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CHARITY AND WELFARE:
HOSPITALS AND THE POOR IN MEDIEVAL CATALONIA

JAMES WILLIAM BRODMAN

[73] Until the fourteenth century, Catalan hospitals emphasized care over cure. As a consequence, most shelters did not discriminate in any fundamental way between the sick and the homeless; and, when the term infirmi was used to designate certain inmates, it is unclear whether the malady in question was chronic or acute. The condition that qualified an individual for assistance was poverty, and it did not matter directly if its cause was an affliction, such as blindness, old age, or disease, or the homelessness of the traveler and vagrant.⁽¹⁾ Even after 1300, this sort of hospital, which sheltered pilgrims, invalids, and paupers, continued to function; indeed, there were even a scattering of new foundations.⁽²⁾ Alongside these shelters, however, new categories of hospitals began to appear. In the mid-twelfth century, there were those dedicated to particular groups of the needy, like lepers, the victims of ergotism, and orphans. In the fourteenth century, with its recurrence of plague and other diseases, new facilities, as well as older shelters, began to add medical treatment as a regular component of patient care. This culminated in the fifteenth century with the establishment of large general hospitals that offered, in addition to food and shelter, a broad array of medical and social services. Of these new and specialized institutions, the earliest and most numerous were the leprosaria.

Lepers and Leprosy

Instances of leprosy increased in Europe after 1000. ⁽³⁾ In the twelfth century the first leper colonies appeared, organized not too differently from the contemporary communities of Augustinian canons and frequently headed by the oldest surviving leper. Gradually a process of institutionalization and [74] definition unfolded, as the leper settlements acquired a legal status and the right to own and receive property and alms. Ultimately, just as in religious communities, various statutes were drawn up to govern life within the leper colony. A significant ecclesiastical acknowledgment of their existence came in Canon 23 of the Third Lateran Council (1179), which gave leper communities an official status within the Church by stating: "When these men are gathered in a number sufficient to lead a common life, we enact that they can have a church and a cemetery, and the benefit of a priest among them." The establishment of a chapel, or the conferral of donations in property or cash, brought such communities to notice as a leper hospice or hospital, often under the invocation of a saint.⁽⁴⁾

Leprosy is caused by mycobacterium leprae, which is related to the bacteria that produce tuberculosis, and which has existed, like the plague, as one of mankind's chronic diseases. G. H. A. Hansen first isolated the bacterium in 1874, but even today there is disagreement about whether it is transmitted by contact, or through the respiratory or gastrointestinal systems. Five variants of the disease have been identified, the most serious of which is the lepromatous leprosy, which produces the extreme disfiguration that most associate with this malady. Today, we know its incubation period averages between three and five years, and that 90 percent of those infected with leprosy bacteria never show external signs of the disease. But most of this was unknown in the Middle Ages; the disease itself did not begin to be medicalized until the fourteenth century.⁽⁵⁾ Before that time, its identification was the responsibility of priests, and then of barbers, who probably detected the malady only in its later stages, when victims began to show large lumps or patches on the skin, which eventually disintegrated into discharging sores. The disease was regarded by medieval physicians and other authorities as difficult to diagnose. Nonetheless, excavations of leper cemeteries have revealed signs of the disease in 77 percent of the skeletons, showing a relative accuracy in the medieval process of identification. ⁽⁶⁾

Medieval thinkers regarded leprosy as degrading in both a physical and a moral sense. The disfiguring symptoms were viewed as marks of sin, from which prudent Christians should flee. It was commonly believed that the innocent could become infected by touching a leper, or breathing in his exhalation, or by having sexual relations, particularly during periods of menstruation. Consequently, it was a serious matter to label anyone as a leper; false accusations were regarded as slanderous, akin to calling someone a whore, traitor, or Saracen. Standards of diagnosis, moreover, did not coalesce until the fourteenth century when leprosy began to fall under the [75] purview of physicians. In Catalonia, an important turning point was the great lepers' plot of 1321 when French lepers were widely accused of poisoning the water supply so as to infect others with their malady. As a consequence, in June 1321, King Philip V of France ordered their arrest and execution, causing many lepers to flee for safety into Catalonia, where Jaume II ordered them to be detained, questioned, and, if found guilty of some crime, executed. Perhaps as a reaction to the hysteria of false arrest, the following years saw greater physician involvement in the diagnosis of leprosy, clearer descriptions of the disease (like Arnau de Vilanova's De signis leprosorum and Jordanus de Turre's De lepra nota), and the development, particularly among those trained at the medical school in Montpellier, of a more clinical, and less moralizing, attitude toward the disease.⁽⁷⁾

The primary reaction of society to lepers was to house them far from populated areas. Some date these efforts at segregation to the acta of the Third Lateran Council (1179), but realistically such a policy is apparent only from the fourteenth century. The first French ordinance, for example, that called for the strict seclusion of lepers dates from 1321, the year of the alleged plot; in Italy, Florence ordered their expulsion from the city only in 1325. The most influential medical treatise to set down criteria and procedures for the seclusion of individuals suspected of leprosy, that of Guy de Chauliac, did not appear until 1363. ⁽⁸⁾ Earlier, such quarantine was relative. Towns, for example, usually located leprosaria, as well as other shelters for the poor, away from populated areas. Paris' Saint Lazare, for example, was two kilometers from the city, and Narbonne's hospice a kilometer away. In northern France, near Bourges, Paris and Limoges, as we have already noted, leper hospitals were positioned downwind, usually on the north or east side of town, and only rarely to the south or southwest. But there was always some contact between the leper and the rest of society, if for no other reason than lepers begged as a principal means of their support. The law, for the most part, did not forbid lepers to interact with others, although it could restrict the nature of this contact. The Rule of the Hospitaller Order of the Holy Spirit, for example, insisted that members who had contracted leprosy be permitted to remain in and be treated as a part of the community. Lille in 1239, on the other hand, permitted lepers in town only with permission, but otherwise allowed them free passage through the countryside as long as they entered no houses. The Asturian town of Oviedo, perhaps because it had to cope with many northern Europeans traveling the pilgrim route to Santiago, enacted an ordinance in 1274 that was more severe, although it treated lepers and vagabonds alike. Because these unfortunates [76]  lacked any local roots, the ordinance forbade them entry to the town on penalty of expulsion for the first offense, whipping for the second, and burning for the third. In France, however, at Coutances lepers were merely barred from crowded places, like markets, and in the province of Auch, lepers were required only to wear distinctive dress as a warning to others. Ironically, in the fourteenth century, as leprosy itself began to diminish, restrictions upon lepers multiplied. Clickers and other noisemakers, for example, became common as a warning of approaching lepers. Because some believed that leprosy could be contracted by eating tainted food, lepers were forbidden to touch food or to enter kitchens and pantries. At Périgueux, they could not sell their cattle, poultry, or eggs to others. Towns like Amiens and Chartres barred lepers from municipal wells and cisterns; and at Chartres lepers were forbidden to wash their laundry with that of others. But, on the other hand, lepers were expected to carry with them a wooden goblet, into which others could place gifts of food, drink, and money without touching the leper. In France, these regulations culminate with the Ordonnance cabochienne of 1413 that forbade lepers to enter Paris or any other town.⁽⁹⁾

Leper Houses

If leprosaria began to appear at the onset of the twelfth century, the numbers of new foundations peaked between 1150 and 1250, and then fell off rapidly.⁽¹⁰⁾ New establishments in the fourteenth and fifteenth centuries were usually just reorganizations of older institutions. It is impossible to estimate the numbers of these hospices, because most were small, with perhaps a half dozen inmates and few, if any, documentary traces. Furthermore, leprosaria were generally local institutions because this work never was taken up in any consistent way by the religious orders. Even the Order of Saint Lazarus, itself a society of lepers whose work was the care of lepers, remained small. While there were a large number of hospitals under the patronage of this saint, most had no connection to the order.⁽¹¹⁾ Thus, Louis VIII of France, in the early thirteenth century, bequeathed money to some two thousand leper shelters in his kingdom, but there must have been more than these in France since major regions at that date were still outside royal control.⁽¹²⁾ It has been estimated that in medieval Yorkshire, in England, a quarter of all hospitals were leprosaria. All of these were established before 1300, with most in the twelfth or early thirteenth century. The most important shelters [77] were of aristocratic foundation, but in 1200 at least half of all towns also had a hospice for lepers.⁽¹³⁾

In Spain, leper hospitals multiplied in the twelfth century, and their appearance might well coincide with the development of the Santiago pilgrimage route, which likely introduced numbers of lepers into the peninsula. One estimate argues that there were twenty thousand lepers in medieval Spain and approximately two hundred leper shelters. While we do not know the relative size of these Hispanic institutions, in nearby Toulouse, John H. Mundy's study shows an average of ten inmates per house.⁽¹⁴⁾ One of the earliest Hispanic houses, established at Palencia in 1067, is attributed to the Cid who is said to have met and cared for a leper pilgrim to Santiago, later revealed to be San Lázaro himself. ⁽¹⁵⁾ In the province of Asturias, through which a branch of the Santiago road ran, there were over twenty leprosaria, established between the mid-twelfth and later thirteenth centuries.⁽¹⁶⁾ At Burgos, there were two houses, both under the invocation of San Lázaro, one just outside the walls on the Santiago road, and the other in a more rural locale.⁽¹⁷⁾ León had its own shelter in 1171, and Seville and Córdoba not long after the Christian conquest in the mid-thirteenth century. ⁽¹⁸⁾

Lepers in Barcelona

The leprosarium of Barcelona, variously called the Casa del Malalts or Masells or Mesells, the Hospital of Sant Llàtzer, or the Domus Infirmorum, has no known act of foundation. Despite traditions that date its origins to the mid-ninth century, it is likely that its foundation, like those of so many others, took place in the second half of the twelfth century. One tradition credits its establishment to Bishop Guillem de Torroja (1144-71); the earliest direct reference to the leper hospital is dated 1200. The institution was located across the modern Ramblas from the twelfth-century city, in the plaza Pedró, a garden district that only became fully urbanized in the fourteenth century. Its chapel in the thirteenth century was under the invocation of Santa Maria dels Malalts, but later it became dedicated to Sant Llàtzer al Pedró. The hospice was supervised by the bishop and the chapter who appointed its proctor. The rector was the chaplain, who served at the altar of Santa Margarita, which was endowed in 1218 by the powerful Ramon de Plegamans, and later in 1295 by his grandson Marimon de Plegamans. Sant Llàtzer endured as an independent institution until 1401, when it was joined, first to the Hospital of Santa Eulàlia, and then to the new general [78] hospital of Santa Creu. Subsequently, due to a rise in the incidence of leprosy in Catalonia during the fifteenth century, there was an attempt by the city council to establish a new and larger leper hospital outside the Porto Nou. This effort, however, floundered, not only because of its projected cost of six thousand florins, but also because of a fear that such a structure would only stimulate the immigration of lepers into Barcelona. Ultimately, the council decided to make due with the current facilities by barring their use to lepers who originated from outside of Barcelona itself.

