By Lucie Laumonier
The birth and rise of a charitable institution in Europe during the Early Middle Ages.
The history of Western hospitals intrinsically connects with the history of Christianity, as it was a Christian’s duty to tend to the poor and to relieve their sufferings. But medieval hospitals did not fulfil a curative purpose. Rather, they aimed at sheltering, feeding, clothing and supporting travellers, pilgrims and the poor.
The earliest medieval hospitals were created in the Eastern Roman Empire, also known as the Byzantine Empire, and afterwards started appearing in Western Europe. Let’s paint with large brushstrokes the early history of the European hospitals, their ties and connections to the Byzantine usages and practices, and their development during the Carolingian era.
The Eastern Tradition
The first hospitals were established in the fourth century. In the 350s, a xenodochium was established in Antioch to shelter travellers and foreigners and give them a bed and some food. Some twenty years later, a larger institution was founded in Kayseri, in the Turkish region of Cappadocia, to offer housing and support to the sick, the paralyzed, the lepers and the travellers. The earliest Western hospital is attested at the very end of the fourth century; in Ostia, Rome’s port, senator Pammachius and his wife Fabiola had established a xenodochium to tend travellers’ needs.
But, while in the East foundations multiplied, in the West, the fall of the Roman Empire put a temporary stop to the establishment of hospitals. The Church, however, remained a driving force supporting the foundation of charitable institutions that paved the way for hospitals. The 451 Council of Chalcedon required that monasteries offer shelter to travellers and pilgrims. A pontifical decree from the late fifth century asked bishops to keep a portion of their diocese’s revenues for alms and shelter for the poor. The actual implementation of these rules was left to the abbots’ and bishops’ discretion. However, the first “medieval” hospitals were founded by local bishops, in the sixth century. The oldest is believed to have been established in Arles, southern France, and the second oldest in Merida, western Spain.
Meanwhile, in the East, Emperor Justinian (527-565) encouraged the foundations of more hospitals and structured their organization in the Empire. The early Western hospitals, founded from the sixth century onwards, borrowed from the Eastern practices, traditions and language. The xenodochium cared for travellers and pilgrims, the ptochotrophium was for the poor, the nosochomium for the sick, the orphanotrophium sheltered orphaned; the brephotrophium cared for babies and foundlings, the gerontochonium was for the elderly. This typology was more established in the Eastern Empire, where hospitals were better organized and structured than in the West. In Europe, the noun xenodochium often functioned as an umbrella term for all sorts of charitable institutions.
The establishment and consolidation of the Merovingian kingdoms in Western Europe came hand in hand with the gradual establishment of hospitals, mainly in cities, and usually under a bishop’s supervision – although kings, queens and members of the nobility sometimes initiated these foundations. In 542 for instance, King Childebert established a house in Lyon “for the care of the sick and to welcome pilgrims.” Some of these foundations had a long history. The hospital established in Amiens next to the cathedral church only disappeared in the thirteenth century.
In Poitiers, Western France, Queen Radegund (d. 587) had established a charitable institution in the monastery where she resided. It was dedicated to poor women to whom alms were given, and the queen is said to have been washing their feet (a symbolic Christian practice). In the later seventh century, the bishop of Poitiers established a larger hospital with 12 beds for the poor and sick. The hospital was endowed with lands, with its revenues financing the institution. Likewise, in the seventh century, the bishop of Clermont founded in the city a hospital that counted 20 beds.
These charitable institutions were sometimes divided into two sections: one for the poor and sick (the hospital), and one for the travellers and pilgrims (the hostel). Often, an almsgiving service coexisted with the houses to distribute food to the poor. Such hospitals-hostels-alms services were attested in Auxerre and Bourges in the seventh century. Some cities developed a strong charitable network in the course of the sixth and seventh centuries. At Le Mans, a hospice for the poor had been created in the early sixth century next to the cathedral church. The poor came to the hospice for alms and feet-washing. Within a century, six more hospices and hospitals were created in the city, some for pilgrims and travellers, others for the poor.
At the close of the Merovingian era, historians estimate that a little more than 30 hospitals were in operation. Most of them had been established in the northeastern regions of the Merovingian kingdoms, close to the center of power. This pales in comparison with the Byzantine Empire: in Constantinople alone some 30 hospitals and hospices were in operation in the eighth and ninth centuries, not counting some 25 houses dedicated to the elderly. In the rest of the Empire, at least 160 hospitals tended to the needs of travellers, pilgrims and the poor.
The Carolingian Empire: from Xenodochium to Hospitalis
The Carolingian era was a time of consolidation for the early medieval hospitals. Carolingian rulers heavily relied on the Church and its clergy to consolidate the imperial power and took several measures favourable to the establishment of hostels, hospices and hospitals. For instance, the 789 capitulary known as the Admonitio Generalis asked monastic and clerical communities to have a “hospice” for travellers and the poor. In the same train of thought, the Council of Aachen (816) required canons (members of a cathedral chapter) to keep 10% of the church’s revenues for the cathedral hospital and poverty relief. The council’s decision had a long-term effect in Paris, where the cathedral opened a hospital in 829, which would become the Hôtel-Dieu, still in operation today.
The Carolingian Empire also witnessed the establishment of a large number of rural hospitals and alms services, beyond those that belonged to preexisting monastic houses. Parishes had been created in the seventh century and their priests were asked, in the ninth, to take care of “guests, especially the poor and sick, as well as orphans and travellers.” Priests had to make sure they could offer them shelter and feed them, ideally every day, at their own table. At the same time, the number of monasteries multiplied in the eighth and ninth centuries, which meant that, in turn, more and more hospices and monastic hospitals were established in their quarters.
Since the Admonitio Generalis, all monasteries were expected to have a room or a space to welcome travellers and pilgrims and to provide daily alms for the poor. These recommendations had been reiterated by the 816 Council of Aachen. Two new monastic offices emerged in the ninth century in response to these new needs. The hospitalarius major was in charge of managing accommodation for travellers and pilgrims, and the elemosinarius was responsible for almsgiving and food distributions. Sick people were taken care of in the monastery’s infirmary. Usually, one-tenth of the monastery’s revenues were allocated to the hospital and alms service.
Finally, it is during the Carolingian era that the term hospitale or hospitalis first emerged. It would completely replace the Greek noun xenodochium within a few decades. The first hospital to be called a “hospital” was established in Rome by Pope Leo III (795-816). Close to St. Peter’s Basilica, the hospital was called Hospitale Sancti Peregrini and was open to pilgrims, as its name suggests. Besides offering food and shelter to pilgrims travelling to Rome, the hospital probably tended to the needs of the poor of the city.
The golden age of the medieval hospital is tied to the twelfth and thirteenth centuries and the “charitable revolution” that then unfolded. But the high medieval flourishing of hospitals and hospices for the poor stems from the very beginning of the Middle Ages, when local bishops and devoted laypeople encouraged and promoted the works of mercy by the foundation of hospices for travellers and hospitals for the poor. During the Carolingian era, hospitals grew in numbers, alongside churches, cathedral churches and monasteries. The next step, from the twelfth century, would be privately funded hospitals and municipal hospitals.
Davis, A. J., The Medieval Economy of Salvation: Charity, Commerce, and the Rise of the Hospital. Cornell University Press: 2019.
Horden, Peregrine, ‘The Earliest Hospitals in Byzantium, Western Europe and Islam,” Journal of Interdisciplinary History, XXXV-3 (2005), p. 361-389
Imbert, Jean (dir.), Histoire des hôpitaux en France, Toulouse, Privat, 1982
Top Image: British Library MS Additional 42555 fol. 30r