the sick and aged among their members.

The hospital at this time did a few basic things for its patients. First, it gave them a bed: literally a bed, perhaps the first bed the patient had ever seen. The rooms were heated and sometimes had lights burning at night. The patients got regular meals and baths. For many sick people, this was enough to recover. Second, it gave them spiritual care, which was seen as a key service in medieval times. The sick so often did not recover, and to die unconfessed meant spending much more time in Purgatory. So the monks and nuns who staffed the hospitals kept up regular prayers and masses, and patients were required to participate if at all able. Dying in a hospital meant almost certainly having the benefit of the last rites, which gave the dying some peace of mind, easing their pain.

 

 

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Medieval Muslim medicine

Posted on November 26, 2019 by Ruth

Medicine in the Muslim regions was at once better and slightly worse than in the Christian areas. In the academic realm, all the best books were in Arabic, and the cutting-edge research (such as it was) was too. But at the day to day treatment and care level, medical practice was in general more passive in the Muslim regions. The difference may not have been great, since effective medicine was generally lacking. Passivity for philosophical reasons probably also varied with place, time, and person (same as with anything).

My comments in this article are based on general knowledge from many sources, and specifically on the Tibb al-A’imma, an Ismaili (Shi’ite) collection of medical advice. You can find this document here: https://www.al-islam.org/printpdf/book/export/html/41434

Most of Europe and the Middle East accepted the Greek doctrine of four humors. This framework was simply Science, their construct of how things worked. Bodies, climates, foods and herbs, were divided into hot and cold, wet and dry. The Tibb al-A’imma notes that, of course, medical treatment had to take climate into consideration. A cold rainy place like Paris needed different medicine from a hot dry place like Cairo.

The Muslim philosophical tradition was ambivalent about intervening in disease. Religious leaders had been respected as physicians, so there are sayings from the Prophet, his Companions, and leading men (including the others in the line of 12 Imams) explaining the connection between physical and spiritual. The Tibb al-A’imma notes that emotional and mental sources of stress could cause physical symptoms, which is why its writers generally justified the use of charms which addressed the beliefs of the sufferer. The key point was that the charms had to be phrases from the Quran, to make sure that nothing illicit was allowed. Christian use of charms followed the same principle, but the Islamic charms may have been more strictly straight out of the Quran than the syncretic Christian charms.

Islamic philosophy saw pain as a way to expiate sin. One saying notes that “a night of fever expiates a year of sins.” Because the soul’s health mattered most, a doctor might hesitate to relieve pain when it was better for the patient to suffer patiently. In practical terms, a physician probably used whatever herbs for pain that he could supply, without hesitating, but the philosophy supplied him with reasons to feel less urgency about curing a pain at all costs. Some pains were direct rebukes from Allah, so should these be cured at all?

Perhaps for this reason, Islamic medicine focused primarily on prevention. Good health came from eating little and abstaining from various excesses, and also from strong faith. Strong faith meant not going to doctors. The Tibb al-A’imma praises those whose faith was so strong that they were rarely sick and never called doctors. The four humors theory, of course, also focused on prevention. Eat for your physical type and climate, which is the will of Allah anyway. It was not clear what was the will of Allah for the sick, but for the healthy, it was clear, so squandering your health with overeating was seen as close to a sin. Prevention and piety were hand in hand.

The hadiths about medicine were evaluated not for success in healing, but as hadiths were in general:  by who had transmitted them, and how. Pragmatic success was not a way to judge skill, as illustrated by a hadith of the Prophept. A man asked Mohammad about his brother’s abdominal pain, and the Prophet suggested honey in hot water. The next day, the man reported that it had not helped. The Prophet said that Allah does not lie, but the brother’s belly could. Privately, he told his followers that this man must be a hypocrite, and medicine could never help such a one.

One of the points of dispute among Muslim physicians was in the role of wine in medicine. It was the base fluid for many, if not most, Christian herbal medicines. We moderns can’t help pointing out that alcohol kills germs. But since the Prophet had forbidden wine, most Muslim doctors held that no, it could not be used as medicine. Why would Allah use something forbidden to heal? That made no sense.

Islamic medicine may have focused more on bleeding and cupping than Christian medicine at this time. It certainly recommended these remedies, cautioning that recitations of the Quran had to be pronounced over the flowing blood. I wonder if treating blood this way became a more common practice when mixtures with wine were prohibited, and also I wonder if bleeding came into European early modern medicine mainly through the Arabic medical texts. But I haven’t researched these questions.