Bishop Ponç de Gualba carried out a pastoral inspection on February 24, 1307, that reveals to us the personnel of the leprosarium: Bernat d'Orts, the rector; Jaume de Rocafort, a cleric and a leper who disliked the rector; Berenguer de Canal, the chaplain; and three male attendants. In 1379, the staff had grown to include an administrator, several chaplains, six full-time attendants, and several part-time alms collectors and neighborhood retainers. Statutes concerning its operation are extant from a reform by Bishop Ponç de Gualba in 1326, instituted to correct problems in the hospital's administration. Evidently, the rector, reacting to charges that the leper inmates were not receiving proper care, had responded by proposing a reduction in the number of admissions. The bishop's solution was to overhaul the hospital's administration in order to correct fiscal irregularities and to improve the inmates' access to daily mass and the sacraments.⁽¹⁹⁾

Financial accounts for Sant Llàtzer survive for the eleven-month period from May 1379 to April 1380, and these give us a brief glimpse of its economic status, the sources of its support, and some indication of its internal operation. The overall figures suggest that the hospital was prospering, with a budgetary surplus of over twelve hundred sous from revenues of almost forty-six hundred sous; yet this conclusion would be somewhat precipitous given the source of most of this income. Approximately one-half came from short-term giving: the sale of bread alms (30 percent), alms collected in town (11 percent), legacies (6 percent), and chapel offerings (3 percent). Only a quarter came from permanent endowment: investments, rentals and endowments established for anniversaries. The remainder derived from the sale of wine and other agricultural products (20 percent) and money contributed by leper inmates (5 percent). Thus, half of Sant Llàtzer's revenue was subject to the vagaries of Barcelona's economy and could be expected to fluctuate with the times. Lacking comparative figures, it is impossible to determine whether 1379 was a typical year, or an unusually good one. ⁽²⁰⁾

The largest expenditure of Sant Llàtzer was for food (38 percent), [79] followed by wine (31 percent). While almost the entire expense of the latter was recovered through the sale of surplus vintage to others, all of the former went to feed both staff and inmates. While fragmentary to be sure, this evidence suggests something of the configuration of the house and the treatment of its residents. Because more was budgeted per capita to feed the staff, we can assume that they ate better than the lepers. ⁽²¹⁾ In 1379, furthermore, we know that the staff included an administrator, two or three chaplains, five staff members, and a slave. That being so, the food budget would seem to have allowed for the support of fourteen or fifteen lepers, a modest population indeed given a staff of approximately ten. This ratio, however, evidently did not translate into a high level of care for the leper residents, because of the ten paid personnel only one female attendant was directly charged with patient care. ⁽²²⁾

Lepers Elsewhere in Catalonia

Outside of Barcelona, one of the earliest leprosaria was founded at Lleida, where a hospital of Sant Llàtzer is cited in Berenguer de Boixadors' will of 1185. The hospice was located on inexpensive land on the left bank of the Segre, near the Hospital of Guillem Nicolau, on which there was an old mosque and a half dozen buildings. In the next century, a confraternity that enrolled men, women and clergy was established to provide support; King Jaume II is said to have belonged. Another hospice on the road to Gardeny was established early in the thirteenth century.⁽²³⁾ At Girona, the Hospital of Sant Jaume de Pedreto, or Le Pedret, was located outside the walls.⁽²⁴⁾ The Hospital of Santa Maria Magdalena was probably a mid-thirteenth-century foundation at Urgell, with 1284 being its first citation. Like others, its location was extramural. It was a popular charity, with over a third of the wills extant for 1287 to 1291 remembering it with small legacies. Leprosy, however, must have soon declined at Urgell since the property in the early part of the next century was made into a residence for hermits. ⁽²⁵⁾ At Vic, lepers were not segregated but rather included within the patient population of several public shelters. These include the hospice operated by the church of Sant Bartomeu, the Hospital of Sant Jaume and its confraternity, and the annex of the hospital for the poor that Ramon de Malla founded in 1275.⁽²⁶⁾ At Cervera, Santa Magdelena is first mentioned in a will of 1235 but the leprosarium's origins were in the twelfth century. The hospital and church must have existed under some manner of municipal jurisdiction [80] because in 1246 town officers ousted the hospital's administrators in a dispute over its expansion.⁽²⁷⁾

The lepers' plot of 1321, during which native as well as foreign lepers were accused of poisoning wells, led to scattered violence against lepers and the suppression of some houses by the Crown. King Jaume II gave leper property at Cervera and Tàrrega to the Franciscans, while Minorite nuns received the goods confiscated at Vilafranca del Penedès in Catalonia and at Morella in northern Valencia. Other lands at Tarazona and Borja were retained by royal agents. At Tàrrega, the Franciscans were given permission in 1322 to sell the leper house and use its proceeds toward construction of a new residence on the condition that they would care for all present and future lepers born in the town; but without the need for a separate leprosarium, their numbers must have been few. At Cervera there is no indication that the friars cared for lepers at all. Indeed, responding to protests from municipal officials that lepers were being driven to starvation, King Alfons III in 1331 forced the friars to restore the confiscated property to the lepers. Whether or not the loss of leper houses suggests any decline of the disease during the fourteenth century, as some have argued, the aftermath of the lepers' plot demonstrates not only the precariousness of the leper's place in society but also the increasing role the king was playing in the formulation of public policy.⁽²⁸⁾

Lepers on Majorca

In Christian Majorca, the oldest known citation concerning leprosy is in the constitutions of the Monastery of Santa Margarida (circa 1330) which address the problem of leper monks. In the fifteenth century, Majorca had an officer called the morbería who was charged with keeping those carrying infectious diseases, which included the plague, tuberculosis, and leprosy, from disembarking on the island. Under him were various officials who dealt specifically with leprosy. The vesador i instigador dels massells was charged with identifying cases of leprosy; however, the disease here, as elsewhere, was evidently in decline because in 1468 this position was consolidated with that of a second official, the examiner of lepers. The Hospital dels Massells was functioning in 1440 with a physician to oversee the care of lepers. This was located outside the walls, near the gate of Santa Catalina, where lepers could beg alms at a safe distance from town residents. Frequently in the fifteenth century, the instigador dels massells also served as governor of the leper hospice.⁽²⁹⁾

Lepers in Valencia

[81] Sant Llàtzer in Valencia, located just outside the city on the road to Murviedro, is cited in wills as early as 1251 and must have been established shortly after Jaume I's conquest of the city in 1238. It is unclear under whose authority this asylum was first established, but it was the first of the city's charitable institutions to become the responsibility of the municipal consell. In 1319, the jurats and consellers decreed that the hospital be governed by a proctor, who was to be a citizen of Valencia, and who would serve a term of two years. In 1334, the councilors issued a brief handbook to govern the conduct of inmates and the administration of the house, and in 1474 they discharged Philip de Vezach as administrator after inmates had complained of his failure to provide sufficient food and fuel.⁽³⁰⁾ The hospital evidently used a panel of doctors to screen prospective inmates for actual signs of the disease. An instance in 1318 reveals that one such individual, Bernat Cubelles, who had been expelled as a leper from the Valencian village of Ontinyent, was declared to be free of the disease by these physicians and permitted to return home.⁽³¹⁾

The Care of Lepers

Were all lepers treated alike? All of these unfortunates were marginalized to the extent of being segregated from society and, whether or not they actually underwent the ritual of civil death, they were regarded as terminal patients, not as apt candidates for any sort of medical treatment. ⁽³²⁾ Yet various studies--for example, in the Asturias region and in Catalonia--suggest that rich and poor lepers received different levels of care. Unlike cases of the sick, where the affluent were tended at home and the indigent in public shelters, wealthy lepers tended to reside in endowed hospitals where they were provided decent accommodations, a bed, and even some recreation, while paupers were more likely to end up as members of rural communities supported by begging. Hospital admission, in addition to being influenced by factors of family and wealth, also could be conditioned by geography, in that local residents were usually given preference over outsiders in the competition for a limited number of places.⁽³³⁾ At Barcelona, after 1326, a committee composed of the bishop's almoners and two upstanding citizens of the city decided whom to admit to Sant Llàtzer. First priority was to be given to lepers from the city itself, followed by those from the diocese, then other Catalan lepers, and finally transients. ⁽³⁴⁾

[82] Perhaps the most important concern in deciding matters of admission was the cost of care, since anyone admitted might well remain in residence for several years. In France, and perhaps elsewhere, the presumption was that the property of the perspective inmate would belong to the leprosarium. ⁽³⁵⁾ By the end of the thirteenth century, notarial manuals record contracts between lepers and shelters concerning the disposal of the former's property. ⁽³⁶⁾ But many lepers were too poor to make any contribution toward their care. In some instances, the poor were expected to provide, as a minimum, their own clothing and bedding; in other instances, alms from the community supported the indigent. At Barcelona, lepers or their families in theory were required to pay nothing, but in fact those with means were expected to defray, in whole or in part, the cost of their care. Most if not all of Sant Llàtzer's inmates must have been indigent, however, since the records of 1379, for example, show that lepers contributed just over 5 percent of the house's total income. At Manresa, however, Guillem de Pujol was admitted into the leper house in 1326 only after paying his fellow inmates seventy sous, for which he was to receive bed, board, and a share of any alms received. Françoise Bériac's study of French leprosaria, indeed, reveals no consistent pattern of admission. Biases existed against the poor and against strangers (Sant Llàtzer's in Valencia, for instance, barred the admission of wandering minstrels), but these were not absolute. Likewise, the ability to pay was also no guarantee of admission. The leper community itself and its leader had a great deal of discretion in deciding these matters. ⁽³⁷⁾

Canon law imposed no particular form of governance upon leper communities, and the chaplains appointed by bishops did not always serve as rectors or administrators. At Toulouse, for example, the leper houses seem to have had no single head, but instead appear to have been governed by a council or chapter composed of hospitallers and/or the lepers themselves. In the thirteenth century, some bishops promulgated statutes for leprosaria that placed lepers and/or their healthy aides under a kind of religious observance. ⁽³⁸⁾ In France, lepers at Meaux in 1300, for example, had to promise to live without property, observing chastity, obedience, and silence. At Saint-Lazare of Montpellier, inmates were forbidden to fornicate, quarrel, sell the house's property to outsiders, or steal, and were enjoined to pray together silently in church at the appointed hours. The English hospital at Sherburn required inmates to recite 161 paternosters a day, and another at Dover demanded 200 paternosters and Ave Marias during the day, and an additional set at night. At Sant Llàtzer's in Valencia, men and women evidently ate apart (but could not eat alone without good cause) and were [83] forbidden to talk to each other "continuously."⁽³⁹⁾ But the archdeacon of Paris argued that lepers should not be treated like religious because many were married and had purchased their place in the asylum. For similar reasons, Bishop Ponç de Gaulba of Barcelona in 1326 eliminated the requirement that inmates at Sant Llàtzer take vows of chastity and obedience, although he did express the wish that the lepers would live chastely and avoid sin. In the interests of maintaining order, however, even secular authorities attempted to impose a quasi-religious regimen upon lepers, but simultaneous promulgation of statutes against theft, assault, and battery and the threats of imprisonment also demonstrate that this ideal was rarely attained.⁽⁴⁰⁾

Leprosy was a terminal disease from which no recovery was expected, and consequently leprosaria were, like most medieval hospitals, places of residence rather than centers of treatment.⁽⁴¹⁾ Lepers would be fed and clothed; at Barcelona's hospital of Sant Llàtzer they were also given a small amount of spending money, one diner on each of the fifteen major feasts celebrated in the house. While those who became too ill to share the communal meal were given a special diet, the hospital's Libre dels Comptes reveals that only minor provisions were made for medical care. Regulations did permit a portion of the twelve diners that were set aside each week for an inmate's food to be used for lancets and bandages, but there is only a single reference to a physician being called to visit an inmate. Furthermore, the accounts indicate that virtually nothing was spent on any products of a therapeutic nature.⁽⁴²⁾

Ergotism

In addition to leprosy, medieval people suffered from various other forms of painful and disfiguring maladies, the chief of which was ergotism. This is a disease caused when ergot, a wind-borne fungus, invades the ovaries of edible rye, producing a dark purplish-black mass called a sclerotium . Cold winters, warm and wet weather in spring and summer, or poor field drainage promoted the spread of ergot. The resulting ergotism recurred in epidemic proportions in Europe between the ninth and nineteenth centuries, where the descriptive terms holy fire (ignis sacer) and Saint Anthony's fire, for the intolerable burning pains felt in the limbs, came into use. There are two forms of the disease, although these were not distinguished until the seventeenth century. The first and most common is gangrenous ergotism, [84] characterized by a sense of lassitude, painful contractures, alternating sensations of severe heat and icy cold, followed by the loss of all sensation and the onset of dry gangrene. The affected parts of the body became dry and mummified and eventually dropped off. Convulsive ergotism was more common in Germany than in France and was characterized by severe itch, sensations akin to ants crawling over one's body, and powerful spasms that could contort individual limbs or the whole body. The victim could also be subject to hallucination since ergot contains compounds related to LSD (lysergic acid diethylamide). Impairment of hearing and sight, glaucoma, paralysis, and epilepsy are other complications of the convulsive form. ⁽⁴³⁾

