Acta Theologica Supplementum 7 2005

THE EVOLUTION OF HOSPITALS FROM

ANTIQUITY TO THE RENAISSANCE

ABSTRACT
There is some evidence that a kind of hospital already existed towards the end of the
2nd millennium BC in ancient Mesopotamia. In India the monastic system created by
the Buddhist religion led to institutionalised health care facilities as early as the 5th
century BC, and with the spread of Buddhism to the east, nursing facilities, the nature
and function of which are not known to us, also appeared in Sri Lanka, China and
South East Asia. One would expect to find the origin of the hospital in the modern
sense of the word in Greece, the birthplace of rational medicine in the 4th century BC,
but the Hippocratic doctors paid house-calls, and the temples of Asclepius were vi-
sited for incubation sleep and magico-religious treatment. In Roman times the military
and slave hospitals were built for a specialised group and not for the public, and were
therefore not precursors of the modern hospital. It is to the Christians that one must
turn for the origin of the modern hospital. Hospices, originally called xenodochia, ini-
tially built to shelter pilgrims and messengers between various bishops, were under
Christian control developed into hospitals in the modern sense of the word. In Rome
itself, the first hospital was built in the 4th century AD by a wealthy penitent widow,
Fabiola. In the early Middle Ages (6th to 10th century), under the influence of the Be-
nedictine Order, an infirmary became an established part of every monastery. During
the late Middle Ages (beyond the 10th century) monastic infirmaries continued to expand,
but public hospitals were also opened, financed by city authorities, the church and
private sources. Specialised institutions like leper houses also originated at this time.
During the Golden Age of Islam the Muslim world was clearly more advanced than
its Christian counterpart with regard to the magnificent hospitals which were built in
various countries, institutions which eventually became the true forerunners of the
modern teaching hospital.

1. INTRODUCTION
Public health was until relatively recently very low on the list of priori-
ties in the Western world — in fact, it only became a national objective
in some countries in the late 18th century. This is, however, not surpri-
sing when one considers all the forces working against it since the be-
ginning of Western civilisation, especially in Greece and Rome. Various
factors prevented the early development of an adequate health service,
for instance ignorance, the unsympathetic attitude of the Greeks and
Romans towards the sick, superstition and religious beliefs. There were,
however, also positive measures taken by the Roman government in par-

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ticular to promote public health, like the appointment of state phy-
sicians and free medical services to the poor. The provision of a re-
latively advanced infrastructure in the form of aqueducts to provide
sufficient fresh water for the population, a network of gigantic sewers un-
derneath the city for the disposal of sewage, and numerous public baths
all over the city were further ways of promoting hygiene.
From a modern point of view, the most important and lasting con-
tribution of the ancients to public health was the establishment of the
hospital in the modern sense of the word, i.e. an institution where the
sick and disabled could receive treatment for a period of time. It is,
strangely, not in Greece, the birthplace of rational medicine in the 4th
century BC that one finds the origin of the hospital, nor in the temples
of Asclepius, or even the Roman military and slave hospitals which can
be traced back to the 1st century BC. It is to the Christians that we owe
the origin of the modern hospital — perhaps paradoxically, because in
certain respects Christianity had a rather negative effect on medicine:
anatomy was denounced, human dissection was prohibited because a
man’s body is the temple of the Holy Spirit, the occurrence of miracles
advanced superstition, and diseases were regarded as a punishment for
sin. However, Christian contribution lay on another plain, namely com-
passion with and caring for the sick. Under their control hospices built
to shelter pilgrims and messengers between bishops developed into hos-
pitals in the modern sense of the word.
Sir William Osler once said that Imhotep, grand vizier to king
Zoser (Third Dynasty, c. 3 000 BC, and builder of the first pyramid
at Sakkara), was “the first figure of a physician to stand out clearly
from the mists of antiquity” (Major 1954:39-40). If we assume that
our written records of medical endeavour do date back to that distant era
of Egyptian and Mesopotamian development, it is indeed surprising
that hospitals as we know them today did not appear until the 4th
century AD. However, evidence that forerunners of hospitals might
have existed in the 2nd millenium BC will be discussed. In this article
the development of the hospital is traced from its onset up to the end
of the Middle Ages, with emphasis on Europe and the Near East.