Herbal treatments and accompanying charms were not very different from those we saw in Bald’s Leechbook, accounting for different climates and plants. One of the Imams left us a treatment for phlegm: Equal parts of Byzantine mastic, frankincense (a major product of the Arabian peninsula), thyme, bishop’s weed, and fennel were ground into powders, sifted, and combined. This mixture was added to honey, to be taken twice a day.

Quran-based charms were also similar in spirit. One charm for tooth pain in Timm al-A’imma says to take 3 olive leaves and write on each one, “In the name of Allah. There is no sovereign greater than Allah, the King, and you are his Khalifa. Ya Haya Sharahiyya, remove the illness and send the cure, may Allah bless the Prophet and his family.” A note explains that Ya Haya and Sharahiyya were names of God from Hebrew. (Ya Haya must be the four-letter name of God that we render Jehovah, but I can’t place the other.) A further instruction to make the charm better suggested putting the olive leaves into a cloth, and tying the cloth with seven knots, and naming each knot after one of the prophets: Adam, Nuh (Noah), Ibrahim, Musa, Isa (Jesus), and Shuayb (?). The cloth was to be attached to the tooth while praying for peace on the Prophet and his family.

I doubt that the differences in medical philosophy meant much for the health of a population during the main medieval centuries. It was in the following centuries, the Renaissance to Early Modern periods, that it mattered. European medicine became based on dissection and experimentation with herbal chemicals, but Islamic medicine was forbidden to pursue dissection, at least. Europe’s Christian philosophy promoted intervention in nature’s ways, perhaps based on how the stories of the saints showed them putting out fires and curing diseases. If the saints changed the course of nature, how could it be wrong to imitate them? This early stage laid the foundation for modern science.

People often ask why the Muslim world, with its base of Egyptian, Persian and Indian sciences, fell behind after the close of the Middle Ages. I think here is one of the reasons: the rise of scientific medicine was not something Islamic philosophy could at first accept, especially as embodied by the Ottoman Empire of the 16th and 17th centuries. The Empire was wary of innovative religious ideas, because they had learned the hard way that such things led to revolts. It preferred a uniform and change-resistant set of religious beliefs and practices. At the same time, Europe was exploding into diversity of opinion and practice in the Reformation. Europe paid in massacres and persecutions, but it also made space for intellectual innovation that broke previous religious barriers in medicine.

 

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Medieval discrimination against Jewish doctors

Posted on November 23, 2019 by Ruth

Medieval Christians often feared that Jews were not bound by the same moral rules as Christians. Their helplessness in the face of disease or medical hocus-pocus made them suspicious that their medicine might be poison.

Leprosy had already established medicine as an adjunct of the legal profession: there were court battles over whether a man did or did not have leprosy, because if he was certified to have it, he had to die legally. The city enforced his writing a will and vanishing from society. Some men hired their own doctors and took the city to court. Sometimes juries had to decide if they could trust the word of a Jewish doctor who disagreed with Christian doctors.

All medieval doctors were liable to being sued for malpractice. Doctors were frequently fined, and sometimes they were condemned to banishment or even death. Jewish doctors were not more liable than others, but when they were found guilty, it reinforced Christian suspicions against their whole community. When fines were too heavy for an individual doctor to pay, the Jewish community often helped because paying the fine made the talk settle down.

Jews avoided working as pharmacists. That was the quickest way to be accused of maliciously compounding a poison. If a Christian did the compounding, then the Jewish doctor at least did not bear responsibility if he could prove that his prescription was reasonable. After the plague of 1347-50 sharpened Christian fears that some disease was deliberate Jewish poisoning, Jewish doctors were required to taste their medicinal wines before administering them—and the wine not being kosher was excluded as an excuse.

But the basic problem was that medieval people had begun to expect doctors to care for them in sickness, even if they were not aristocrats, and there was a shortage of Christian doctors. University education was incredibly expensive, and the Church forbade its priests and monks from studying medicine. But Jewish families that arranged for training within a family network were able to manage the training more easily. The number of Jewish doctors was rising, so forbidding Jews too widely would mean cutting off medical care.

Eventually, some rulers forbade Jews to practice medicine. A number of doctors had been accused and convicted of deliberately poisoning their patients; those convicted were hanged. Christians also had rumors going back to to the 12th century that suggested Jews liked to dig up dead Christian bodies and make potions out of their ground-up bones, adding Hebrew spells that invoked Satan.

Provence forbade Jews to practice medicine, or Christians to consult them, in 1306. Sicily did the same in 1310. In 1337, the Pope at Avignon spelled out rules forbidding Christians to consult Jewish doctors unless the patients was at death’s door and nobody else was reachable. But Provence had to revoke its decree a few years later, as did the Pope.

