Neonatal Research at the Archiospedale Santo Spirito in Rome

Abandoning infants was a heritage of the Roman Empire. Foundling hospitals were established in Italy earlier and in greater number than in other countries; their goal was to prevent infanticides. The Foundling Hospital in Rome, established in the Santo Spirito Church in 1204, paved the way toward modern hospital care and child protection. The Order of the Holy Spirit was appointed by Pope Innocent III to care for foundlings, and set up a network of infant nurseries all over Europe. Poor unmarried pregnant women received obstetric services free of charge. Infants were admitted anonymously by the ruota, a baby hatch or turning wheel. The Order’s rule regulated infants’ admission, care, nutrition by wet nurses, and boarding out to foster families in the countryside. Chief physicians of the Santo Spirito Hospital were often Sapienza University professors and/or personal physicians to the Popes. Among them were Realdo Colombo, Andrea Caesalpino, Giovanni Lancisi, Giuseppe Flajani, Domenico Morichini, and Tommaso Prelà. They made major scientific progress in anatomy and surgery: descriptions of the pulmonary blood transit, embryonic formation, fetal circulation, malaria transmission from mosquitos, and surgery for congenital malformations such as hydrocephalus, anal atresia, and cleft lip. Per year, 800–1,000 exposed infants were admitted. Despite sufficient funding and meticulous regulation of care and nutrition, mortality in the hospital during the first month of life was around 70%; the causes were neglected surveillance, cleanliness, and artificial nutrition. The institution persisted for more than 700 years due to numerous connections with the Vatican.


Introduction: Sociocultural Settings and Forerunners
The collapsing West-Roman Empire left behind conflicting heritages all over Europe.Patria potestas, however, the father's right to dispose, sell, or kill his children, was incompatible with another legacy of the Roman Empire: Christianity.Psalm 27.10 promised: "When my father and my mother forsake me, then the Lord will take me up," and the Council of Nicaea decreed in 325 CE [1] that each Christian village should establish a xenodochion [hospice for the sick and the poor].The second Council of Vaison ruled in 442 CE that an abandoned child should find shelter and care for 10 days in a hospice near the church [2].The Church's ascent raised the status of children, especially in Italy.
The Foundling Hospital in Rome, established in the Santo Spirito Church in 1204, developed into a large institution that paved the way toward modern hospital care and child protection.Being one of the world's oldest hospitals, the institution, its architecture and history have been repeatedly described, i.e., by Morichini and Dell Archiospedale di [3,4], Lefebvre [5], Azzurri [6], Brockhaus [7], Albini [8], Pagano [9], Schiavoni [10], Mattoni et al. [11].Its organization by the Santo Spirito Order was described by Saulnier [12], Helyot [13], La Cava [14], Drossbach and Wolf [15], and others focusing on religion, art, social history, and the dilemmas of unmarried mothers.The present paper focuses on medical aspects of infant care in this hospital during the 16th to 18th century.Religious aspects such as baptism of the foundlings, oroblatio ("offering"), and the schooling provided for older children are not covered in this article (Table 1).