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2. DEFINITION OF TERMS
A hospital is defined as a room, rooms or building specifically employed
for the investigation and continued treatment of the diseased. For the
purpose of this study, the Greek iatreion and Roman taberna medica, com-
parable to the modern physician’s consulting room, are excluded from
consideration (Harig 1971:184-185), but it is accepted that under
special circumstances these rooms might well have been put to short-
term use as hospital equivalents (Woodhead 1952:245).
The words hospital, hôtel, spital and hospice are all derived from the
Latin word hospitium meaning “a place of entertainment for strangers, a
lodging, an inn, a guest-chamber” (Lewis & Short 1958:867). In late
Christian times such hospitia were often attached to a monastery and
primarily intended for accommodating pilgrims. Today a hospice usu-
ally indicates a home for the terminally ill. The word hôtel is an early
French term, and is a forerunner of the present word which refers to
a building offering accommodation to paying guests — with no con-
nection to illness (Aitken 1984:9-11).
The word infirmary (from Latin infirmarium) originally referred to
a room or rooms attached to a monastery for the treatment of dis-
eased monks (Aitken 1984:9-11). In the Roman world a valetudinarium
referred to a hospital initially solely for the treatment of military per-
sonnel, but the word was later also used to denote hospitals for the
civic population (Scheider 1953:262-264). In the monastic period the
term nosocomium came into use to indicate a small Roman type hospital,
while the Greek word xenodochion which initially denoted a home for
strangers and the poor, eventually referred to charitable hospitals in
the early Christian era (Allen 1990:447-450).
During the Golden Age of Islam (9th-13th centuries) the Persian
word bimaristan denoted a hospital, while maristan referred to an in-
stitution for the insane (Major 1954:229; Porter 1997:105).

3. EARLIEST TIMES
There is some evidence that the earliest hospitals known to us may
have been in ancient Mesopotamia. Reiner (1964:544-549) presents
evidence that royal physicians at Assyrian and Babylonian courts to-

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wards the end of the 2nd millennium BC, cared for ill court singers in
what were probably elementary hospitals or nursing homes. Classical
sources also refer to possible hospitals in the Hellenistic Age attached
to the Egyptian temples for Saturn in places like Heliopolis, Memphis
and Thebes. However, this probably denoted sleeping accommodation
in temple precincts, rather like that associated with the Asclepian cult
(Aitken 1984:7).
The Buddhist religion with its roots in 6th century BC India led to
the creation of a monastic system, which, as with subsequent Christ-
ianity, gave rise to institutionalised health care facilities in and around
these monasteries as early as the 5th century BC. The nursing profes-
sion may also have originated here (5th century BC), and we are told
that Sri Lankan hospitals date back to 431 BC. We know very little
about the nature and function of these institutions, but the great Indian
king, Asoka, is credited with the construction of hospitals for humans
and also for animals during the 3rd century BC (Aitken 1984:7; Haeger
1988:53-54). With the eastward spread of Buddhism, so-called hospi-
tals, almshouses and convalescent homes also appeared in China (perhaps
as early as the 5th century BC) and South East Asia. The precise nature
of these institutions is obscure (Major 1984:100; Philips 1993:149;
Chrystal 2000:536).
In antiquity the Mosaic laws covered health matters extensively,
but the Jewish nation is not associated with the founding of hospital
systems (Major 1954:55-65). The Bible does not mention such insti-
tutions, but we do know of persons treated for illness in private homes,
e.g. the child in Zarephath (I Kings 17:17-24), Lazarus (John 11:6-25),
the centurion’s child (Luke 7:1-9), the illness of king Ahaziah (2 Kings
1:1-16) and the Good Samaritan in the parable (Luke 10:34, 35).

