James Brodman provides a fascinating and judicious account of how the poor, sick and hapless were succored or managed in the Principality of Catalonia and Kingdom of Valencia from the eleventh to sixteenth centuries. Although the book is entitled Charity and Welfare, Brodman avoids an over-simplified narrative of selfless charity giving way to bureaucratic control of the marginal. He is similarly judicious about applying other binary models: the supposed movement from symbolic to practical concern for the poor, from small to large-scale foundations, from ecclesiastical to municipal sponsorship, or from custodial care of the dying to active medical treatment. All these developments are considered but as intermingling institutionally and overlapping chronologically.
Brodman has an eye for the individual and the diverse. Skillfully joining together various specialized and local studies he describes how assistance to the poor changed in the face of urban population growth, shifts in piety, and the evolving image of the unfortunate. This book relies on printed sources and secondary literature and suggests avenues of future research that might use the extensive surviving archival material. Much of this documentation has only recently become readily accessible (the Hospital de la Santa Creu records in the Biblioteca de Catalunya in Barcelona, for example).
The subjects of this book, hospitals and the poor, changed in nature and definition over the course of the medieval centuries. The hospital was originally a place of refuge, a shelter for pilgrims, orphans, the hungry as well as the sick. Many of these establishments founded in the eleventh and twelfth centuries were attached to cathedral churches or were run by churches from endowments provided by pious donors. They tended to be small and were so far from having any visible impact on widespread misery as to appear ritualized gestures of charity rather than attempts at any substantial social (let alone medical) impact.
Until the fourteenth century very little effort was made to treat the sick who were not really distinguished from the destitute homeless and hungry. Those who were sick were expected to die and medical intervention was not provided. Without displacing the older sorts of foundations for the relief of destitution and its attendant ills, the fourteenth century witnessed the development of centers to treat disease, especially chronic wasting diseases such as leprosy and St. Anthony's Fire (ergotism). It also saw the integration of at least minimal medical treatment into what remained essentially custodial care. Beginning with the thirteenth century municipalities became more involved in providing assistance. Towns attempted to organize and consolidate the collection of small foundations established under various pious endowments. In Barcelona six hospitals were merged in 1401 to form the Hospital of Santa Creu and a large edifice was constructed which functioned as a medical center until 1926.
If the hospital changed in its mission, scale and sponsorship, the definition of the poor also altered. The first chapter describes efforts at poor relief that amounted primarily to feeding the hungry in Catalonia's cities. Here there were dispersed small-scale efforts that resulted from legacies intended more as benefits for the donor's soul than public assistance. The most ambitious of these foundations was at Girona where only bread was given out but to a large number of people under the direction of a foundation administered by the cathedral. Beginning in the thirteenth century there were attempts to identify the worthy local poor who deserved relief and to discourage a more threatening transient or simply disreputable population. Rather than seeing charity as extended indiscriminately, even arbitrarily, the provider of medical treatment and poor relief chose those whom they regarded as worth helping.
At the same time the indices of poverty multiplied and efforts at relief were more specifically targeted. Thus in a chapter on aid to women and children Brodman discusses not just the sick and hungry but such matters as the regulation of prostitution, provision of wet nurses for abandoned infants and charitable foundations to provide dowries for impoverished young women, none of which might seem to fit under the rubric of hospitals but whose importance to late-medieval social policy and charity is clear. The establishment of hospitals for foundlings and orphans also shows the multiplication of functions within a narrower definition of who were the worthy and helpless poor, usually those who were permanent residents of the localities as opposed to strangers or the truly marginal.
Within its relatively brief span of pages, therefore, Charity and Welfare touches on a large number of topics including the various classes of the deprived and impoverished as well as different attempts to deal with them. The hospital is seen as an expression of piety and social regulation more than as a part of the history of medical care.
From this account Catalonia appears to have been neither particularly precocious nor backwards. In the twelfth and thirteenth centuries it had numerous small foundations to shelter the dying, aid pilgrims and feed the poor. These were established in secondary towns such as Vic, Lleida, Cervera as well as in the large port cities. Catalonia did not have as many hospitals as did Paris or northern Italian towns, nor were its hospitals very large in comparison even with Burgos (which helped a considerable pilgrim traffic). As late as the fourteenth century the important city of Valencia had enough beds to accommodate a maximum of only eighty people. Even Santa Creu in Barcelona, representing a huge investment during the acute economic crisis of the early fifteenth century, served from 120 to 200 individuals at a time. Yet Catalonia had a great variety of charitable enterprises directed towards lepers, foundlings, the insane, the sick, prostitutes, the hungry. That such efforts were insufficient goes without saying. Our world, with its surpassingly greater medical knowledge and aggregate wealth in comparison to the medieval Mediterranean, can hardly boast of a proportionately more effective alleviation of deprivation. Rather than seeing either a smooth progress towards better medical care or a contrasting pessimistic account of a movement from selfless charity to harsh social regulation, Brodman depicts a society attempting to deal with suffering and poverty for mixed motives of piety, sympathy and desire for orderliness. The foundations erected for these purposes were religiously oriented and fell under municipal responsibilities; in essence they were neither completely selfless or solely mechanisms for preventing disorder. The attitude of governing elites towards public assistance was perhaps not extraordinarily interventionist or creative, but then again this was a world that managed to survive the Black Death with its social bonds essentially intact if frayed, an accomplishment I am reasonably sure we could not duplicate.