Because the victims of ergotism were at times viewed with suspicion and, like lepers, marginalized,⁽⁴⁴⁾ their care and cure came to be the work of the brothers of the Order of Saint Anthony, or the Antonines. This laic hospitaller community was established in France at Bourg-Saint-Antoine, near Vienne, the site of a Benedictine priory that preserved a reliquary of Saint Anthony. Here, around the dawn of the twelfth century, a noble named Gaston asked the saint's intercession to cure the ergotism of his son Guérin. While modern scientists speculate that "cures" in this region resulted from the local rye being free of the ergot fungus, Gaston attributed the remedy to the saint and vowed to establish a hospitaller community to serve other sufferers. The religious order that resulted was headed by a clerical master, but was composed for the most part of serving brothers, donati or conversi, whose habit was adorned by a Greek tau, and who lived according to the Rule of Saint Augustine. Shelters or domus eleemosynaria were established in France, Germany, England, Tuscany, Bohemia, Palestine, Constantinople, and Spain to serve the victims of skin disease of all sorts, and even travelers and pilgrims.⁽⁴⁵⁾

There is no study of the history of the Antonines in Iberia, but a few notices testify to their existence in Catalonia and eastern Spain. Their first Iberian center may have been at Cervera, where a church and hospital dedicated to Sant Antoni functioned from the thirteenth until the early fifteenth century. Agustí Duran argues that this house possessed a royal guiatge, a form of protection, and sheltered the king and queen when they passed through the town. The Order abandoned the hospital circa 1401 because ergotism had disappeared from the region, and most of the brothers moved to a new hospital in Barcelona, taking with them the house's liturgical treasures and endowment, much to the consternation of the residents of Cervera. ⁽⁴⁶⁾ But the Antonines have left few traces at Barcelona and Tàrrega and none at all at Girona, Tarragona, or anywhere else in Catalonia, [85] where a hot, dry climate would not favor the development of ergotism. Lleida, on the other hand, where the order was established, controlled the grain produced on the plain of Urgell, Catalonia's principal granary. ⁽⁴⁷⁾ At the beginning of the thirteenth century, the order functioned in Lleida where it possessed a hospital and residence, called Pere de Deu, located outside the walls on the Gardeny highway, but near enough to town to be incorporated into the new wall constructed by Pere III in 1357. Income from the royal chapel in the castle of Zuda was donated by Jaume I. ⁽⁴⁸⁾ Apart from Lleida, the Antonines were established in the Kingdom of Valencia, where in 1276 Geoffrey of Casca was identified as commander of the order in the dioceses of Valencia and Tortosa. The evidence suggests that he oversaw hospitals at Fortaleny and at other sites in the Kingdom of Valencia. A hospital opened in Valencia City itself sometime between 1333 and 1340, and there was another in Alicante; in 1353 the bishop acceded to the order's request to beg alms throughout his diocese for the support of those cared for in this hospital.⁽⁴⁹⁾

Mental Disorders

People whose behavior we would now characterize as disturbed were not differentiated from the run of beggars until the fourteenth century when society began to sort the poor into various categories. Arnau de Vilanova, for instance, in his De parte operativa, attempted a differentiation of various types of mental impairment and distortion. But before the late fourteenth and early fifteenth centuries, the insane were considered to be primarily the responsibility of relatives. Those without family were generally housed alongside other needy individuals because their malady was not considered to be contagious. For most communities, the issue raised by insanity was not one of health, but one of public order -- those whose behavior was violent and disruptive had to be kept under some restraint.

In regions like Germany, the response to mental illness was to flog and expel anyone who was not a resident. Locals so afflicted would be encouraged and paid to go on pilgrimage to a religious shrine to seek a cure. But for many others, for whom recovery seemed unlikely, institutionalization became necessary. Because their condition was chronic and their care would be of long duration, many ordinary hospitals, like Saint John's in Oxford, refused to admit the insane. Consequently, special shelters slowly began to appear in the fourteenth century to provide extended care, although these [86] institutions would not become common until the sixteenth century. Among the earliest mental institutions were those located in Hamburg (1375) and in London (1403). In Spain, the first such asylum is contemporaneous to its northern European counterparts, the casa dels orats, which appeared in Barcelona during the 1370s as a division of the Hospital of En Colom. Here the mentally disturbed were restrained at times by chains and shackles, or confined in closed cells, in the so-called house of lunatics. In the fifteenth century, En Colom was absorbed into a general hospital of Santa Creu, which continued to admit demented priests. Other general hospitals, in Córdoba and Saragossa, included the disturbed in their inmate population. In Valencia, the Hospital de Ignoscents, Folls e Orats , which Rubio Vela argues was the first completely independent mental asylum to be established in Europe, began to function in 1409. Another soon followed in Seville.⁽⁵⁰⁾

Medical Practitioners

The association between hospitals and medicine, so axiomatic in the modern world, was not common in Europe until the fourteenth century. In Spain, Catalonia, but not Castile, conforms to this general pattern. ⁽⁵¹⁾ The necessary precondition to this conjunction of shelter and care was the professionalization of medicine itself, that is, the articulation of recognized standards for medical education and the licensing of its practitioners. Among medical providers, there were four officially recognized categories of personnel: the physician (phisicus, fisicus), the surgeon ( cirurgicus), the apothecary (apothecarius, speciarius, herbolarius ), and the barber (barberius, barbitonsor). The term medicus or metge, which is common in Catalan documents, is best translated as healer, and could apply to either a physician or surgeon. ⁽⁵²⁾ The first official notice of medical personnel within the Crown of Aragon occurred when Jaume I in 1272, as lord of Montpellier, which was one of the continent's premier centers of medical education, attacked practitioners who had no university degree or who had taken no examination. ⁽⁵³⁾ The Cortes that met under Alfons III at Monzón in 1289 was the first to address medical issues. Section 18 of its acta placed physicians and surgeons under the same regulations that applied to lawyers, which meant that prior to being admitted to practice they had to be examined by the councilors of their town and by members of their profession. This regulation was modeled on the customs that had been established by Roger II in 1140 within the Kingdom of Sicily, a territory that in 1282 had become part of the Crown of [87] Aragon. Similar practices had already been instituted by 1220 in Paris, by 1239 in Montpellier, and would follow in 1306 in Toulouse. The first Catalan towns to require practitioners to possess an academic knowledge of medicine were Cervera (in 1291) and Valls (in 1299). ⁽⁵⁴⁾

While such enactments did not specifically mandate any particular course of medical studies, the implicit expectation of competence became impossible to separate from some sort of educational regimen. The Furs or law code of Valencia in 1329, for example, demanded four years of study at a studium generale and successful examination before a panel of two municipally appointed physicians as preconditions of licensing for physicians, surgeons, and barbers. The physicians of Barcelona, undoubtedly influenced by the Valencian model, complained to Prince Pere about unqualified practitioners in the city. He responded in 1334 by mandating formal examination for any who had not attained the degree of master or bachelor of medicine. As king, Pere reacted to complaints from the Aragonese town of Teruel in 1348 that incompetent individuals were taking advantage of the emergency brought on by the plague and causing great damage. Whether or not the blame for these casualties was medical malpractice, the king forbade any man or woman from practicing medicine or surgery in Teruel who had not been examined before municipal officials by the magistrates of the confraternity of Saints Cosmas and Damian. The Cortes of Cervera in 1359, perhaps responding to other complaints of malpractice, legislated that all Catalan physicians were to have at least three years of university training.⁽⁵⁵⁾

In 1300, King Jaume II, in recognition of the realm's loss of Montpellier and its university, established a new university at Lleida that also included a medical faculty, upon which the monarch then attempted to confer a monopoly over medical education.⁽⁵⁶⁾ But demands of the plague and the resistance of Barcelona's physicians to Lleida's privileged status led to the establishment of additional schools at Perpignan (1350), Huesca (1354), Valencia (1373), and Barcelona (1400), and a surgeon's school at Valencia (1462). The king evidently played some role in their governance, for in 1401 he granted licenses to Pere de Coll, a future physician at Barcelona's Hospital of Santa Creu, and to six others so that they could commence their study of medicine at Barcelona. ⁽⁵⁷⁾

How effective were these requirements for university study, licensing, and examination in uplifting the quality of medical care? Studies of enrollment patterns at the medical schools of Montpellier and Lleida suggest that only a few academically trained physicians were actually graduated; and [88] Michael McVaugh has been able to discover the names of only seven physicians within the entire Crown of Aragon in the 1340s who claimed any sort of academic title.⁽⁵⁸⁾ The evidence from medical licensing is more abundant, but the verdict from this source is decidedly mixed. On the one hand, the level of medical knowledge required from those who underwent examination in Valencia, and seemingly elsewhere, was high; applicants were expected to demonstrate both theoretical and clinical experience. Conditional licenses, which required a physician to consult with more experienced colleagues, were granted to those who failed a portion of the examination. Because "these things pertain more to experience and manual activity than to scientific understanding," would-be surgeons were examined about actual techniques, and the less competent were restricted to "minor surgery" that avoided the three great cavities: the head, chest, and abdomen. But, on the other hand, the vast majority of medical personnel, both within the Crown of Aragon and elsewhere in Europe, never underwent the examination and licensing procedure. For example, even though some eighty-seven physicians and surgeons have been identified as being in practice in Valencia between 1376 and 1400, during that period only twenty-eight licenses were actually awarded. And of these, only one was granted to an individual who had the requisite university schooling, an Italian named Tommaso de Maestre Tone. Indications are that licenses were not routinely sought by new medical "graduates," but rather obtained only after an individual had already been in practice, and then only if that person were coerced for some reason to submit to examination. In the main, formal academic training was regarded more as an ideal than as the sine qua non for practice. Furthermore, not all health professionals were subject to formal scrutiny. While the barbers of Valencia were licensed, their counterparts in Catalonia were not. The municipal council of Valencia did not begin to regulate apothecaries until 1350, after the outbreak of the plague; and self-scrutiny by this profession did not begin until 1441 when a guild of apothecaries was finally established. ⁽⁵⁹⁾

Communities of physicians, surgeons, barbers, and apothecaries, nevertheless, became distinguishable in the fourteenth century.⁽⁶⁰⁾ Valencia, for example, in 1347 had a dozen physicians and thirty-one barber-surgeons. By 1283 the barbers had achieved a corporate identity through the establishment of a religious confraternity.⁽⁶¹⁾ Along with the surgeons, they formed a college in 1433 that by 1462 had evolved into a full school of surgery. By 1480 it had a full-time instructional staff, and in 1486 inaugurated a mandatory five-year course of study. The apothecaries founded their own college in [89] 1441, which acquired the right to appoint two of their number to serve the city's public institutions each year. In fourteenth-century Barcelona, apothecaries must have shared some common culture since all lived in the same district, on the carraria apothecariorum (the modern Carrer de la Llibreteria). Evidence from fourteenth-century Girona shows that barbers and apothecaries were trained through an apprenticeship system that required between five and seven years of service for the former, and between two and eight years for the latter. Physicians, on the other hand, were slower to develop a corporate existence, but they became visible in private practice and as providers of health care under contract to various municipalities, guilds, and confraternities. ⁽⁶²⁾ Despite their lack of formal organization, physicians were capable of mounting collective action against unlicensed practitioners, as they did in Barcelona in 1334 and in Valencia in 1356. In 1356, for example, the physicians of Valencia declared that no one could practice in the kingdom without four years of university training and an examination of their fitness. Specifically, they convinced King Pere III to revoke the license that he had earlier granted to Guillem Carner, an apothecary, on the grounds that Guillem had served the poor without fee. Competence, or more likely privilege, here won out over charity. ⁽⁶³⁾