4. GRAECO-ROMAN ERA
Primitive health care associated with the temples of Asclepius are con-
sidered by many to have been the forerunners of true hospitals (Thompson
1975:3, 4). Founded at Epidaurus in the 5th century BC (Fig. 32), the
Asclepian cult revolved around temple complexes usually built at scenic,
wooded sites with an abundant water supply. Asclepiea were later built
all over the Roman Empire, and flourished up to 391 AD when as

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Figure 32: Remains of the sanctuary of Asclepius, Epidaurus.

pagan temples, they were officially closed by the Christian emperor

Theodosius I. Their structure was fairly standardised, usually consisting
of large rooms, closed on three sides, orientated to the sun and opening
to the south with a row of pillars in the form of a Greek stoa (portico).
Big Asclepiea like that at Pergamum included treatment halls, libraries,
a stadium, baths and latrines.
Patients normally entered the temple for incubation sleep in the stoa
(Fig. 33). Their dreams were then interpreted by priests, who also sug-
gested the appropriate therapy (Thompson 1975:3-4). The hypochon-
driacal Aelius Aristides for instance, relates how he spent considerable
time as a patient in the home of an Asclepian temple warden, and how
in consultation with a physician he was given a therapeutic medica-
ment after his dreams had been interpreted (Orations 48.34-35, 46-49).
Therapy was mainly of magico-mystic nature, and completely alien to
the co-existing Hippocratic medicine which was based on contem-
porary scientific knowledge and abhorred the occult in medicine.
There was, however, ironically, a famous Asclepieum on the island of
Cos, where Hippocrates taught. The Hippocratic doctors visited and
treated patients at their homes and performed the occasional surgical

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Figure 33: Incubation sleep: Asclepius, attended by Hygiea, treats a

sleeping woman. Votive relief, 4th century BC. Piraeus Museum.

procedure, but there is no evidence in Classical Greece of the use of

hospitals in the modern sense of the word, although there is suggestive
evidence that rooms in private homes were occasionally adapted for longer
term medical treatment (Major 1954:121-136; Woodhead 1952:245;
Harig 1971:183).
The first official step taken by the Roman government in public
health care — other than the passing of various laws in this regard
(Cilliers 1993) — was the establishment in 293 BC of a temple of
Aesculapius on the Tiber island in the aftermath of a disastrous epi-
demic. In the crisis the Senate took the traditional step and consulted
the prophetic Sibylline books; the recommendation was to import the
cult of Asclepius, the Greek god of medicine, from its main centre at
Epidaurus. Tradition has it (Ovid, Metamorphoses 15.669ff.; Livy 10.47
and Valerius Maximus 1.8.2) that a serpent (the symbol of the god)
came on board the ship at Epidaurus of its own accord, and when the
mission arrived at Rome, it swam ashore to an islet in the Tiber. After the
epidemic had subsided, the Romans in gratitude for their deliverance
built a temple to the god on the island. What probably happened in
reality was that the Roman state, due to the unsophisticated stage in
which health care was in the 3rd century BC, sought outside assistance.

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The advice from the priests in Epidaurus was that it would be more hy-
gienic to treat the sick outside the built-up area of the city. Therefore
the temple of Aesculapius was built on an island in the Tiber, outside
the precincts of Rome. This Asclepieum (Fig. 34) later became known
as the “Slave hospital” because of the accumulation of slaves, taken
there when chronically ill (to avoid expenses for the owners) and never
re-collected by their masters.1 In Christian times the hospital became
famous as the St. Bartholomew Hospital and provided shelter for sick
pilgrims — a function which it has in effect retained since. On the site
once occupied by the ancient temple there now stands a modern hospital
run by a religious order (Staccioli 1989:60).

Figure 34: Reconstruction of the Asclepieum on the Tiber island.