Founders and Patrons
Following the sack of Rome by the Visigoths in 410 CE, Italy remained split into a dozen kingdoms and principalities until unification in the 1860s.The Saxon Church located close to the Vatican on the Tiber's West Bank had been a hospice for Anglo-Saxon pilgrims since 715 CE.After its destruction by the Normans, the "Apostolico Archiospedale di Santo Spirito in Saxia" was rebuilt in 1198 on the Saxon church and school foundations [20].At that time, Rome had 25,000 inhabitants, their number dropped to 17,000 when the popes were exiled to Avignon, rose to 60,000 following their return in 1377, and then steadily increased up to 165,000 in 1765 [21].In 1348, the plague epidemic claimed 25 millions of human lives in Europe, which triggered public health measures and hospital hygiene.
The Order of the Holy Spirit in Montpellier was appointed by Pope Innocent III to care for the foundlings, and during a few years set up a network of brephotrophi [infant nurseries] in regions which today are France, Germany, and Italy.In 1204, Innocent III.called Guy de Montpellier to Rome and by the Bull "inter opera pietatis" entrusted him with the direction of the institute and supervising of Santo Spirito Hospitals throughout Europe [16].After devastating fire in 1471, the building was reconstructed, enlarged, and modernized by Pope Sixtus IV., thereafter functioning as a papal and teaching hospital [22].It also organized care and breastfeeding for more than 2,000 infants by mercenary wet-nurses in the city and nearby [13].As the order thrived, more and more foundling hospitals were established and the abandonment of newborns spread from Italy to France, Spain, and elsewhere.
In 1649, Petrus Saulnier published a richly illustrated description of this huge institution [12] which, among other buildings at that time included church, commander's palace, monastery and minister houses, the hospital, foundling hospice, pharmacy, laundry, stables, and lodgings for the guardians and wet-nurses.Saulnier also listed the staff, which, with exception of the wet-nurses, was not limited to the foundling hospital alone.In addition to the clerics, the medical staff included four primary physicians "of whom often the pope's personal physician was elected," four assistant physicians, one lector "supervising the anatomical dissections," two principal and two assisting surgeons, one pharmacist with five assistants, and 24 caretakers.During the 16th century, culminating in the Reformation, the power of the Catholic Church waned: more and more hospitals became independent.Rivalry between the institutions in Montpellier and Rome weakened the influence of the Santo Spirito Order.But as depicted by Vasi in 1750 (Fig. 1), the archiospedale remained a large and powerful institution until recently [23].In the aftermath of the French Revolution, the Santo Spirito Order was repealed in 1847 by Pius IX.In 1896, the fusion of the church's medical institutions of Rome (called "Pio Istituto di Santo Spirito e Ospedali Riuniti") made the Ospedale Santo Spirito, with 12,000 beds, the largest hospital complex in Europe.Due to the establishment of the National Health Service, the hospital was closed in 1976, transferred to the Comune di Roma, and is today a congress center.

Admission by the Ruota
For the poor, children were often unwelcome.More than shame it was necessity that led parents to expose their infants, even those born in legitimate marriage.Social historian Edward Shorter pointed out [24]: "Good mothering is an invention of modernization.In traditional societies, mothers viewed the development and happiness of infants younger than two with indifference."Since the Middle Ages, marble shells were installed in many churches near the entry, in which unwanted babies could be deposited.But as this custom led to hypothermia and death, it was modified into a baby hatch or turning wheel named torno or ruota [13].Peter Saulnier, in his extensive History of the Santo Spirito Order, described the admission procedure in 1649 [12]: "Close to the main entrance a window with a turning box was equipped with a mattress and armed with an iron grid whose bars prevented the passage of infants older than 3 months. . .When turned, the revolving cradle made a noise, alarming a servant who had to ask the baby's name, if it was baptized, and if there were any tokens for later identification.No other questions were asked, and it was strictly forbidden to inquire about the deposing person's identity or to follow her or him.The baby was dressed and brought to the head nurse, who recorded the date, assigned an admission number, and carefully looked for tokens or leaflets attached to the infant, which were stored at a secure place.Then the infant was washed with wine, wrapped in new diapers, and entrusted to the wet-nurse.For this first care alway twenty-four wet-nurses lived in the house."A cross was tattooed with indelible ink on the right foot to prevent the infant's fraudulent exchange [5].A number and a Saint's name were attached to the baby's clothes at admission [4].The plan was to board out the infant to a wet-nurse as soon as possible and to continue breastfeeding for 15-18 months.Surviving children should stay with their foster family up to the age of 7 years.Figure 2 shows the ruota of the Santo Spirito Hospital.The multitude of revolving cradles signalized that abandoning infants, against the jurisdiction in all European countries, was an allowedor at least toleratedaction.In many countries, the admission via revolving cradle was criticized because it augmented the number of abandoned infants and led to overcrowding of the foundling hospitals.Turning-wheels were established in Italy earlier and in greater number than in other countries, and in 1811 their number rose further after Napoléon's decree to establish wheels in every district.Until the National Unification in 1866, the ruota system was active in 1,179 communes [19].Thereafter, it was officially suppressed, but from 1879 to 1881, 36,552 living infants still were found in the wheels, in addition to 541 found dead.There were wheels still in action in 503 communes as late as 1895.Santo Spirito's ruota was in use until 1870 [9].