Recent studies permit us to reconstruct the configuration of medical communities in several towns. In the middle decades of the fourteenth century, Girona's medical population ranged from twenty-nine during 1320-30 to fifty-four during 1341-4854 and included physicians, surgeons, barbers, and apothecaries, who served an urban constituency that ranged between eight and ten thousand. Apothecaries, in the years between the two outbreaks of plague, that is, 1348 and 1362, formed the largest group with twenty-nine practitioners, followed by twelve barbers, six surgeons, and six physicians. In 1366 twenty-seven of these organized themselves into the confraternity of the Ten Thousand Martyrs, or that of Physicians, Apothecaries, and Barbers, which met annually on the feast of Saint John the Baptist in the dining hall of the Carmelite convent. Girona's medical community was comparable to Perpignan, which just prior to the plague had nine physicians and eighteen barbers and surgeons, and Montpellier.⁽⁶⁴⁾ In 1334, Barcelona had fifty-five health professionals (ten physicians, eight surgeons, twenty-five apothecaries, and twelve barbers), while the statistics for Valencia show fifty-seven (respectively ten, nine, twenty, and eighteen).⁽⁶⁵⁾

Among medical personnel, however, physicians were fewest in number, perhaps only four or five physicians and/or surgeons per ten thousand of population in Catalonia and Valencia, rising only to six or seven in towns [90] like Valencia, Barcelona, Lleida, or Tortosa. The figure rises to twenty practitioners if apothecaries and barbers are added. ⁽⁶⁶⁾ Girona, according to Guilleré's count, had in 1360 one physician or surgeon for each eleven hundred of population, dropping to one to about six hundred when barbers are included among the medical personnel. Yet, statistics compiled by Luis García Ballester and Michael McVaugh show that Catalonia and the Crown of Aragon were much better served by medical personnel than the neighboring Crown of Castile.⁽⁶⁷⁾ The experience of eastern Spain was closer to that of Toulouse, which in 1405 had as many as thirty-five practitioners in a population of twenty thousand, or Italy, where fourteenth-century statistics for Venice and Florence show similar ratios. In both instances, where the ratios rise to twenty per ten thousand of population, barbers and even apothecaries are included in the statistics. In the first half of the fourteenth century, in contrast, Paris had approximately a third fewer physicians as a proportion of the population.⁽⁶⁸⁾ In modern terms, however, no community was amply served, and the relatively small size of the medical community meant that villages, rural areas, and the poor in general were not well provided for at all. In Catalonia, for example, the rate of twenty medical personnel per ten thousand drops to 1.7 outside of the five largest urban areas.⁽⁶⁹⁾

In the decades before the plague, the size of the medical community increased. In Barcelona and Valencia, for example, the numbers, especially of apothecaries and surgeons, grew by 50 percent between 1310 and 1335. A decline set in, however, during the famine years of the 1330s and 1340s. Barcelona's medical community peaked at fifty-eight in 1333; by 1340 its size was down to forty-five, and in 1345 to thirty-two. Valencia also reached its apogee of sixty-six in 1333, and this declined to twenty-eight in 1345. Even more dramatic are the figures from Saragossa, which show a reduction from thirty-one (1330) to three (1345). The bad times, which began in 1333, the introduction of licensing, and competition, particularly among barbers and surgeons, have all been given as reasons for this decline. Notably, this shrinkage did not occur in smaller towns like Girona and Manresa until the advent of the plague.⁽⁷⁰⁾

The plague is another factor in the contraction of the medical community at midcentury, because medical personnel would experience relatively higher mortality rates due to their exposure to infected individuals. Girona, for example, which suffered a relatively modest mortality rate of about 15 percent during the first siege of the plague in the summer of 1348, still lost 40 percent of its physicians, 25 percent of the barbers, and a fifth of the apothecaries. At Perpignan, where the plague is estimated to have taken [91] over half of the adult male population, only two of nine physicians and two of eighteen barbers and surgeons are known to have survived the pestilence. At Xàtiva in the Kingdom of Valencia, the king, acknowledging that after the plague scarcely a single surgeon was to be found in the town, reduced the legal requirement that two surgeons attend anyone found to be seriously wounded.⁽⁷¹⁾ Yet, towns, as centers of culture and possessed with a population that could afford medical care, were able to recover from such losses by attracting practitioners from other venues. Florence, whose population had declined by half on account of the plague, nonetheless had as many medical practitioners in 1399 as in 1338.⁽⁷²⁾

Medieval communities, like their modern rural counterparts, were concerned about the shortage of medical personnel, particularly after the devastation of the plague. Several stratagems were thus pursued to augment the supply of legally licensed medical personnel. The first was to petition the king for an exception, as did the lord of the town of Nules in Valencia in 1332; he asked the king to permit an apothecary (Ramon Sa Lena from Borriana) who could not meet the educational standards of the licensing statute to continue his practice. Such royally sanctioned exceptions became commonplace in the fourteenth century. A second stratagem was to utilize the services of non-Christians, despite the concerns of the Church, which, having little faith in the curative powers of medicine, saw as the prime duty of physicians the obligation to encourage patients to confess their sins. ⁽⁷³⁾ Thus, the Cortes of Monzón in 1363 provided an alternative licensing procedure for Muslim and Jewish physicians who would not have access to Christian universities, and the registers of the bishop of Barcelona contain instances of licenses being granted to Jewish physicians to treat Christian patients. At the end of the century, after the persecutions of 1391 and 1392, some of these Jewish physicians changed their names and converted to Christianity. ⁽⁷⁴⁾ On the other hand, few Muslim physicians practiced among Christians in Valencia; most of their numbers seem to have followed other members of the Islamic elite into exile in Granada or Africa. Among Muslims or mudéjars , medical practice continued to be carried on by metgesses, female practitioners who served not only as midwives, but also as general physicians and surgeons.⁽⁷⁵⁾ Such Muslim women were used not only by their own coreligionists, but by Christians as well. In 1332, for example, one such practitioner named Çahud resided within the royal household; and in 1338, when another, who practiced surgery in Barcelona, was accused of malpractice, the king did not automatically ban her from practice. Instead, he ruled that she be subjected to an examination by competent [92] surgeons. Indeed, it may well be that the prohibition contained in Valencia's Furs in 1329 that "no woman may practice medicine or give potions" may have been aimed specifically against these Muslim metgesses and not against women in general. Nonetheless, given the scarcity of Christian physicians, especially in Valencia, both metgesses and Jewish physicians continued to practice well into the fifteenth century.⁽⁷⁶⁾

Given such shortages, medical care was limited to private clients able to afford its cost, or to larger groups who would contract with medical personnel to provide services to their members. The inability of the poor to afford medical services undoubtedly was the motivating force behind the petition of the councilors of the Kingdom of Majorca to King Alfons the Magnanimous in 1420 that medical practitioners provide care at no cost to those unable to pay.⁽⁷⁷⁾ Among the early "health care alliances" were cathedral chapters. At Girona in 1296, the physician Ramon Cornellà was paid an annual retainer of one hundred sous to care for members of the cathedral chapter, and in 1305 the physician Albert received six hundred sous. ⁽⁷⁸⁾ In the fourteenth century, increasingly detailed contracts were signed between the chapter and both physicians and surgeons. The Pia Almoina of Girona, operated under the direction of the chapter, evidently provided similar care for its familia, paying one Caravit three mitgeras of wheat in 1338-39 for his services. Beginning around 1300, towns would also make arrangements with medical personnel.⁽⁷⁹⁾ The earliest contract survives from the small town of Castelló d'Empúries, which paid two hundred sous in 1307 to the physician Bernat de Cremis, but it appears that this and other small communities like Manresa, Puigcerdà, and Cervera had difficulties retaining physicians, despite their payment of increasingly larger stipends. Larger communities, which could provide physicians more attractive conditions of practice and income, felt little need to enter into such contracts until after the onset of bad times and the plague. Tortosa, for example, had a physician and surgeon under contract in 1339, and Girona paid Guillem Colteiler twenty pounds in 1357, a substantial amount, but one which paled against the one hundred pounds or more that the count-king would lavish on his own doctors. Other towns, like Murcia in 1432, appointed a local physician to serve as surgeon of the poor, charged with providing free care to the needy of the town. The Kingdom of Majorca in 1372 paid a retainer of one hundred pounds to a physician and another hundred and fifty pounds to a surgeon to serve the poor, although the latter stipend was eliminated when the royal auditor discovered that no town then had a surgeon in residence. Perhaps the decree of King Alfons noted above had some result, because by [93] the late fifteenth century the Crown was able to reduce the physician's allotment to forty pounds and the surgeon's to a mere ten pounds.⁽⁸⁰⁾ Before and after the plague, communities in the Kingdom of Valencia like Morella, Borriana, Xàtiva, and Alzira complained of a shortage of medical workers. Outlying villages, on the other hand, could at best support the services of a resident barber, but even he would have to be trained in a larger town.⁽⁸¹⁾ Thus, these smaller municipalities might contract with physicians from the larger towns to visit periodically, but there were frequent complaints that such doctors failed to appear.⁽⁸²⁾

Medical Care and Hospitals

Because of such shortages and their own lack of economic resources, the vast majority of small shelters that called themselves hospitals lacked any sort of medical personnel. Yet, by the thirteenth century, there are signs that medical care was being introduced into a few institutions. Timothy Miller argues that the European houses of the Hospitaller Order of Saint John were particularly influential in this development because, as early as its statutes of 1182, the order maintained four physicians at its large hospital in Jerusalem to diagnose disease and prescribe medicine. Within Europe, Roger I of Sicily tells us in 1137 that the Knights of Saint John were treating the sick within their houses, and in the thirteenth century several French Hôtels-Dieu, including that of Paris (1217), wrote statutes that mirror the provisions for care in the Hospitaller statutes. ⁽⁸³⁾ The Knights of Saint John, however, do not seem to have practiced the healing arts in the realms of Aragon.⁽⁸⁴⁾ Indeed, evidence of medical care in Iberian hospitals does not emerge until the end of the thirteenth century or later.⁽⁸⁵⁾ In Valencia, the earliest example of the formal provision for medical personnel is the Hospital of En Clapers, where in 1311 the founder provided fifty sous as an annual stipend for a medical doctor. By midcentury, however, the administrators had difficulty locating physicians who would accept such "a small amount" and in 1379 were forced to pay four times that salary, or two hundred sous, to Jacme d'Avinyó for his services as a physician and surgeon. In return, Jacme was obligated to make the journey from town every day to visit the hospital's inmates. Jacme's expertise in both medicine and surgery was evidently not common because, when he was ultimately replaced in 1383, the hospital was forced to engage the services of Jacme Maderes, a physician, and Francesc Riera, a surgeon.⁽⁸⁶⁾

[94] Medical care was introduced into Catalan hospitals around the middle of the fourteenth century. Tortosa, which had been contracting with medical personnel since at least 1339, demanded in 1345 that the town physician also visit and treat the sick in the municipal hospital. Likewise, by the later fourteenth century, the Hospital of the Poor in Girona and the Hospital of San Feliu de Guixols had contracts with physicians. ⁽⁸⁷⁾ At Barcelona's Hospital of Sant Macià, physicians like Berenguer Banyeres and Francesc Pedralbes were placed on an annual retainer of ten florins at the end of the fourteenth century; other physicians could also be consulted, but not frivolously because the fee was one sou per visit. In addition, the hospital would utilize as necessary the services of certain apothecaries. Instead it seems that Barcelona hospitals counted on an amount of gratuitous service from local medical personnel who had been commanded by King Pere in 1336 to visit all who were lying ill in the city's hospitals free of charge. In the early fifteenth century, the new Hospital of Santa Creu in Barcelona had a barber and an apothecary in residence, and there were additional barbers and physicians under retainer, who were expected to make their rounds in the hospital every morning and afternoon. ⁽⁸⁸⁾