With the probable exception of valetudinaria (described below),

ancient Rome, like Greece, had no public institutions where sick ci-
vilians could be treated for a longer period of time (Majno 1975:393).

1 According to Suetonius, Divus Claudius c. 25 and Digesta 40.8.2, such slaves were
freed by an edict of the emperor Claudius.

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The poorer patients were brought to the doctor’s iatreion/taberna where
they were treated and then sent home, while the rich were visited at
home by the doctor. This custom of treating the sick at home (cf.
Celsus I.65; Cato I.1 and 2; Columella XI.1.18; XII.1.60) still ob-
tained in the time of the Roman Empire, as is evident from an event
described by Tacitus (Annales IV.63). During a disaster which took
place in a small town near Rome when an amphitheatre collapsed, the
injured were taken to private houses where they were treated by phy-
sicians. If a hospital had existed, the injured would have been there,
not in private houses. Even as late as the 3rd century AD there is still no
evidence of hospitals, as is clear from a remark made by Aelius Lam-
pridius (Scriptores Historiae Augustae Alex. Sev. c.47) that the emperor
Alexander Severus (AD 222-235) distributed those who were seriously
ill between the individual families to be cared for.
With the extension of the Roman Empire, when it was no longer
possible to send wounded and sick soldiers home for treatment, military
hospitals were established. Two kinds of hospitalisation existed: per-
manent fort hospitals erected at strategic points (valetudinaria) (Fig. 11),
and temporary field hospitals at the front during active campaigns (Scheider
1953:262-264; Thompson 1975:4-6; Jackson 1988:133-137).
The first valetudinarium was probably built in the 1st century BC
at Carnuntum (near Vienna). These soldiers’ hospitals became part of
established Roman fort architecture and were usually placed near the
outer wall in a quiet part of the fortification. Valetudinaria were placed
in major as well as in smaller forts for auxiliary troops — the size va-
rying with the size of the fort. The larger hospitals traditionally con-
sisted of four wings with a central open courtyard. The number of wards
roughly matched the number of centuries in the legion, each accom-
modating no more than three beds, and designed for maximal privacy.
Usually there were treatment rooms, a dispensary, staff quarters, and
washing, cooking and latrine facilities. Calculations suggest that about
5% of the unit’s strength could be accommodated, although this number
could easily be doubled by utilising corridors and ancillary rooms.
Each military unit had its doctors (milites medici) and medical assistants
(capsarii — named after the bandage box, capsa). Behind the lines the
field hospital (housed in tents) was the medical responsibility of the

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camp prefect, second-in-command and most experienced soldier of the
unit. It was actually administered by the optio valetudinarii, a junior HQ
officer who was an administrator rather than a doctor. Adequate sup-
ply lines to these field hospitals had high priority; in times of star-
vation the army was the last to suffer. The number and experience of
medical staff varied according to the size and prestige of the unit, and
staff were probably organised into an overall hierarchy of military doctors
serving the valetudinaria. There was also a specialised person (the marsus)
who looked after snake bites and other problems of envenomisation (the
Marsi were a mountain tribe famous for miraculous snake-bite cures,
Hornblower 1996:930).
Although Jackson (1988:65) points out that we have no archae-
ological proof of civilian hospitals, there is evidence that hospitals, also
called valetudinaria, were later also established for the civilian popu-
lation and upper classes in particular, for imperial staff in provincial
cities (probably private institutions), and for gladiators and slaves on
large farms (latifundia) (Harig 1971:189, 193-195; Thompson & Golden
1975:4). Landowners realised the necessity of keeping their labour force
healthy in order to ensure that they could fulfil their duties.2 There
is little information on how these institutions were run, but they were
probably a combination of private and state-run establishments. Al-
though Woodhead (1952:245) suggests that doctors’ tabernae often evolved
into sanatoria and small house-hospitals (nosocomia), this is little more
than speculation. Harig (1971:183-187) warns that evidence for pro-
nouncing even the well-known “physician’s home” in Pompeii a house-
hospital, is slim. However, he speculates that serious accident cases
might well have received prolonged therapy in a doctor’s house. We
therefore must accept that the valetudinaria played no direct role in
the evolution of the public hospital — they were established for a par-
ticular purpose and for a particular class of patient. Not even the term
valetudinarium survived — when hospitals for the general public did
arise, they initially became known by the Greek term xenodochia (Allan
1990:446-447). Well-to-do households did however have their own
treatment quarters for the ill (Seneca, De Ira 1.16.4). It is interesting to
note that the famous Roman architect, Vitruvius, insisted that careful
2 In a treatise on agriculture Columella (Rust. XI.1.18), a contemporary of St.
Paul, specifically pointed out the need for providing such valetudinaria for slaves.

