The Ca’ Granda hospital

The land necessary for the construction of the hospital was donated by the condottiero and Duke of Milan Francesco Sforza in 1456 marked the foundation of the Ospedale Maggiore. Its creation was set in a context of reformation of the healthcare facilities between the fourteenth and fifteenth centuries in Italy, characterised by the reorganisation and merging of numerous agencies into a single healthcare organisation.Footnote ¹ This led to the construction of the Ospedale Maggiore, affectionately called Ca’ Granda (a nickname for ‘Casa Grande’ or ‘Big Factory’) by the Milanese due to its massive dimensions following Sforza’s wishes. Antonio Averlino, known as ‘Il Filarete’, was the architect of the hospital until 1465. Adopting the model of various Tuscan hospitals, he designed a rectangular building composed of two symmetrical square bodies, divided by four aisles arranged in a Greek cross. According to the initial idea, one of these so-called ‘crociere’ was reserved for men (on the right) and one for women (on the left) and gave life to eight internal courtyards. An altar was placed at the crossing point of the wards so that the patients could observe the sacred images and the assistants could maintain control over the area. Each arm of the crociera was about 10 m high and lined with windows; the beds were organised into two parallel rows with their headboard resting against the wall. In the middle of the structure, a rectangular courtyard separated the two symmetrical bodies with a marble church at its centre, covered with mosaics. Following the example of the hospitals in Siena and Florence, mediaeval medical institutions were always built near waterways. The Ca’ Granda represents the first hospital where water canalization was used to supply and maintain high hygiene standards. In fact, the most innovative aspect of the hospital’s architecture was the ‘Destri’, or rooms for toilets. These rooms were arranged along the entire perimeter of the hospital and were provided with an entrance every two beds. Thanks to a system of canalizations for the flow of water to and from the Naviglio (the artificial canal in Milan), the destri allowed for the disposal of urine, faeces and other waste limiting the risk of contaminating the patients. In addition, the underground tunnels gave access to various structures, such as the laundry room, essential for the hospital’s daily life (Figure 1).

Figure 1 F.B. Werner, Veduta della Ca’ Granda nel 1740, engraving from the Archivio dell’Ospedale Maggiore Ca’ Granda Policlinico, Milan.

The institution of the Ospedale Maggiore also gave way to a reformation of the Milanese hospital system. Indeed, it not only aimed at the social control of poverty, marginalisation, and deviance, but it also became the centre of a system composed of fourteen other minor health centres (seven religious, one administered by a civil committee and six with mixed administration). This reform involved juridical-administrative changes, with new rules that clearly established all tasks, functions, and behaviours of the administrators, as well as ethical–economic principles, where assistance became less spiritual and more clinical, and the aim was not only to immediately improve the health of patients but also to reintroduce them into the labour market and society.Footnote ² Through this reform, a new social and health network was created: in this new hospital, the patients suffering from acute conditions were admitted, whereas the patients suffering from disabilities, chronic and incurable diseases (i.e., whose health could not be fully recovered), were treated in the aggregated decentralised structures (i.e., the minor hospitals). The Ca’ Granda welcomed patients with acute medical or surgical conditions, as well as citizens of low social class with no specific ailment but suffering merely from starvation, which explains why the number of hospitalised patients increased very quickly (Figure 2).

Figure 2 Lombard painter, Il cortile dell’Ospedale Maggiore, circa 1670–1690, oil on canvas, quadreria dell’Ospedale Maggiore di Milano, Milan.

From the inauguration of the hospital, each wing of the crociera was specialised in the treatment of a given pathology. Despite the heterogeneity of the pathological conditions of the patients, each was treated with a specific therapy by doctors and surgeons specialising in various diseases such as syphilis (also called ‘brossole disease’ or ‘mal franzese’), ‘mal di pietra’ (bladder stones), ‘tigna favosa’ (the term used for scabies, a condition affecting the scalp, skin, or nails) and hernias. Admission to the hospital was decided on the basis of financial means and not health conditions: the patient had to show a ‘faith of poverty’ (through a document in which he or she swore to be poor because of ill fortune or ‘povertà laboriosa’) and the council hence decided on the admission to the facility. At the end of the fifteenth century, doctors and surgeons began to access the hospital wards (previously the task of assisting the patients was reserved to priests and nurses). In the early years of the sixteenth century, doctors and surgeons took full charge of caring for the patients. They were also in charge of admission and the equivalent of today’s triage (diagnosis and sorting of patients). Such ‘health charity’ thus shifted to ‘assistance’ conceived as care but above all as therapy, in order to return healthy individuals to society and remove the incurable: in this sense, the hospital became a true health factory, hence the name Ca’ Granda (as previously mentioned).Footnote ³

In addition, the hospital possessed vast lands, which were used as a source of income and to provide useful resources for both the refectory and pharmacy.