Thus, by the end of the fourteenth century, hospitals like En Clapers would have a physician, a surgeon, plus a barber, an apothecary, and several metgesses, or female practitioners, to serve a patient population that ranged from between one and two dozen. It is difficult to gauge the level of care actually provided to patients, but, derived from the accounts of 1388 which show that 9 percent of the budget was expended on medicine and the salaries of medical personnel, the sense is that care was consistent if modest. Despite the requirement of the Furs de València that the physician was "obligated to treat the infirm poor without demanding any payment," the hospitals were forced to pay for these services and did so by placing medical personnel under some form of term contract or retainer. ⁽⁸⁹⁾ Accordingly, at another Valencian hospital, that of Santa Llucia or La Reyna, the town council paid physicians two hundred sous a year, surgeons one hundred sous, and wet nurses fifteen sous a month. The dides or wet nurses were in residence, but others, such as apothecaries and barbers, came at regular intervals or as needed. The Hospital of Santa Creu in Barcelona, for instance, had a number of physicians and surgeons on retainer, sometimes at substantial sums. In 1409, for example, the surgeon Pere Garbí received 990 sous, but his payment evidently was variable because in later years the stipend was considerably less. Other medical personnel were paid about three hundred sous a year, a part-time salary that reflects the consultative [95] nature of their employment.⁽⁹⁰⁾ Santa Creu accordingly worried that medical personnel might extort additional payments from individual patients, and so in its Ordinacions of 1417 banned this practice and stated that "they [that is, the barbers and physicians] should be content with the stipend or salary that the said honorable administrators will assign to them."⁽⁹¹⁾ Unlike barbers and physicians, apothecaries were generally paid no salary, but derived compensation from the price of the medicine they provided. Nonetheless, hospitals like En Clapers, did give certain individuals exclusive rights to supply the institution with medicine. Barbers, according to the accounts of En Clapers for 1382-83, were paid per service, generally three or four diners for bleeding or shaving patients. Similarly, metgesses were summoned as needed, like the Muslim woman who was paid three sous in 1396 for curing a female servant at En Clapers of an inflamed spleen that the hospital's own physician was unable to treat.⁽⁹²⁾

Records of late medieval hospitals show that the sick comprised substantial proportions of the inmate population, indicating that the transformation of these institutions from mere shelters to facilities dispensing medical care was indeed well underway. Among the inmate population in late medieval Valencia, for example, were individuals of various ages; many of these were awaiting some form of surgery, others had advanced cases of typhus, malaria, tuberculosis, cachexia (a wasting away due to chronic disease), dropsy, pustules, consumption, scrofula, and lesions of major organs and vessels. But, the largest number of recorded diagnoses were for those suffering from some sort of wound. There are also instances of the plague, both among inmates as well as the staff, and of the admission of children whose mothers had died from the pestilence. General hospitals like En Clapers refused entry to lepers, who were instead conducted to the leprosarium of Sant Llàtzer; and those who suffered from mental disorders would be held only until they could be returned to relatives.⁽⁹³⁾ At Barcelona's Santa Creu, the earliest Llibre de entrades des malalts dates from the period February 10 to November 23, 1457 and records the facts of some 346 admissions. Of these 171 almost half, had some sort of fever and another 18 percent suffered from symptoms of the plague. An eighth of the patients came from vessels in the harbor, presumably sick but with no diagnosis specified; another three patients, described as del mar , presumably came from outside the harbor area. The remaining 20 percent of patients had a wide variety of ailments: dropsy (eight), apoplexy (two), ulcers (six), pains (four), leg and feet problems (five), fractures (two), old age (one), itching (one) and stomach problems (one). Fewer than 10 [96] percent of the admissions (thirty-two) carried no diagnosis. Of all those who were admitted, only 26 percent (ninety-one) died, a much smaller statistic than the 49 percent recorded for the years 1473 to 1491; the rate was almost twice as high for women (47.8 percent) than it was for men (24.7 percent). Not surprisingly, the highest death rate, two-thirds, was experienced by victims of the plague. In contrast, only three of the eight patients with dropsy died, and 17 percent of those with fever. Unfortunately, data for other patients is too meager to be statistically significant, but it does indicate that those who entered the hospital did have a realistic expectation of recovery and discharge. Perhaps the reason for this is that, to judge by our meager information regarding admissions, there was a bias in favor of admitting the acutely over the chronically ill, individuals who would either be cured or die without the necessity of extended care. In terms of gender, higher mortality rates indicate that elderly women were more likely to receive admission and extended care than men.⁽⁹⁴⁾

Late medieval physicians felt that their main task was to keep patients alive and comfortable and so generally shunned aggressive treatment. ⁽⁹⁵⁾ Thus, besides prayer, the major forms of treatment within medieval hospitals involved diet, medication, and surgery. By all accounts, diet mimicked that of public shelters, and of the population at large, with its reliance on bread and wine, with small quantities of meats and vegetables, for the bulk of calories. This can be seen in the food accounts of En Clapers for 1388-89 that show an expenditure of 30 percent on wheat, 26 percent on wine, and 24 percent on meat and fish. Despite the fact that poultry was regarded as a proper food for the sick, most of the meat purchased was mutton, only 5 percent was chicken.⁽⁹⁶⁾ Thus, it seems in matters of diet the emphasis was on ensuring that the sick had food to eat, rather than on providing any kind of therapeutic diet. For example, when one individual arrived at Barcelona's Hospital of Sant Macià with fever, he was confined to the hospital and provided with a diet of chicken, raisins, and sweets, at a cost of nine diners; only if necessary would a physician be called because of the sou that the visit would cost. The ordinances of Santa Creu, which outline the general regimen of care, speak of foods, as well as medicines, being prescribed for various patients.⁽⁹⁷⁾

The form of actual therapy that is easiest to document is the pharmaceutical, because herbal remedies, ointments, syrups, and other preparations had to be purchased from an apothecary. While drugs, most often elaborate recipes compounded from as many as a dozen ingredients, were available in Catalonia, they do not seem to have been widely prescribed for [97] patients in hospitals, perhaps because of their cost.⁽⁹⁸⁾ The invoices of Valencia's Hospital of En Clapers, for example, show that the products most prescribed by physicians and other personnel were syrups (made, for example, from roses, sugar, vinegar, endive, maidenhair, fumitory, julep, a mixture of honey and vinegar, or violets), enemas, plasters, powders of various sorts, and ointments (made from roses, gold, camphor or sandalwood). Also purchased, but much less frequently, were pills of various sizes, confections, and eyewashes. There were also various potions, called variously waters (e.g. of the dog rose), oils (bitter almond, dill, quince, spinach, blue lily, mastic, myrtle, scorpions, or roses), conserves, juices, boiled wine, and concentrated syrups. The accounts also show quantities of tragacanth (a gum), musk, plaster, incense, small crustaceans, lemon juice, melon seeds, honey, black pepper, saffron, salsa, and sugar. Taking into account all the perils of medieval accounting, all of this represented between 5 and 10 percent of the hospital's total expenditure.⁽⁹⁹⁾

Santa Creu, according to its ordinances, was as careful as modern hospitals in the distribution of medicine. Nothing could be dispensed to patients unless it were prescribed by a physician or barber. As a safeguard, these individuals were supposed to order the medication "in their own hand in the book of the apothecary of the hospital." The apothecary, for his part, was forbidden to compound or dispense any medications not prescribed for patients by medical personal; additionally, if the prescription were for a member of the hospital staff, it required the authorization of the upper administration. ⁽¹⁰⁰⁾

Positive medical interventions included bleeding and purging, although not to the extent that was once believed, and surgery. Given the lack of anesthesia and a means for preventing infection, surgeons were reluctant to open the body cavity. Their ministrations more commonly were confined to setting fractures, binding and suturing wounds, fixing dislocations, and dressing sores and rashes. One has the sense from the ordinances of Barcelona's Santa Creu in 1417 that the hospital functioned as a kind of emergency room. While most medical personnel were merely on call, one barber, who was to be expert in the art of surgery, was to be present day and night to serve patients who suffered some sort of emergency and the poor who might arrive at any hour and require immediate treatment.⁽¹⁰¹⁾

The final services that the hospital provided to inmates were comfort in death and a burial. A sworn deposition of 1335, for example, reveals that an attendant at Valencia's Hospital of En Clapers, Guillem Busquet, stood beside the dying Pero López d'Arbull, holding a candle and reciting various [98] prayers. After a person died, the hospital had to prepare the corpse for burial, wrap it in a shroud, and if necessary inter the body in the hospital's own cemetery. Rubio Vela estimates, based on the amount of money spent on shrouds, that En Clapers buried an average of thirty or forty individuals per year, rising to almost ninety during the months of plague and famine between April and October 1375. It is difficult to estimate the hospital's mortality rate, even though we can estimate the average daily population, because there is no information concerning length of hospitalization. Nonetheless, given a daily population that ranged between eight and eighteen, the number of deaths suggests that many patients were seriously ill, and perhaps also reflects the hazards of medieval medicine. ⁽¹⁰²⁾ Katherine Park and others have argued that hospitals served the economic function of protecting the urban work force from infection by providing a place for sick people, particularly victims of the plague, to die. These institutions might heal individuals and restore them to employment, but more importantly they served to quarantine those who might infect the healthy population.⁽¹⁰³⁾

In the twelfth century, hospitals, even those that sheltered individuals suffering from a specific disease like leprosy or ergotism, served fundamentally as shelters. Their purpose was to provide a decent place in which the individual patient would die or, less likely, recover; care itself emphasized the welfare of the soul more than it did of the body. By the early fifteenth century, however, the outlines of the modern general hospital had emerged, staffed with physicians and nurses, who made rounds, prescribed medicine, and undertook other forms of treatment. While mortality rates remained high, a majority of patients recovered and returned as healthy members of the community. What forces are responsible for this transformation? Among the most important is the development of medicine as a profession, not only as an academic discipline taught in universities but also as a practical craft pursued and handed on by experienced physicians, barbers, and surgeons. Advances in pharmacology and diagnosis made their contribution. Essential as well was the evolution of municipal government, which could apply collective resources to procuring medical services for the less affluent, within hospitals and within the community. Efforts to inspire or compel medical personnel to serve the poor without charge met with indifferent success, and one suspects that limitations in society's ability to afford medical care is a significant reason for the concern, one with decidedly [99] modern overtones, over a shortage of adequate medical services, particularly in smaller towns and rural areas. Catalonia, which had commercial and political ties to Italy and the rest of the Mediterranean and its own medical school, had an advantage over the rest of Iberia and much of northern Europe. With proportionately greater numbers of medical personnel, and with some of Europe's first general hospitals, medieval Catalans and Valencians had gained some access to medical care, which was now considered to be part of the routine of hospitalization.

Notes for Chapter Five

1. For a discussion this problem, see Cullum, Cremetts and Corrodies , 2.

2. For example, in 1397, the apothecary Francesc Conill of Valencia left his goods to endow such a hospital for the sick and others (Rubio Vela, Pobreza, enfermedad y asistencia, 38).

3. There are scattered references to lepers in northern France and England during the eleventh century; the first reference in Aragon is Pedro I's grant in 1096 of revenues "for the support of the poor and of lepers" (Ubieto Arteta, "Pobres y marginados," 21). See also Moore, Persecuting Society, 50. To the argument that leprosy was introduced into Europe by returning crusaders, Dols argues that there is no evidence that Muslims spread leprosy into Europe either during the era of Islamic conquest, or during the era of the Crusades, principally because Western polemical literature of the era makes no such charge. He does allow that sub-Saharan Africa was an important source for leprosy, and that there is little evidence of the disease in North Africa or Spain before the era of Muslim government. The first known leper hospital in North Africa, the Dimnah Hospital in Ifriqiyah, dates from circa 930; in al-Andalus, there was a leprosarium in ninth-century Córdoba in an orchard on the western edge of the city. The disease was prevalent in Palestine and Syria during the crusading era, and the increase in traffic between East and West might well have aggravated the disease in Europe. Michael W. Dols, "The Leper in Medieval Islamic Society," Speculum 58 (1983):898, 905-8.

4. For Canon 23, see Bériac, Lépreux, 155-161. Most frequently the invocation was that of Saint Lazarus, whom medieval people tended to identify as both the brother of Mary and Martha and the pauper at the gate of Dives (Cullum, Hospitals in Medieval Yorkshire, 32).

5. Ward E. Bullock, "Leprosy (Hansen's Disease)," in Cecil Textbook of Medicine, ed. J .B. Wyngaarden and L. H. Smith (7th ed.; Philadelphia, 1985), 1634-35.