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analysis of the environment’s health status be performed before esta-
blishing new cities and presumably hospitals (De arch. I.4).

5. THE CHRISTIAN ERA

Even during the early phase of the Christian era when Christians suf-
fered severe religious persecution, their selfless dedication to relief of the
suffering of the poor and ill, was remarked on by historians (Cyprian,
De mortalitate VI.1-2; Eusebius, Hist. Eccl. IX.7.15-8.3). The Christians’
typical attitude towards the sick was based on Christ’s parable of the
Good Samaritan — mercy and compassion for anyone in need. This ethos
of caring did however not translate into action regarding hospitalisa-
tion until Emperor Constantine promulgated his Edicts of Toleration in 311
and 313 granting religious freedom. And then their charitable actions,
concentrating on the needs of the wretched, did not differentiate between
assistance for paupers, pilgrims, orphans, the aged, insane and the diseased
(Thompson & Golden 1975:6; Ferngren & Amundsen 1996:2971-2975).
The earliest hospices for instance, called xenodochia in the mainly Greek-
speaking East, initially built to shelter pilgrims and messengers be-
tween the various bishops, eventually also housed disadvantaged, dis-
eased and mentally infirm persons. In the course of time, many of these
developed into standard hospitals (Allan 1990:447). By the 4th century
xenodochia were well-known institutions in the West as well, mainly
because the emperor Julian the Apostate (361-363), in his attempt to
revive paganism, tried to attract support by establishing xenodochia such
as the Christians had. In a letter to Arsacius, his pagan high priest in
Galatia, Julian wrote: “In every city establish xenodochia in order that
strangers may profit by our benevolence” (Epistula 49). About a century
later (470) we also find the law of the emperors Leo and Anthemius
ordering the establishment of xenodochia (Codex Justiniani I.i. tit.3).
With the rapid rise of Christian monasticism, it was logical that
charitable endeavours would often emanate from monasteries. Infir-
maries originated as health care facilities inside monasteries, designed
for care of the monks. In time infirmaries also took in civilian patients,
and even later treatment originally supplied by the monks themselves,
was supplemented by help from physicians from outside the institu-
tion. In this way monasteries played a vital role in promoting health
care and developing hospitals. These hospitals were now supported by

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Christian charity, and were no longer founded on the state’s economic
considerations, as had largely been the case in earlier Roman times
(Thompson & Golden 1975:6).
St. Basil of Caesarea (in Cappadocia) was a pioneer in establishing
hospitalisation and care of the disabled and sick. In 369 he founded
the celebrated Basilica at Caesarea, comprising a hospital which appa-
rently had as many wards as there were diseases, and even included a
section for lepers who had previously been kept in isolation and were
now for the first time really cared for. The hospital also had extended
quarters for medical staff, workshops, hospices for travellers and the
poor, as well as an industrial school. We happen to have a detailed
description of this hospital in an oration of Gregory of Nazianus, who
delivered St. Basil’s funeral oration (Orations xliii). At St. Basil’s insis-
tence, hospitals were also built in neighbouring regions, and the Eastern
Roman Empire often gave state assistance. At Edessa, for instance, a
300 bedded hospital was established by St. Ephraim in the aftermath
of an epidemic in 375. In the following century a series of monastery-
based hospitals, often with associated buildings for orphans and the
poor, sprang up in many cities. In Rome the first hospital was found-
ed in 390 by a Roman lady, Fabiola, a wealthy widow who sought abso-
lution by spending her wealth on charitable works (recorded by Jerome,
Epistula lxxvii, Ad Oceanum de morte Fabiolae). Two other wealthy ladies,
Pulcheria and Pauline, later followed her example and built or endowed
hospitals in respectively Constantinople and Jerusalem. The Empress
Eudoxia (401-465) also ordered the building of a hospital in Jerusalem
(Aitken 1984:9-11; Allan 1990:452-454).
The fall of Rome in 476 precipitated a prolonged period of deve-
lopmental stagnation in Europe (the so-called Dark Ages), but chiefly
because of Christian monastic influences hospitalisation still moved
forward.