Dating back to the foundation of the hospital, the archives of the Ca’ Granda contain all the economic and administrative documents relative to its management until the closure of the hospital. These documents reveal which plants were used for the treatment of patients, new medical techniques and the type and specialisation of all the medical staff. In addition, the pharmacopoeia of the hospital is still available and is a fundamental part of the ongoing research. Since the fifteenth century, the pharmacopoeia of the ancient hospital of Milan listed all plants and substances used for the preparation of the therapeutic remedies (such as ointments, compresses, decoctions, etc.) with a meticulous account of the medicinal inventory including dosage and frequency for specific conditions. Finally, the documents and reports concerning the food and care of patients detail the everyday life of the ill as well as that of the doctors who worked daily at the Ca’ Granda.

The Ca’ Granda crypt

The sixteenth century saw the Ca’ Granda emerge as one of the main institutions of Milan benefitting from the growing support of substantial private donations.

In fact, tax relief by the city governor facilitated donations to the structure and refectory. In 1624, the church of the Beata Vergine Annunciata (or Santa Maria Annunciata) was instituted within the hospital grounds with the creation of an underground crypt.Footnote ⁴ The church, and in particular the crypt, became the place of burial of those who died in the hospital from 1637, with the construction of sepulchral chambers in 1634 below the crypt of the church (Figure 3).

Figure 3 View of the inside of the crypt of the Beata Vergine Anunciata, below the Ca’ Granda hospital.

The architects designed the crypt to bury the corpses inside the underground chambers where they were to decompose and skeletonise. Once the chambers became full of osseous remains, the bones were displaced in a cemetery area (called fopponi in Milanese dialect) within the hospital grounds. Nonetheless, the new sepulchral spaces were insufficient because of the increase in the number of patients (due to the expansion of the hospital) and the concomitant increase in the number of deaths. Furthermore, available burial space became a constraint due to the impossibility of proceeding regularly with the emptying of the sepulchral chambers, whose construction had placed them in close contact with an aquifer, thus creating an atypical microclimate which slowed down the decomposition processes. This emergency, together with the pestilential smells that developed from the crypt, made it necessary in 1698, to build a new cemetery area outside the Ca’ Granda (San Michele ai Nuovi Sepolcri, now known as Rotonda della Besana).Footnote ⁵ Consequently, from 1697, the remains of the deceased patients were no longer deposited in the crypt of the hospital, but in a new and dedicated location further away from the living, in a suburban area of the city. Hence, the remains contained in the crypt today should refer to the period between 1637 and 1698 and represent 50 years of the life of the hospital, and of the Milanese population of the seventeenth century.

However, the remains of the Ca’ Granda crypt did not stay undisturbed until 2009: in 1848, during the insurrections of the historical Five days of Milano (Cinque Giornate) which started the First Italian War of Independence, it was not possible to bury the bodies of the fallen outside of the city. This led to the reuse of five of the antique chambers of the crypt of the Ca’ Granda. The bones already present were moved to different chambers and so these patients may still ‘contaminate’ the original remains of the crypt.Footnote ⁶ Finally, in 1943, during the Second World War, the bombings over Milan destroyed the Ca’ Granda and damaged part of the crypt.Footnote ⁷

The Ca’ Granda hospital and its crypt filled with the remains of the ancient patients could represent (with some contamination) not only a glimpse of the past but also a unique monument for reading the history of medicine and its applications. The successes (and failures) of this art, which can be analysed here, may help us better understand the efforts implemented over time that allowed us to reach the science we know today.

The Crypt and the Ca’ Granda Project

The Ca’ Granda Project, which first started in 2010,Footnote ⁸ represents an initiative taken by the University of Milan and the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and is currently funded mainly by Regione Lombardia. The aim is to restore the crypt, excavate and study the remains and finally open its spaces and the results of scientific research involving archaeologists, historians, anthropologists, toxicologists, botanists, data scientists and entomologists to the scientific community as well as to the general public.

The crypt of the Ca’ Granda has 14 sepulchral chambers with a total surface area of 365 m² (Figure 4a). Each chamber is accessible through 50 cm large square manholes. The chambers have different sizes, with openings ranging from a single manhole (chamber A) to nine manholes (chamber O). Chamber O was the first to be investigated thanks to a large opening due to the destruction of a wall during World War II bombings. The chambers are about 2.20 m high, and the level of the fill reaches about half the height (Figure 4b). Below the manhole, there are anthropic conoid accumulations composed of bones and sometimes ruins (bricks, wooden tables, nails, rubble) due to wars and restoration of the building.

Figure 4 (a) Representation of the Ca’ Granda hospital (Catasto Urbano di Milano, Foglio 438, Particella 61), and the crypt (b) from the Archivio dell’Ospedale Maggiore Ca’ Granda Policlinico, Milan.

During the archaeological investigations, surveys were carried out to determine the internal situation of the chambers and to observe the accumulation of anthropological (bones, hardened and mummified soft tissues, skin appendages, etc.) and archaeological (jewellery, clothing, coins, pottery, etc.) remains and the structure of the chambers themselves (Figure 5). The stratigraphic excavation, supported by important activities such as photogrammetry and 3D surveys, is leading to the discovery of different mechanisms and phases of deposition of the corpses in the chambers as well as anthropogenic events (such as continuous lime pours) aimed, in vain, at accelerating the decomposition processes (Figure 6).