6. Cullum, "Hospitals", 23; Peter Richards, The Medieval Leper and His Northern Heirs (Cambridge, 1977), viii. Twelfth-century doctors, for example, dropped cold water on the skin of suspected lepers to watch how it ran, a test that is capable of identifying leprosy (Moore, Persecuting Society, 47). Other techniques of diagnosis included examination of the extremities for sensation and of the face for signs of deformation; less effective was the examination of how the patient's urine and blood reacted when mixed (David Nirenberg, Communities of Violence: Persecution of Minorities in the Middle Ages [Princeton, N.J., 1966], 94-96).

7. Nirenberg, Communities of Violence, 105; McVaugh, Medicine before the Plague, 218-23; Jacquart and Thomasset, Sexuality and Medicine, 184-86. On leprosy as a sign of sin, or as an expiation for sin, see Moore, Persecuting Society, 60-65. Luke Demaitre, citing the desire of Jordanus (a master at the University of Montpellier) for "the benefit of the commonwealth," argues that the lepers' plot may well have motivated his Notes on Leprosy; see Demaitre's "The Relevance of Futility: Jordanus de Turre (fl. 1313-1335) on the Treatment of Leprosy," Bulletin of the History of Medicine 70 (1996): 28.

8. Merovingian legislation did, on the other hand, call for such segregation. The Council of Lyons (583), for example, ordered bishops to provide lepers with "alimenta et necessaria vestimenta," but at the same time to deny them any permission "per alias civitates vagandi" (Loren C. MacKinney, Early Medieval Medicine With Special Reference to France and Chartres [Baltimore, 1937], 178). Many have argued that Western Christian society segregated lepers to a greater extent than did Muslims, or even Western crusaders in Palestine, because lepers were feared not only as a source of contagion but also as a source of religious impurity. Leprosy, it is argued, was more than a disease; it was a punishment inflicted on individuals who were damned by God. For a discussion, see Dols, "The Leper in Medieval Islamic Society," 912-16; Richards, Medieval Leper, 41-2, 48-49; Shulamith Shahar, "Des lépreux pas comme les autres. L'ordre de Saint-Lazare dans le royaume latin de Jérusalem," Revue historique 267 (1979): 22, 40-41. But, as the following discussion illustrates, the segregation actually practiced in the West differed little, if at all, from that found in the contemporary Middle East or North Africa; and the moral regime demanded in Christian asylums for lepers does not appear to give them up as damned. Indeed, Richards acknowledges that leprosy in the thirteenth century was an offense under English common law, as well as Scandinavian law, only if the leper insisted on continued residence in town and attendance at church and neighborhood affairs (Richards, Medieval Leper, 49-50). See also McVaugh, Medicine before the Plague, 218-19; Henderson, Piety and Charity, 244.

9. Various artistic depictions show lepers with short tunics in the twelfth century, but in long garments in the fourteenth. The diocese of Coutances prescribed a closed, hooded cape, as did the leprosaria of Lisieux (in 1256) and Chartres (in 1264). The Council of Lacaur in 1368 stated that lepers must wear closed garb that was neutral in color and which bore a distinctive insignia. See Bériac, Lépreux, 185-91; Geremek, Margins of Society, 174-75. "Regula ordinis S. Spiritus," PL 217: 1146, cap. 51. For Oviedo, see López Alonso, Pobreza en la España medieval, 434. For a survey of practices of segregation, see Moore, Persecuting Society, 55-60.

10. Medieval Toulouse, for example, had seven leprosaria, the earliest in existence by 1167, with the last having its first mention in 1246 (Mundy, "Charity and Social Work in Toulouse," 227-30). Moore's compilation of first references to leprosaria shows that in England the most active period of foundation was 1175 to 1200, followed by 1225 to 1250, with a gradual falling off thereafter. For the region around Paris, foundations begin a rapid development in the era of 1175 to 1200 and peak between 1225 and 1250. See Moore, Persecuting Society, 52.

11. The Franciscans, the Order of the Holy Spirit, and the Hospitalers of Saint John cared for lepers here and there, but more by way of accident than intention. See Webster, Els menorets, 186; Bériac, Lépreux , 233-34. The Order of Saint Lazarus, itself, was founded in Jerusalem during the 1120s as a confraternity that cared for the sick and lepers; Malcolm Barber argues that the order became an honorable refuge for Latin colonists in Palestine who had contracted leprosy. In Palestine, particularly under Baldwin IV of Jerusalem, the leper king, it acquired military responsibilities, and its grand master up until 1253 was required to be a leper. The order was introduced into France after the Second Crusade by Louis VII who is said to have given it a hospital in Paris to care for lepers, although others assert that even this institution remained under the jurisdiction of the bishop of Paris. Mutel's recent study of the order's commanderies in Normandy indicates that property management, initially for the benefit of the brethren in the Near East, and not the care of lepers, was their primary function, and the leprosarium of Saint-Lazare in Montpellier was a laic foundation with no connection to the order. In the Crown of Aragon, towns like Valencia, Girona, and Lleida had Hospitals of Sant Llàtzer, but their connection to the Order is uncertain. Studies of similar hospitals in the region of Asturias show no affiliation to the Order of Saint Lazarus. In August 1265, Pope Clement IV issued a bull that placed all lepers in Christendom under the care and protection of the order, but practical barriers to such a sweeping reform guaranteed that it came to naught. See Tolivar Faes, Leprosos en Asturias, 261; Burns, Crusader Kingdom, 1:242; W. G. Rödel, "San Lazzaro, di Gerusalemme," DIP 8:579; Gautier de Sibert, Histoire de l'Ordre Militaire et Hospitalier de Saint-Lazare de Jérusalem (1772; Paris, 1983), 48-63; Charles Moeller, "Lazarus, Saint, Order of," The Catholic Encyclopedia (New York, 1910), 9:96-97; André Mutel, "Recherches sur l'ordre de Saint-Lazare de Jérusalem en Normandie," Annales de Normandie 33 (1983): 121-42; Marcel Baudot, "La gestation d'une léproserie du XIV^e siècle: La maladrerie Saint-Lazare de Montpellier," Actes du 110e Congrès national des sociétés savants (Paris, 1987), 1:411; Malcolm Barber, "The Order of Saint Lazarus and the Crusades," Catholic Historical Review 80 (1994): 443-4, 454.

12. Bériac, Lépreux, 163-66.

13. Cullum, "Hospitals", 20-26.

14. Mundy, "Charity and Social Work in Toulouse," 253.

15. López Alonso, Pobreza en la España medieval, 439-40.

16. Toliver Faes, Leprosos en Asturias, 251-54.

17. Martínez García, "Asistencia material," 353.

18. Sanchez Herrero, "Cofradías," 41; Carmona García, Hospitalidad publica en Sevilla, 26; García del Moral, Hospital Mayor , 39-40.

19. Pérez Santamaría, "San Lázaro," 1:77-89, 105-6, 114-15; Battle and Casas, "Caritat privada," 1:144; Batlle, L'assistència , 67-69.

20. Pérez Santamaría, "San Lázaro," 92-93. In contrast, during a similar period, 1374-75 to 1396-97, the Hospital of En Clapers in Valencia derived 66.5 percent of its income from land rents, 22 percent from various rights of lordship, 6.5 percent from municipal bonds, and only 5 percent from such variable sources as the sale of surplus food, the effects of deceased inmates, and alms (Rubio Vela, Pobreza, enfermedad y asistencia, 92-3).

21. For example, the statutes permitted two diners to be spent per day on each staff member for food, while inmates were allotted only twelve diners per week. On feast days, a single diner could be spent on each leper and staff member, but the administrator and chaplains were to receive food worth three diners each (Pérez Santamaría, "San Lázaro," 99-100).

22. Besides the administrator and chaplains, the staff included a porter, three individuals who collected bread as alms for the hospital (whose subsequent sale represented 30 percent of the hospital's income), a slave, a laundress, and the attendant (Pérez Santamaría, "San Lázaro," 99-100; 104-106). At Valencia's leper hospital, inmates were cautioned not to exceed their daily quota of wine and not to give any food to their friends or relatives. There is no evidence of any staff to provide care and it seems that inmates were expected to cook their own meals (Rubio Vela, Pobreza, enfermedad y asistencia, 165).

23. Tarragó, Lérida, 31, 36, 69.

24. Guilleré, Girona medieval, 89; idem, "Charité à Gérone," 1:196.

25. Batlle, Urgell medieval, 139-41.

26. Ollich, "Les entitats eclesiastiques de Vic," 97; Junyent, Vic, 87-88.

27. Nirenberg, Communities of Violence, 101; Danon, Visió històrica, 16; Duran, Llibre de Cervera, 213-14.

28. On the leper plot and the property confiscations within the Aragonese Crown, see Nirenberg, Communities of Violence, 93-108. See also J. R. Webster, "La reina doña Constanza y los hospitales de Barcelona y Valencia," Archivo Ibero-Americano 51 (1991): 378; and Webster, Els Menorets , 55, 186. Duran adds that the hospital was reconstructed with two hundred pounds left by the merchant Joan Llop in his will of 1377, and the church with money willed by another merchant, Bertran dels Archs, in 1389. Llibre de Cervera, 214-15. The decline in leprosy suggested by the Catalan evidence is also reflected in sources from England where many leper houses began to fall into disuse or else were converted into shelters for nonlepers during the fourteenth century (Cullum, Cremetts and Corrodies, 4).

29. Contreras and Rosselló, Leprosos en Mallorca, 21-2, 42, 57-59.

30. Burns, Crusader Kingdom, 1:242; Rubio Vela, Pobreza, enfermedad y asistencia, 54, 165; Mercedes Gallent Marco, "Instituciones hospitalarias y poderes públicos en Valencia," Saitabi 34 (1984): 82.

31. Local prejudice, however, was not so easily assuaged; Bernat was expelled a second time only to be declared healthy again by the doctors of Sant Llàtzer. The matter ultimately came before the king (Nirenberg, Communities of Violence, 106).

32. The ritual of civil death was practiced in England; for an example of the rite, see Richards, Medieval Leper, 123-24.

33. López Alonso, Pobreza en la España medieval, 435-36.

34. This prioritization is contained in statutes promulgated in 1326 (Pérez Santamaría, "San Lázaro," 88-89).

35. My own study of medieval wills in Spain shows that, for the most part, families would automatically inherit all of a decedent's real property and up to 80 percent of his personal property, with the remainder disposable at the testator's wish. See James W. Brodman, "What is a Soul Worth? Pro anima Bequests in the Municipal Legislation of Reconquest Spain," Medievalia et Humanistica , new series, no. 20 (1994): 20-21. In France, the customs of Beauvais in effect gave the leprosarium the family's right to a leper's property, leaving the disposition of only a fifth of those goods to the leper. See Bériac, Lépreux, 226.

36. For example, a leper at Castelsarrasias gave six pounds in 1300 for his admission, while in 1280 a father promised his daughter's future inheritance to the commander of the leprosarium at Capdenac (Bériac, Lépreux , 226).

37. Ibid., 228-31; Pérez Santamaría, "San Lázaro," 88, 92-93, 111; Rubio Vela, Pobreza in la Valencia, 165; McVaugh, Medicine before the Plague, 224.

38. Mundy, "Charity and Social Work in Toulouse," 249. The leper hospital at Chartres, the Grand Beaulieu, imposed its statutes, based loosely upon the Rule of Saint Augustine, on both healthy and leprous, although these were separated by condition as well as by gender. Since this hospital was successful and of note, its usages were imitated by other leprosaria, such as that of Saint Gilles, established in 1135 in the Norman town of Pont-Audemer. See Simone C. Mesmin, "Waleran of Meulan and the Leper Hospital of S. Gilles de Pont-Audemer," Annales de Normandie 32 (1982): 8-11.

39. Rubio Vela, Pobreza, enfermedad y asistencia, 165. While both Christian and Muslim medical authorities allowed that leprosy might be communicated through sexual intercourse, concern for containing the disease within a society already infected could hardly have been the reason for this call to chastity. For ideas concerning communicability, see Barber, "Saint Lazarus," 444; Dols, "The Leper in Medieval Islamic Society," 897-98; and Richards, Medieval Leper, 54.

40. Bériac, Lépreux, 235-44, 249; Pérez Santamaría, "San Lázaro," 89; Rubio Vela, Pobreza, enfermedad y asistencia , 165.