6. MEDIEVAL TIMES
6.1 Early Middle Ages (6th to 10th centuries)
By the middle of the 6th century the establishment of hospitals was se-
curely anchored in the Eastern as well as the Western parts of the Roman

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Empire, due also to the support of various monarchs. Childebert, King
of the Franks, founded the Hôtel Dieu in Lyons in 542, and Theodoric
the Great (493-526) encouraged any Christian initiative concerned with
hospitalisation. Charlemagne (747-814) promulgated a decree that a
school, monastery and hospital be attached to every cathedral built in
his territory (Aitken 1984:10, 11; Haeger 1988:55, 70-71). The term
xenodochion now began to give place to hospitalium — in a letter written
in AD 796, the English scholar and ecclesiastic, Alcuin, urged Eanbald
II, Archbishop of York, to found in his diocese “xenodochia, id est
hospitalia” (Wallach 1951: Letter 56, Ad Eanbaldum).
With the founding of a monastery and hospital at Montecassino
in Italy in 529, St. Benedict of Nursia launched one of the most in-
fluential of all Medieval initiatives in the field of hospitalisation. He
insisted on excellence and dedication in the care of illness, and in time
his Benedictine Order became the model for later monastic establish-
ments.3 In 742 a Church Council decreed that all monks and nuns
should run their lives, monasteries and hospitals according to the
Benedictine Rule. Montecassino was sacked by the Lombards in the
6th century, rebuilt in the next century and again sacked (by the Sa-
racens) in 884. In the 10th century it was finally reconstructed (Aitken
1984:11; Major 1954:272).
Other famous monastic hospitals built at this time included those
at Merida, Spain (580), St. John’s Hospital at Ephesus (610), Panto-
krator in Constantinople (7th century), Hôtel Dieu at Paris (651), Mont-
pellier (738), St. Albans in Engeland (794), St. Maria della Scala, Siena
(898), and St. Bernard’s Hospital in the Swiss Alps (962) (Aitken
1984:12).
Concomitant with these developments, the Islamic conquests of the
7th and 8th centuries had given rise to the Golden Age of Islam (9th to
13th centuries) which facilitated a unique contribution to medical
development and hospitalisation. This will be dealt with later.

3 Benedict’s original Rule called for the establishment of an infirmary in every

monastery and placed the care of the sick “above and before every other duty”
(Green 1985:200, 240).

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6.2 Late Middle Ages (beyond the 10th century)