For the next few centuries, this pattern continued. A ruler would forbid Jewish doctors, but everyone would circumvent and complain against these laws. Sometimes the decrees were repealed, other times both the Church and secular officials continued to call in Jewish doctors. It got worse after the plague, and by the early 1400s, Italian cities that had public hospitals were confronted with firing their Jews or dealing with paranoid patients. Still, Christians really never stopped consulting their favorite Jewish doctors. By this time, medicine was widely taught among Jewish families. It was a life-preserver.

 

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My son, the Jewish doctor!

Posted on November 20, 2019 by Ruth

During the Middle Ages, Jews became prominent as doctors, but it took a few centuries for this to happen. There was no real Jewish medical tradition, apart from common sense patient care.

The first step toward Jewish medicine was that Jews in the Arabic world began translating books into Hebrew, so that Jews in Europe could read them. In 800, the Caliph of Baghdad had ordered his new House of Books to buy and translate every book they could find. This project became the main way that a lot of Greek literature was preserved when its original cities were sacked or burned. We have Euclid’s Geometry only as translated back out of Arabic into Greek and Latin.

During the 11th and 12th centuries, enterprising Jewish scholars who spoke Arabic as a first language were involved with Christian efforts to translate Arabic medical books into Latin. Naturally, they also produced Hebrew renditions.  Toledo was a center of this translation activity, because Spain had such a large Jewish community that spoke Arabic as a mother tongue, learned Hebrew at home and synagogue, and studied Latin in school. Maimonides’ medical books in Hebrew were primary sources for Jewish study.

The most prestigious doctors held the “laurea” degree from universities, but these schools did not admit Jews during most of the medieval period. All doctors, university-trained or privately schooled, had to pass licensing exams. Each city had a medical examining board composed of two or three Christians. Aspiring physicians had to give lectures and explanations of material in medical textbooks and answer other questions. They could be licensed with limitations if the board was uncertain of their skill; for example, a Jewish doctor with a limited license might be required to practice in partnership with a Christian, or a young doctor with an older, more experienced one, or the license might specify the areas of medicine in which the board felt the holder was competent.

A licensing process like this was personally biased against Jews, but it also was reasonably objective. If a man studied privately with an established doctor, the board did not discriminate against this education if he could pass their exam. That’s where it all came together for Jewish doctors, because their distant relations in the Arabic world could provide them with textbooks, and their families could arrange mentoring, sometimes through marriage to a doctor’s daughter. Medicine became a sort of family dynastic practice.

Outstanding Jewish doctors were richly rewarded by Christian city or national rulers. They were paid a lot, of course. Additionally, they could be given special exemptions from taxes or rules imposed on other Jews. Some got permission not to wear weird pointy yellow hats or other distinctive clothing. In some cases, the secular rulers sent word to synagogues stating that the favored doctor should be given precedence in the service. There’s no question that “My son, the doctor” became an exceptionally important bragging point.

 

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Avicenna

Posted on November 13, 2019 by Ruth

Avicenna was one of the first medieval scholarly medical doctors. “Avicenna” is how his name came into Latin, the way al-Khwarismi came to us as algorithm. It’s a shortening of Ibn Sina, son of Sina, which was actually his family’s more-or-less surname since Sina had lived many generations previously. Wikipedia tells me his full name was Abū ʿAlī al-Ḥusayn ibn ʿAbdillāh ibn al-Ḥasan ibn ʿAlī ibn Sīnā. His personal name was Husayn, and the names after that are a listing of his father, grandfather, and great-grandfather—-while the “Abu Ali” part means his son was probably named Ali. “Ibn Sina” is how his works were signed.

Born around 980, Avicenna grew up near Bukhara, the capital of the Saminid Iranian dynasty. In theory, the Caliph in Baghdad ruled over all, but in practice, independent Sultans ruled small Persian and Turkish kingdoms from Afghanistan to Syria. Bukhara was a great imperial capital with income from the Silk Road trade. The Sultan funded scholarship, which was a nucleus of early university activity.

Young Husayn Avicenna began normal Islamic education with the Quran, but he was a prodigy who quickly moved on to mathematics, medicine and philosophy. By age 18, he was counted as a medical doctor in his own right, and he had extensively read the works of Aristotle and Islamic law. For four years, around the year 1000, he was chief doctor to the Sultan of Bukhara, until his father had died and the dynasty was overthrown. Then he moved westward through Iran by stages, serving as the Sultan’s doctor wherever he was.