41. Bériac, Lépreux, 84, 262.

42. The physician's charge was three sous per visit, suggesting, inter alia, an economic motive for avoiding medical care (Pérez Santamaría, "San Lázaro," 112-13). Records at Urgell show that lepers were administered oakum or tow, perhaps as a kind of bandage (Batlle, Urgell medieval , 1300). Jordanus de Turre, a master at the University of Montpellier in the 1320s, diagnosed three stages in the progression of leprosy and, in his De lepra nota, prescribed a regimen of care for each stage, hoping for a cure in its earlier phases and greater comfort for the patient in its terminal period. There are no indications, however, that Jordanus's advice had an impact on the character of care actually dispensed in Catalan leprosaria (Demaitre, "Relevance of Futility," 30-46).

43. Matthew J. Ellenhorn and Donald G. Barceloux, Medical Toxicology: Diagnosis and Treatment of Human Poisoning (New York, 1988), 1317-18; A Companion to Medical Studies, ed. R. Passmore and J. S. Robson, 3 vols. (Philadelphia, 1970), 2:13.1-2. Mary Matossian argues that some victims of ergotism, because of their hallucinogenic behavior and spasms, were accused of witchcraft; see her Poisons of the Past: Molds, Epidemics and History (New Haven, Conn., 1989), 9-14, 57.

44. For example, the statutes of the Hospital of Saint Jean at Angers forbade the admission of both lepers and those who suffered from ergotism, in addition to paralytics and young children (Moore, Persecuting Society, 55).

45. I. Ruffino, "Canonici Regolari di Sant'Agostine di Sant'Antonio, di Vienne," DIP, 2:134-141; J. F. Hinnebusch, in Jacques de Vitry, Historia Occidentalis, 281.

46. Duran, Llibre de Cervera, 209-11. Before moving to Barcelona, the brothers were nonetheless active there seeking alms for their order, as evidenced by a privilege of June 3, 1349, allowing them to announce indulgences in the city to their benefactors (Gyug, Diocese of Barcelona, 331-32 n. 878).

47. Mutgé, Ciudad de Barcelona, 49; Duran, Llibre de Cervera , 209.

48. Tarragó, Lerida, 65-66.

49. Burns, Crusader Kingdom, 1:244; Rubio Vela, Pobreza, enfermedad y asistencia, 35, 45-6.

50. The Valencian institution, however, does not seem to have been fully utilized because in 1493 its administrators petitioned that other poor be accepted as well. See García Ballester, Medicina a la Valencia, 111; López Alonso, Pobreza en la España medieval, 440-44; Cullum, Cremetts and Corrodies, 3; Rubio Vela, Pobreza, enfermedad y asistencia, 44; McVaugh, Medicine before the Plague, 225-35; Katherine Park, "Medicine and society in Early Medieval Europe, 500-1500," in Medicine and Society: Historical Essays, ed. Andrew Wear (Cambridge, 1992), 88-90; and George Rosen, "The Mentally Ill and the Community in Western and Central Europe during the Late Middle Ages and Renaissance," Journal of the History of Medicine 19 (1964): 377-83.

51. Or, one could argue, the medieval era witnessed the reprofessionalization of medicine, since hospitals or xenodochia of the late Roman period had also associated the two elements. Paul the Deacon described the sixth-century hospital established by Bishop Masona at Mérida: "He built a xenodochium and endowed it with a large patrimony, and he ordered that, with the appointment of ministers or physicians (medici), it serve the needs of the sick and pilgrims." Likewise, in southern France, Bishop Praeiectus of Avernus founded a hospital "where he established medical men or strenuous men, who had charge of care, to always tend to twenty sick people, and to provide them with an allotment of food there; but after they get well, they give their places to others." For the Latin texts, see MacKinney, Early Medieval Medicine, 170, 177. The first medical school in medieval Spain was recognized by Alfonso VIII of Castile in 1209 at Palencia, but evidence suggests that this had disappeared by 1250 (Hergueta, "Noticias," 424-25). Alfonso X, in his legal works, acknowledged the importance of physicians and medicine, but his interest seems to have been in the social, rather than the scientific aspects of medicine. The University of Salamanca, for example, was given an endowment for two chairs in medicine in 1254, yet there is no evidence for an active medical faculty there until the early fifteenth century. See Luis García Ballester, "Medical Science in Thirteenth-Century Castile: Problems and Prospects," Bulletin of the History of Medicine 61 (1987): 188-90; Marcelino V. Amasuno Sarraga, La escuela de medicina del estudio salmantino (siglos XIII-XV) (Salamanca, 1990), 14-32. Outside of Iberia, the fourteenth century likewise marked the appearance of physicians at hospitals. The first surgeon, for example, was appointed to the Holy Spirit Hospital at Frankfurt am Main in 1377 (Rosen, "Historical Sociology," 17).

52. Physicians generally treated internal or systemic illness, while the surgeon dealt with fractures, wounds, abscesses, skin ailments, and external complaints. The apothecary could recommend as well as prepare medication. He could also sell wax and candles for funerals and other types of merchandise. Barbers bled patients and also shaved, cut hair, and pulled teeth. Being relatively low paid, they often engaged in a number of unrelated occupations and also attempted to infringe upon the domain of the surgeon. McVaugh cites several cases in which individuals moved from calling themselves barbers to being surgeons, and of others who claimed dual competence. See McVaugh, Medicine before the Plague, 38-40; 123-25.

53. Montpellier became a center of medical activities in the mid-twelfth century, and medical instruction had begun there before 1200. A "university" of both medical masters and students was subsequently established, whose statutes received papal approval in 1220. See Nancy G. Siraisi, Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice (Chicago, 1990), 59.

54. Roger II of Sicily (1130-54) had mandated that practitioners be examined by royal officials; in 1231, the Emperor Frederick II entrusted this function to the masters of the University of Salerno, although contemporaries lamented that such regulations were not well-observed. See Siraisi, Medieval and Early Renaissance Medicine, 17-18. See also Luis García Ballester, Michael R. McVaugh, and Agustín Rubio Vela, Medical Licensing and Learning in Fourteenth-Century Valencia (Philadelphia, 1989), 2-4; James M. Powell, "Greco-Arabic Influences on the Public Health Legislation in the Constitutions of Melfi," Archivio storico pugliese 31 (1978): 80, 88-89. At Toulouse, as the result of complaints about unqualified practitioners, those who wished to practice were required to be examined by the bishop, with the assistance of experienced physicians. The masters of the university questioned the bishop's competence and stated that inept individuals continued to practice. As a result, the town council transferred this function to the masters, and the king in 1411 upheld the requirement: Philippe Wolff, "Recherches sur les médecins de Toulouse aux XIV ^e et XV^e siècles," in Assistance et assistés jusqu'à 1610. Actes du 97^e congrès national des sociétés savantes, Nantes, 1972 (Paris, 1979), 534-35. See also McVaugh, Medicine before the Plague, 69-71.

55. García Ballester, McVaugh and Rubio Vela, Medical Licensing , 6-8; McVaugh, Medicine before the Plague, 95-96; López, "Documentos acerca de la peste negra," 305, no. 18.

56. For an account of the foundation and history of medical study at Lleida, see McVaugh, Medicine before the Plague, 83-87.

57. Danon, Visió històrica, 130.

58. For earlier decades, the numbers are even smaller: two in the 1300s, five in the 1310s, three in the 1320s, and four in the 1330s; see McVaugh, Medicine before the Plague, 81.

59. The sentiments concerning the importance of experience in surgery were expressed in November 1389 by two Valencian medical masters, Pere Giguerola and Guillem Ça-Fàbrega, in the report of their examination of the surgeion Johan de Sena. See García Ballester, McVaugh, and Rubio Vela, Medical Licensing, 15-17, 34-39, 54. As late as the sixteenth century, for example, half of the practitioners in London were unlicensed (Siraisi, Medieval and Early Renaissance Medicine, 20, 188-89). In Toulouse, physicians as early as 1306 were required to be examined, but such a requirement for barbers is not found earlier than their guild's new statutes of 1457 (Wolff, "Médecins de Toulouse," 534, 537).

60. In Italy, a medical guild was established in Florence in 1293. In 1314, it divided itself into three branches to represent medici, apothecaries, and barbers. University-trained physicians established their own association in 1393. Venice had a College of Physicians in 1316 (Siraisi, Medieval and Early Renaissance Medicine, 18).

61. This was suppressed, along with most other confraternities, early in the reign of Jaume II but permitted to reform in 1311. Other such bodies appear in early fourteenth-century Aragon (Calatayud and Huesca). These bodies assumed some regulatory authority over their members; elsewhere, in places like Lleida and Barcelona, the regulation was municipal. Much of the concern was centered on enforcing a prohibition against practice on Sundays and feasts, although Barcelona, in also regulating bleeding, recognized the barber's medical functions. See McVaugh, Medicine before the Plague, 125-27.

62. García Ballester, Medicina a la Valencia, 58-67; Guilleré, Girona medieval, 73. At Toulouse, barbers organized themselves into a guild sometime between 1363 and 1391, and by 1404 they had adopted a set of consuetudines that were modified and amplified in 1442. The first required that barbers be residents of the town, while the second more precisely insisted that the practitioner reside in a house with his family, maintain only one location of practice, attend to his patients in person, and not delegate his responsibilities to anyone less qualified (Wolff, "Médecins de Toulouse," 535-36). See also McVaugh, Medicine before the Plague , 118.

63. García Ballester, McVaugh and Rubio Vela, Medical Licensing , 39-40; Siraisi, Medieval and Early Renaissance Medicine, 22.

64. These statistics also hold true for the longer interval of 1320-1370, during which sixty-one apothecaries have been identified as practicing in Girona, along with twenty-nine barbers, twenty-three surgeons, and eleven physicians (Guilleré, Girona al segle XIV, 2:362-65). See also Guilleré, "Le milieu médical géronais au XIV^e siècle," in Actes du 110e Congrès, 1:265-66, 269-70; and Richard W. Emery, "The Black Death of 1348 in Perpignan," Speculum 42 (1967):619-20.

65. A smaller town like Manresa, on the other hand, was served from 1320 to 1345 by a single physician and two surgeons, all of whom were exempted by the town from the payment of taxes on the understanding that they remain and practice in the town. See McVaugh, Medicine before the Plague , 44, 108; the figures, based on fewer sources, are lower in García Ballester, McVaugh and Rubio Vela, Medical Licensing, 37.

66. McVaugh counts 201 practitioners of all types in Barcelona, from 1300 to 1340, and 197 for Valencia, or 20 and 22.7 per 10,000 of population. See his Medicine before the Plague, 42-9.

67. Their count of the names of healers from the fourteenth century preserved in the archives yields some two thousand names for the Crown of Aragon, and only two dozen for the entire Crown of Castile (García Ballester, "Medical Science," 185).

68. Florence, for example, in 1379 had seventy medical practitioners of all kinds for a population of about fifty thousand (Siraisi, Medieval and Early Renaissance Medicine, 23). Toulouse, in 1405, had only three local physicians and twenty-two barbers. Wolff, however, estimates that nonresidents raised the total closer to thirty or thirty-five. See his "Médecins de Toulouse," 533. See also McVaugh, Medicine before the Plague, 64-67.

69. McVaugh, Medicine before the Plague, 49.

70. Ibid., 43-45.

71. The sharp difference in mortality rates between the closely situated towns of Girona and Perpignan is undoubtedly due to the time of the year when each community was infected. Perpignan was hit during the spring, when the bacillus was most active, while Girona was saved by the hot temperatures of the Mediterranean summer that inhibited the disease. See Guilleré, "Milieu médical," 268; and Emery, "Black Death," 612, 619-20. For Xàtiva, see López, "Documentos acerca de la peste negra," 411-12, no. 132 (February 23, 1352).