Gradually the driving force behind hospitalisation in Europe changed
from almost exclusively monastery-associated to greater participation by
civil authorities. The monastic infirmaries continued to expand, but in
large centres the city fathers initiated hospitals driven by civil support,
whilst church authorities also opened public hospitals. And in addi-
tion specialised institutions like leper hospitals made their appearance
(Aitken 1984:12, 13; Porter 1997:122).
Monastic institutions gradually expanded their medical services,
previously restricted to infirmaries, to the community. Famous new
hospitals appeared, like St. Bartholomew’s (1137), St. Mary’s (1179)
and St. Thomas (1215) in London, the Holy Cross hospital in Win-
chester (1132) and St. John’s in Canterbury (1118). During the 12th
century a monastic order was founded by Pope Innocent III, which
led to the establishment of a Hospital of the Holy Ghost in most major
cities. It was said that Islamic hospital design greatly influenced the
construction of the first of these hospitals, the Santa Spiritus in Rome
(1198). The Holy Ghost hospital built at Montpellier (1145) became
one of Europe’s first great teaching hospitals (Aitken 1984:13-14; Allan
1990:456; Mundy 1998:86-87).
The public hospital movement in large cities was financed by city
authorities as well as the Church and even private sources. Lay physi-
cians played an increasingly important role, especially after the Church
placed a ban on monks practising outside monasteries. The medical
dogma, here and in monastic institutions, was based mainly on the
teachings of Galen and Hippocrates, which was also greatly admired
by contemporary Islamic physicians (Allan 1990:451).
In Islamic Jerusalem the Order of the Hospital of St. John was
founded by Brother Gerhard in the 13th century as a charitable orga-
nisation caring for sick pilgrims in the Holy Land. A warrior element
developing from the order, took part in the Crusades, and when Acre
fell (1291), the movement was allowed to depart to Cyprus. From here
it moved to Rhodos (1309), then settled in Malta (1530) and even-
tually moved to Rome. They became known as the Hospitallers in view
of their intrepid and selfless record of charitable endeavours and hos-
pital building in particular. The best known of these were at Mont-

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pellier, Rhodos, Prussia and at various sites in Italy. The present day
St. John’s Ambulance evolved from the Hospitallers. The related Templars
(Order of the Poor Knights of Christ and Temple of Solomon, or the
Teutonic Knights) remained involved in religious-military matters
rather than charity, and amassed great power and wealth but were sup-
pressed by Pope Clement V in 1312 (Major 1954:267; Mundy 1998:
86; Chrystal 2000:536, 1079).
Generally speaking, public hospitals (above) did not specialise, but
in time certain specialised institutions did arise. Although the Basilica
in Caesarea (4th century) already had quarters for lepers, it is probable
that leper houses (Lazar Houses; lazarettes; leprosaria) really originated
during the 11th century when Europe started experiencing an epidemic
of leprosy. When this abated in the 15th century, the leper houses were
transformed by civic authorities into mainly mental asylums or infectious
diseases hospitals. During the 13th century there were 19 000 leper houses
in Europe, mostly run on a self-governing basis. During the early 14th
century a maternity hospital was built at Metz. There were also homes
and hospitals for the aged, which partly evolved out of the monastic
infirmaries, but were later run as independent charity institutions. Re-
latively small and often housing the apostolic number of 13 inmates,
these homes were widespread and many large hospitals, like Stras-
bourg’s St. Leonhardt’s and Nurnberg’s Holy Ghost Hospital, had sec-
tions for the elderly. Larger Jewish communities e.g. in Cologne and
Regensburg had their own hospitals (Mundy 1998:86-87).

7. ISLAM
With their eastern conquests consolidated and the western offensive
decisively defeated at Tours by a Frankish army under Charles Martel
(723), the Islamic revolution, started by Muhammed in 632, conso-
lidated its gains and moved into a period of remarkable stability and
development — the Golden Age of Islam, which terminated in the 13th
century. Whereas Europe was experiencing an era of socio-scientific
stagnation, eventually ended by the Renaissance, Islam succeeded in
stimulating development and original thought. In spite of medical sci-
ence in Europe stagnating around the doctrines of Galen, hospitali-
sation did expand (as described above). In Islamic countries foreign
students were welcomed, and Greek medical dogma was greatly admired,