He appears to have written as many as 450 books on topics of theology, philosophy, mathematics, astronomy and astrology, alchemy (early chemistry) and of course medicine. His five-volume medical encyclopedia became the primary book of its time, translated and copied widely. It was originally written in Arabic, although the Sultans in Iran at that time were encouraging scholars to return to writing in Persian, as they had done in pre-Islamic times. It was translated into Latin, probably in Cordoba during its Golden Age, but it was also translated into Irish, as we know from a fragment found last year.

Avicenna’s medicine isn’t going to impress us; he taught the four humors of the body as did everyone at the time. He had some interesting ideas in other fields, for example, he thought that light had a speed, as we now know it does. He posited that heat was generated from motion. All in all, he was one of history’s most impressive men for the sheer volume of ideas he gathered and generated in his 58 years.

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Dr. Maimonides, 1138-1204

Posted on November 11, 2019 by Ruth

When the Almohad Berber dynasty conquered most of Muslim Spain, their puritanical, tough-nomad attitudes brought persecution on religious minorities. They ended the practice of “dhimmi” minorities as a protected class paying a higher tax. Now, Christians and Jews had to convert, leave, or die. Many left, and the family of Maimon ben Joseph was among them.

Maimon had two sons, David and Moses. Moses studied Torah in Hebrew and Greek philosophy in Arabic, while David was a merchant. After the family resettled in Morocco, then in Egypt, David died in a shipwreck. Moses ben Maimon needed to support both his own family and his brother’s. He became a doctor, probably building on studies begun in Cordoba. We know he also trained in medicine in Fez. In Egypt, his family settled in Fustat where there was a Jewish community and synagogue. He became their doctor.

Fustat was very close to the new city of Cairo, built by the Fatimid dynasty, but now home to Saladin—of Crusades fame. Moses’s reputation reached Saladin, who called him in to consult on his maladies that included asthma. Moses split his time between the royal court in Cairo and his Jewish neighborhood in Fustat for many years. He worked extremely long hours, seeing patients at all hours. Somehow, he managed to write books at the same time.

We know Moses as “Maimonides” in English because when his books were translated into Latin, his Hebrew name “ben Maimon” became “Maimonides.” He is also known in Hebrew as the Rambam, an acronym for “Rabbi Moses Ben Maimon.” Maimonides wrote treatises on Jewish law, theology, and philosophy; he really was very prolific. His most famous title is “Guide for the Perplexed.”

And of course he wrote about medicine. By writing in Hebrew, he made the medical lore of Greece and Rome easily accessible to other Jewish doctors. But he added to it, in fact warning other doctors not to accept anything they read in a book, but always to impose their own empirical testing on ideas. In addition to the theories of the four humors that were typical of his time, he recommended some ideas that still are right to modern eyes. For example, he recommended whole wheat bread and avoiding a lot of meat fat, vigorous aerobic exercise, avoidance of city pollution, and attentiveness to helping patients avoid depression. His medical titles include treatises on hemorrhoids, asthma, poison, and fertility. His fertility book is “On Cohabitation,” and it gives aphrodisiac prescriptions.

 

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Book includes medieval language samples!

Posted on August 30, 2018 by Ruth

This exciting student work/textbook explains how English changed through the medieval period. It even has a section with simple Anglo-Saxon man-on-the-street interviews so you can follow along and hear it spoken. A whole chapter each on the Danish migration and the Norman Conquest!

Excavating English (Digital Download)

 

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Sing the Brain Song!

Posted on August 30, 2018 by Ruth

Ellen’s Basement Workshop song to learn the parts of the brain!

 

“The Brain Song” (Digital Download)

 

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Thaw, feed, serve: very old worms come back to life!

Posted on August 30, 2018 by Ruth

Worms are amazing creatures!

These worms in Siberia were frozen thousands of years ago. In 2018, scientists took over 300 specimens and began carefully thawing them. Two of them came back to life! They began moving and looking for something to eat. Researchers think they are both females, making them the oldest living “women” in the world.

How do worms do it? We really don’t know, but we study worms to try to learn their secrets. They’re just simple enough to be a tantalizing goal, but they’re never as simple as we think.

You can learn the characteristics and classification of 24 types of worms with this game, Worm Farm. It’s a FREE DOWNLOAD with instructions to make and play two games. perfect for teachers! “Worm Zoo”

Want to study the anatomy of a planaria? Here’s a FREE download about planaria that lets you make a front side/inside worm with cardstock, print it yourself!

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