72. Siraisi, Medieval and Early Renaissance Medicine, 24.

73. Indeed, García Ballester and McVaugh have argued that an important motivation in the establishment of licensing requirements for medical practitioners was to take medicine out of the hands on unbelievers and place it into Christian hands, since only Christians would have access to the university training demanded by the law. See García Ballester, McVaugh and Rubio Vela, Medical Licensing, 42, 49; see also McVaugh, Medicine before the Plague, 96-103. The Rule of the Hospitaller Order of the Holy Spirit, in describing the manner of how the poor ought to be received into its hospitals, manifests this concern by mandating that before they are fed or shown to a bed they should be confessed by a priest ("Regula ordinis S. Spiritus," PL 217:1141, cap. 13).

74. Synodal legislation (1354) at Barcelona forbade Christian physicians to begin treatment before the parish priest had been summoned to confess the patient and give him communion and also forbade the use of a Jewish doctor unless he had a Christian assistant on penalty of excommunication. Various exceptions, however, suggest that this was not strictly enforced (Utterback, Pastoral Care, 39). One such convert was Mosse Falcó, who became Francesc Pendralbes and subsequently served as a consulting physician to two hospitals in Barcelona, Sant Macià and Santa Creu (Danon, Visió històrica, 130).

75. The phenomenon is found elsewhere. Twenty-five female surgeons are known to have practiced in Naples between 1273 and 1410; in Frankfurt, between 1387 and 1497, fifteen women, most of whom were Jewish, have similarly been identified. While any statistics on the number of female medical practitioners are problematical, nevertheless, one estimate is that women in late medieval France constituted 1.5 percent of all medical practitioners, and 1.2 percent of those in England (Siraisi, Medieval and Early Renaissance Medicine , 27). See also Muriel Joy Hughes, Women Healers in Medieval Life and Literature (Freeport, N.Y., 1968), 82-96.

76. García Ballester, Medical Licensing, 21-32. Cullum, in her study of Saint Leonard's of York, in England, discovers female nurses like Ann, who in 1276 is described as a medica. She argues that women, as nurses, must have accumulated a body of medical knowledge, probably based on traditional herbal medicine, that they used in the absence of physicians to treat patients. This included even minor surgery (Cremetts and Corrodies , 13-15). On the important role of Jewish physicians within the Crown of Aragon, see McVaugh, Medicine before the Plague, 55-64; on women, see 103-7. The accounts of Valencia's Hospital of En Clapers of the late fourteenth century contain entries showing payment to metgesses called in to care for children, for example, one florin paid in 1396-97 for setting the fracture for an illegitimate child. See Agustín Rubio Vela, "La asistencia hospitalaria infantil en la Valencia del siglo XIV: Pobres, huérfanos y expósitos," Dynamis 2 (1982): 180.

77. The appointment of municipal physicians can be found outside of Catalonia. In 1377, a physician at Frankfurt am Main treated without charge all municipal employees and patients in the town hospital. The Emperor Sigismund in the 1430s issued a number of reform proposals that, inter alia, recommended that each municipality have a physician, and that physicians should treat the poor without charge (Rosen, "Historical Sociology," 17-18). Monarchs like Jaume II routinely appointed physicians, as well as barbers and apothecaries, to positions at court and at relatively high salaries (McVaugh, Medicine before the Plague, 4-34).

78. Albert's contract required him to live within Girona's walls, not to leave the city if any member of the chapter currently was ill, and to treat the canons free of further charge anywhere within the boundaries of the diocese. There are also examples of individuals entering into similar lump-sum contracts with physicians, including members of the royal army who typically yielded the equivalent of a day's pay to a contract physician in return for guaranteed medical care (McVaugh, Medicine before the Plague, 174-76).

79. In Italy, the practice of appointing town doctors, or medici condotti , dates from the 1210s and became almost universal in the fourteenth century. At first these medici were surgeons charged with the treatment of wounds and fractures, but after 1300 physicians were also under contract. Between 1333 and 1377, Venice on average kept seven physicians and ten surgeons under contract to reside in the city, treat the poor free of charge, and give medical advice and testimony. In France, the phenomenon was later, coming toward the end of the fourteenth and beginning of the fifteenth century. See McVaugh, Medicine before the Plague, 190-91; Siraisi, Medieval and Early Renaissance Medicine, 38.

80. López Alonso, Pobreza en la España medieval, 474; Guilleré, "Milieu médical," 266-68; McVaugh, Medicine before the Plague, 191-200; Santamaría, "Asistencia a los pobres en Mallorca," 394-95.

81. For example, in the 1370s, Castelló sued Jacme Maderes, a master of arts and medicine and medical examiner of Valencia, for contractual violations. Those in Alzira, in 1351, lamented, "There was no one to cure the sick or to help the poor" (García Ballester, Medicina a la Valencia , 83-6). The village of Fortià, in northern Catalonia, acquired its barber in 1308 by sending a native son, Bernat Leto, as an apprentice to Castelló d'Empúries, from which he was obligated to return on Fridays to cut hair. After the expiration of his two-year apprenticeship, he moved back home as a resident barber (McVaugh, Medicine before the Plague, 46).

82. The town of Castelló d'Empúries, for example, contracted with a series of town doctors in the first quarter of the fourteenth century to inspect the urine of town residents, to provide advice on bloodletting and diet, and to provide two house calls to any sick resident of the town who requested service (McVaugh, Medicine before the Plague, 138-39).

83. The association between physicians and hospitals occurred earlier in the East than in the West. Not only did Saint John's have four physicians, but it also provided, according to a papal letter of 1184, four surgeons as well. The hospital, or Xenon, of the Pantocrator monastery in Constantinople, perhaps the richest in the Byzantine Empire, was even better endowed. It possessed ten clinics that housed sixty-five beds, served by some thirty-five doctors. See Miller, "Knights of Saint John," 719, 730; and Demetrios Constantelos, Byzantine Philanthropy and Social Welfare (2nd ed. rev.; New Rochelle, N.Y., 1991), 129. In Florence, for example, the Hospital of Santa Maria Nuova, established in the 1280s, grew to contain some three hundred beds in the late fifteenth century, at which time it employed nine resident practitioners; three other Florentine hospitals (San Paolo, San Giovanni and San Mateo), with capacities that ranged between fifty and seventy-five, also employed physicians, surgeons, and pharmacists. See Siraisi, Medieval and Early Renaissance Medicine, 39; Park, "Healing the Poor," 32.The Hôtel-Dieu of Paris had a surgeon from at least 1231. There is evidence of medici with some sort of affiliation with English hospitals in the later twelfth and early thirteenth centuries, but even London hospitals had no permanent physicians until the sixteenth century. In Italy, however, they were a regular fixture after 1350, perhaps as a consequence of the plague (Cullum, Cremetts and Corrodies, 3; McVaugh, Medicine before the Plague, 229).

84. Burns acknowledges that the Hospitallers may have operated the first hospital within Christian Valencia but concedes that it was soon squeezed out by the growth of the brothers' church and cemetery. Elsewhere, and located principally in the rural locales as castellans and property managers, the Hospitallers do not seem to have taken up this work with any seriousness. See Burns, Crusader Kingdom, 1:186-89; María Luisa Ledesma Rubio, Templarios y Hospitalarios en el Reino de Aragón (Saragossa, 1982), 104-5.

85. Within the Kingdom of Castile, the addition of medical care seems to have come later. At Vallodolid's Hospitals of Esgueva and Todos Santos, for example, the first evidence of such care dates from the mid-fifteenth century (Rucquoi, "Hospitalisation et charité à Valladolid," 400).

86. Rubio Vela, Pobreza, enfermedad y asistencia, 71, 122-23, 185-86, no. 21. In contrast, a grateful King Pere the Ceremonious in 1350 paid the physician Berenguer de Torrelles two thousand sous for successfully treating his children during the recent outbreak of the plague. See López, "Documentos acerca de la peste negra," 383-84, no. 101 (April 15, 1350).

87. Guilleré, "Milieu médical," 268.

88. McVaugh, Medicine before the Plague, 230; Roca, Sant Macià , 12, 15-17; Ordinacions, xxxii-xxxiii.

89. In the fourteenth century, among Valencia's Christian population, between fifteen and twenty-three received hospital care per thousand of population (García Ballester, Medicina a la Valencia, 100-10; Rubio Vela, Pobreza, enfermedad y asistencia, 125). Evidently the use of women as medical personnel in hospitals was widespread. In Florence's Hospital of Santa Maria Nuova, for example, several of the resident staff of laywomen or servae are described in the documents also as medicae or doctors (Park, "Healing the Poor," 32).

90. In subsequent years, Pere Garbí's stipend fell to as low as a hundred and ten sous, perhaps reflecting fewer consultations. The physician Pere de Coll was paid forty florins (about six hundred sous) in 1411 and twenty florins in each of the succeeding two years. Francesc Pedralbes, a converted Jew, got two hundred and eighty sous in 1412, about three hundred in both 1413 and 1414 (Danon, Visió històrica, 129-130). See also Gallent Marco, "Hospital de la Reyna," 81.

91. Ordinacions, xxxii-xxxiii.

92. Rubio Vela, Pobreza, enfermedad y asistencia, 124-26.

93. Gallent Marco, "Hospital de la Reyna," 84; Rubio Vela, Pobreza, enfermedad y asistencia, 134-36.

94. Danon, Visió històrica, 76-77. The character of disease is remarkably similar to statistics from Florence's Hospital of San Paolo in 1587-88: 55 percent with fevers (or infections), 15 percent with skin diseases, 8 percent with wounds and fractures, 4 percent with syphilis. Death rates for men were lower, about 10 percent, than the figures from Barcelona, but mortality rates for women were significantly higher (Park, "Healing the Poor," 35-6; Henderson, Piety and Charity, 398).

95. Contemporary medical writers, citing Galen's dictum -- omnium natura operatrix, medicus vero minister --, believed the processes of healing were natural, or as Niccolò Falcucci expressed it, "the art [of medicine] is the image of nature and her follower" (Park, "Healing the Poor," 37).

96. Rubio Vela, Pobreza, enfermedad y asistencia, 142. For prayer, see the statutes of the Hospital del Rey in Burgos that required that the sick, upon admission, be confessed, take communion, and execute a will. Only then would they be visited by a physician (Martínez García, "Asistencia material," 354).

97. Roca, Sant Macià, 11; Ordinacions, xiii , xvi, xx.

98. For a discussion of medieval theories of medicine and their sources, see Siraisi, Medieval and Early Renaissance Medicine, 141-52; for a general description of the confections, syrups, and drugs used in medieval Catalonia, see McVaugh, Medicine before the Plague, 158-58.

99. Rubio Vela, Pobreza, enfermedad y asistencia, 136-38, 197-246. In order to assist the apothecary in the proper formulation of medicine, whether prescribed by himself or a physician, various recipe books like the Antidotarium Nicolai, a thirteenth-century composition that became a text at the University of Paris in the 1270s, circulated within the Crown of Aragon (McVaugh, Medicine before the Plague, 119-20). Records from the Hospital del Rey in Burgos show that the apothecary stocked almonds, sugar, raisins, quince, mint, cassia-fruit, dates and, more exotic ingredients like amber, musk, rhubarb, and agaric (Martínez García, "Assistencia material," 354). Those of Santa Creu in Barcelona speak of the apothecary producing syrups, compounds, and conserves from a supply of oils, sugars, and other materials (Ordinacions, xxiii-xxiv). Among the most commonly administered medications at the Hospital de la Reyna in the fifteenth century were: syrups and extracts derived from dates, lilies, and other sources, mixed with sweeteners and herbs; distilled waters made from honey, copper, and sage, or from orange blossoms and water, or rose water; ointments confected from substances like herbs, roses, and other flowers, walnuts, turpentine, soap and honey, or sheepshead; and purgatives made from rose or meat extracts (Gallent Marco, "Hospital de la Reyna," 84-85).

100. Ordinacions, xxxii-xxxiv.

101. Park, "Healing the Poor," 37; Ordinacions, xxxi-xxxii.

102. Rubio Vela, Pobreza, enfermedad y asistencia, 132, 151-53, 166-67 n. 4.

103. Park, "Healing the Poor," 28. Another indication of the severity of the plague was the shortage of cemetery space. The vicar general of the Barcelona diocese, for example, noted in 1349 that the plague had necessitated that many be buried in unconsecrated ground (Utterback, Pastoral Care , 109.