Nutrition and Nursing: The regula
The Santo Spirito Order's first regula [rule] originated in Montpellier, then belonging to the Kingdom of Aragon.It was confirmed by Innocent III in 1204 in the bull "inter opera pietatis" [14,16].A richly illustrated parchment codex is preserved in the Roman State Archive, including 61 miniatures illustrating life in and around the hospital (Fig. 3).Chapter 41 granted assistance to orphans and abandoned infants and provided wet nurses for the infants "according to the house's ability."The delicate logistics of recruiting, rewarding, and supervising wet-nurses had to have been mastered.Obstetric services were offered for poor [i.e., unmarried] pregnant and parturient women gratanter  [without any fee].The risk of nosocomial infection was wellknown: chapter 59 ordered that each baby must have a crib of its own "that nothing unfortunate may happen to the infant." The pious foundation history [25], palatial architecture, and the dedication to the Holy Spirit made some authors ignore the grim reality of abandoned infants' fate in this foundling hospital.In 1822, the medical officer Orazio Maceroni reported to Ercole Dandini, Commander (governor) of St. Spirito [26]: "In one hall, 68 babies, 19 wet-nurses, and one supervising nurse . . .In another hall, 20 and more large beds were piled up, in which healthy and sick babies had accumulated six by six.No cleanliness at all, no order whatsoever, moaning screams, unhealthy and pestilential smell, the frightening sight of death: this was the gruesome spectacle envisioned at my first visit to the baliatico [nursery]."Meconium was routinely evacuated by enema, and infants were sedated with opium without a physician's prescription, even though the risk associated with this drug was well known.By 1893, the baby nursery consisted of 5 halls with 40 beds for the nurses and 2 cribs each for the infants, one infirmary with several isolation rooms, all rooms could be ventilated and heated.The monthly salary of a wet-nurse was 8 lira up to the end of the infant's first year, and 6 lira thereafter.Every 2 weeks, women from the city and vicinity wishing to obtain an infant for paid nursing, gathered at the archiospedale.They had to present the birth and death certificates of their own child, a personal health certificate, and a morality certificate issued by the parish priest before a foundling was given to them [8].

Medical Research
The Roman University "La Sapienza" was founded in 1303, located not far from the Archiospedale Apostolico.Several of its physicians held simultaneous appointments as chief physician at Santo Spirito Hospital, professor at the Sapienza University, and as personal physician to the pope.The main period of scientific activity was from 1550 to 1790.Research focused on anatomy: in 1482, Pope Sixtus IV gave permission to dissect corpses provided that the dissected bodies were properly buried [17].Anatomy and surgery chairs were combined.The Santo Spirito hospital became an important center and school of anatomical studies.Some of the leading scientists are listed below: Realdo Colombo (1516-1559) was a former pupil and successor of Vesalius in Padova and was chair of anatomy at the Sapienza in Rome from 1548 to 59. His book "De re anatomica," published posthumously in 1559 [27], contains largely correct descriptions of the pulmonary blood transit, fetal circulation, and chapters devoted to fetal formation, nutrition, and various positions during birth.
Andrea Caesalpino (1524-1603) studied with Colombo and became chair of medicine in Pisa from 1569.In 1592, he was called to Rome as professor of medicine at the Sapienza University and as personal physician to Pope Clement VIII.Besides philosophical and botanical works, Caesalpino's medical writings included in 1571 "Peripateticorum quaestionum," with observations on the pulmonary circulation [28]; and in 1606 "Praxis universae artis medicae" with descriptions of congenital syphilis, and the calculation of gestational age [29].
Giovanni Maria Lancisi (1654-1720) was appointed to the Santo Spirito Hospital in 1676 as a surgeon.In 1684, he became professor of anatomy; in 1688 pontifical doctor; in 1714, he founded the library and obstetrical department in Santo Spirito.In 1715, he edited Eustachius' plates of 1562 illustrating the interatrial valve.This manuscript had been hidden in the Vatican library.He described that malaria is transmitted by mosquitos in 1717 [30] "De noxiis paludium effluviiseorumque remediis," in 1728 he published a book on cardiac anatomy [31] "De motu cordis et aneurysmatibus." Giuseppe Flajani (1741-1808) was appointed in 1769 as surgeon in chief of the Archiospedale.In1772 he founded the hospital's anatomical museum, in 1775 he became personal physician to Pope Pius VI.In 1791, he published 6 cases of hydrocephalus, trying to treat this condition by drainage [32].His 3-volume "notes on surgical diseases" appeared from 1798 to 1802 and described numerous surgical techniques (as for anal atresia and cleft lip), [33].He also gave extensive recommendations on hospital hygiene and artificial nutrition of infants.
Domenico Morichini (1773-1836) was appointed in 1797 as professor of clinical chemistry at the Sapienza University and is known for having detected calcium fluoride in teeth.He described (posthumously published, [34]) the treatment of malaria with quinine; the elevated excretion of calcium in rickets; and the success of the vaccinations administered from 1823 to 1824.
Tommaso Prelà (1765-1846) became primarius of the Santo Spirito Hospital in 1793, and physician to Pope Pius VII.He had a special interest in smallpox vaccination [35] and donated a library to his home town Bastia.