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studied and translated into Arabic.4 Physicians like Rhazes (866-932),
Albucasis (936-1013), Avicenna (980-1037), Avenzoar (1091-1162),
Averroes (1126-1198) and Maimonides (1135-1204) made important
contributions, and in the field of hospitalisation great strides were
taken (Major 1954:225-258).
Taking their example from the Christian (Nestorian) teaching hos-
pital at Jundi-Shapur, Islam developed its own impressive hospitals
(bimaristans) at Cordoba, Baghdad, Damascus, Bokhara, Sevilla and Cairo.
A total of 34 major ones have been identified. Tudela, who visited Bagh-
dad in 1160, wrote that there were 60 hospitals in that city and 50 in
Cordoba. The greatest and most magnificent was the Mansuri hospital
in Cairo (completed in 1284). This self-contained institution had four
great courts, each with a water fountain in the centre, separate wards
for men and women and for different diseases, a dispensary, lecture halls,
and an out-patient department (from where patients were visited at their
homes), a chapel and library. Fever wards were cooled by fountains.
Musicians and storytellers entertained the sick, and on discharge each
patient received a sum of money sufficient to pay for immediate expenses
until he could resume work (Major 1954:260; Porter 1997:104-105;
Guthrie 1958:95, 96).
Possibly the first mental hospital for the insane (a maristan) in Europe
was built by Islam in Granada in 1365 (Porter 1997:105).
The hospitals at Cordoba, Baghdad, Damascus and Cairo in par-
ticular, also served as centres of medical education, attracting students from
Europe and the Far East, spanning the void of Medieval scientific
stagnation until the creation of Europe’s own fledgling medical schools
at Salerno (11th century), followed by Montpellier and Bologna (13th
century), Padua and Paris (14th century) (Guthrie 1958:95-96, 102-124).

8. HOSPITALS AND MEDICAL EDUCATION

After the Renaissance when medical schools in cities like Padua, Bo-
logna and Montpellier initiated the blossoming of medical knowledge
after Medieval stagnation, centres of medical excellence were almost

4 In Medieval times Arabic became the lingua franca of science (Major 1954:
223-225).

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 The evolution of hospitals
invariably associated with great teaching hospitals. This was indeed a
new development. Although the Renaissance cities mentioned above did
have hospitals, the primary initiative leading to scientific development
originated in their universities rather than their hospitals. With few
exceptions, e.g. in the field of surgery (Ambroise Paré, Guy de Chauliac)
and women’s diseases, the advances were not in clinical medicine,
but in anatomy (e.g. Vesalius), physiology, herbalism and philosophical
fields of study. Hospitals and clinical medicine became an essential com-
ponent of the doctors’ training only when physicians like Sydenham (17th
century) and Boerhaave (18th century) made the patient pivotal in me-
dical education (Guthrie 1958:202-204, 220-224).
Hippocrates (5th century BC) did of course emphasise the importance
of clinical contact and expertise in medical practice, but neither he nor
Galen nor any other Greek physician of status had access to teaching
hospitals (which did not exist at the time). In the Roman era with the
advent of hospitals (valetudinaria initially) we have little evidence that
these played a significant role in the furthering of medical science. Harig
(1971:188) makes the point that eminent doctors of the quality of Galen
were apparently never associated with valetudinaria, although he did
treat gladiators early in his career. The famous Alexandrian school of
medicine (founded c.300 BC) where human dissection was performed for
the first time, was well known for its magnificent library and museum,
but not for a hospital of significance.
In the Christian era the Church progressively monopolised the pre-
dominantly monastic hospital system, which for its time rendered an
able service to the ill and the aged, but contributed little to the ad-
vancement of medical science (Harig 1971:97). In fact, it is fair to say
that through its strict and slavish adherence to the dogma of Greek
masters like Galen, the Church repressed original thought, and left it
to the doctors and hospitals of Islam to carry the flame of medical know-
ledge through the dark Middle Ages to the new dawn of the Renaissance
(Retief & Cilliers 2001: pp. 259-277 in this volume). The major Islamic
hospitals served as centres of medical education, and in that sense they
were the true forerunners of the modern medical teaching hospital.

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