Statistics and Mortality
With no official birth documents and because of incomplete baptism and burial records, all life statistics during the Renaissance are dubious.From 1580 to 1584, 3,503 exposed infants were admitted to the St. Spirito Hospital, of whom 2,672 died (76%) [9].According to Schiavoni [36], around 1,000 "foundlings" were admitted each year at the Santo Spirito hospital, with a peak of 1,246 in 1651 and a minimum of 442 in 1747.Of all infants born in Rome, the percentage of exposed infants rose from 15% in 1709 to 23% in 1716.By mid-19th century, up to 40% of all births in Italy were abandoned [18].The papal state had 2.5 million inhabitants in 1820, 260,000 of whom lived in Rome [37].In 1860, there were still 34 foundling hospitals in this state [5].
Foundlings' mortality is notoriously difficult to assess, as the official statistics related the number of deceased infants per year to the total number of children both in hospital and countryside.Statistics doctored in this way usually yielded a death rate around 30%.In his reform proposal of 1800, the hospital's chief surgeon Flajani wrote in despair [33]: "The mortality in our hospital during the first month of life is 70%. the causes: neglected surveillance, cleanliness, and nutrition."The priest and hospital administrator Carlo Morichini described a gloomy reality [3]: in 1831, the hospital admitted 831 "foundlings" and had 1,479 infants with wet-nurses in the countryside.682 infants died, yielding a mortality of 30% for the total foundling population, but a mortality of 82% within the first year of life for infants admitted.The same author, meanwhile bishop, reported even higher mortality for 1869: 1,107 admissions and 952 deaths [4].
The infants' condition at arrival in the Foundling Hospital was everything but promising.Congenital disease and malformation were frequent causes for abandoning infants [38].Prematurity and rashes were generally assumed to result from venereal disease, what precluded breastfeeding by a wet-nurse.Handfeeding, the only alternative, gave the baby a minute chance of survival.Transport from the Rome vicinity, especially in winter, further lowered the infant's chance to survive.Finally, the mercenary wetnurses, to whom the infants were entrusted, belonged to the poorest part of the population, were often in bad health, and were having to breast-feed two or even three infants.

Conclusions: Importance for Neonatal Medicine
In the Renaissance, the hospital's role was to care, not cure.The Order of St. Spirito transformed hospital care from mere pilgrim hospitality and spiritual assistance to more corporal care, initiating measures of child protection.The necessity to have wet-nurses in the foundling hospital gave women an important role in the care of newborn infantsremarkable in male-dominated monastic life.Organized infant exposition was intended as a kind of family planning, an alternative to infanticide.The child usually died, but the family had not kill it directly.Moreover, the church had no problem with high mortality as long as the child died properly baptized.The delicate logistics of recruiting, rewarding, and supervising wet-nurses were mastered.That the Santo Spirito Foundling Hospital, despite appalling infant mortality, persisted for more than 700 yearslonger than other foundling hospitals in Europewas due to a regional coincidence: it was located close to the Vatican (and integrated in its hierarchy), the senior consultant acted as papal physician, and the institution's funding was ensured.The Pope allowed corpses to be dissected, which enabled pioneering research and progress in anatomy.The hospital's chief physicians were often appointed to the Sapienza University, thus making the archiospedale a research and teaching institution.

Fig. 2 .
Fig. 2. The ruota (turning wheel) near the main entrance of the Roman Ospedale Santo Spirito.See text for details, left of the grid a donation box is let into the wall.Drawing by Dietmar Stiller, with permission.

Fig. 3 .
Fig.3.Miniatures in the rule of the Santo Spirito Order, approved by Innocent III.In 1204, the parchment codex written during the pontificate of Gregor IX (1227-1271).Left: Fol.127v (detail): wetnursing of a foundling infant and admission of a pregnant woman for delivery.Text: "Abandoned foundlings shall be nursed according to the house's ability and poor pregnant women shall be admitted free of charge and cared for in brotherly love."Right: Fol.163r (detail): Infant rocked in a cradle.Text: "Each infant born in the Santo Spirito Hospital shall sleep alone in its own small cradle, so that nothing unfortunate may happen to the baby."Modified from Codex 3193, Fondo Ospedale di Santo Spirito; State Archive Rome, with permission.

Table 1 .
Timetable of the Santo Spirito Hospital in Rome