Figure 5 Details of the skeletal remains in the crypt. Top image, photogrammetry, and 3D reconstruction of Chamber D2; bottom image, photograph of Chamber O.

Figure 6 Archaeologists and anthropologists during a survey in a sepulchral chamber.

In the chambers, a large portion of the remains of the patients are commingled: this is due to the long-standing use of the sepulchral chambers for almost a century and to the anthropogenic interventions to make room for the ever-increasing quantity of dead to be deposited. However, in the lower layers of the excavations, partially or entirely articulated skeletonised bodies have also been recovered, which demonstrates their primary deposition. Indeed, these findings are fundamental indicators of the deposition of intact cadavers directly from the mortuary (called brugna in Milanese dialect) of the hospital, and not, as has been asserted for decades by historians, of already skeletonised and commingled remains. In fact, the current archaeological investigations are proving that indeed the crypt was both a primary and secondary site of deposition.

Preliminary results of the multidisciplinary analysis of the remains

So far, over 300 000 bones have been studied from all sepulchral chambers: preliminary anthropological osteological analyses have shown there to be an almost equal distribution of males and females of all ages (ranging from third trimester foetuses to older adults),Footnote ⁹ proving how the hospital catered for all, from pregnant women or ill new-borns to the elderly. In depth osteological analyses on the ancestry of the craniaFootnote ¹⁰ show that individuals were predominantly of European origin as expected; however, a comparative analysis between this seventeenth century population and the current Milanese population has shown secular changesFootnote ¹¹: heads and faces in the seventeenth century were somewhat smaller and more gracile than those seen in Italy today. The preliminary results of palaeopathological analyses confirm that the individuals present in the crypt belonged to the poor classes (specifically catered for the Ca’ Granda administration of the Modern Age society), as proven by the presence of stress markers, including cribra orbitalia and enamel hypoplasia (which represent respectively iron deficiency and events of arrested growth during childhood due to periods of stress, disease or malnutrition).Footnote ¹² They also revealed the presence of several morbid and debilitating conditions (e.g., painful joint diseases with reduced mobility, tertiary venereal syphilis, dental diseases showing poor buccal hygiene) as well as traumatic lesions due to falls, arduous activity or interpersonal violenceFootnote ¹³ (Figure 7). Interestingly, signs of both autopsy (craniotomy) and surgery carried out within the health facility were found among the skeletal remains of the crypt.

Figure 7 Details of pathological cases: on the left, humeral-ulnar ankylosis due to rheumatoid arthritis; on the right, osteomyelitis of a tibia with detail of the cloaca.

The anthropological observations and analyses are recorded in Commingled Remains Analytics (CoRA), a cloud-based software application,Footnote ¹⁴ in order to collect and process the huge amount of skeletal data from the ancient hospital site. Data aggregation following a common ontology allows us to propose and test reassociation of commingled remains into individuals and hence gain a better understanding of how many and who are interred in the sepulchral chambers of the Ca’ Granda crypt.

In addition, soft tissue residues of desiccated brain were recovered within the crania, which was confirmed by the presence of cellular neurological structures viewed under 40× magnification. Chemical–toxicological analyses of soft and hard tissues have begun to inform us on the presence of leadFootnote ¹⁵ and mercuryFootnote ¹⁶ as well as other substances that may have been used as a form of patient treatment. Future toxicological results will be confronted to the carefully preserved and extensively detailed pharmacopoeia of the hospital in order to confirm the written source and/or implement it with novel information concerning ‘drugs’ which, for some reason, were given to patients but not registered in the archives. The combination of information (written and osteo-toxicological) can give us a better understanding of treatment available for the poor classes of Milan. Similarly, ancient DNA analyses have been undertaken to reconstruct the complete profile (including the phenotype) of some of these deceased patients as well as possibly infecting pathogens. Pedological and sedimentological analyses will investigate the methods of anthropic activity in the sepulchral chambers. Examination of findings of material culture, mostly relating to the Christian-Catholic faith (e.g., wooden and copper alloy objects), but also footwear, rings, coins (e.g., French and Venetian) and pottery (mostly apothecary vases) will provide information regarding the individuals buried in the crypt (apparently from the lower classes of the population) and by extension the society of the period, which has hardly been investigated archaeologically.

Finally, to better understand the phases and methods of deposition of the bodies, naturalistic residues (e.g., leaves, roots, entomological and faunal findings) are currently being analysed. Botanical analyses are also fundamental to reconstruct the diet through the study of dental calculus. A recent study on starch grains trapped within the calculus of these skeletons revealed high frequencies of cereals, such as barley, rye and spelt, as well as legumes, in particular lentils and broad bean, along with a less common occurrence of corn, rice, millet, durum wheat, buckwheat, pea, and chestnut. These findings are in line with historical sources on the diet of the poor classes of Milan, which was mainly composed of ‘brown bread’, a mix of rye, spelt and barley, and legumes. Interestingly, we also found traces of Equisetum arvense, commonly known as ‘horsetail’, a plant whose sterile stems were used to clean dishes and for oral hygiene (like a toothbrush). However, the presence of these spores could indicate the consumption of this plant as food, especially in times of famine.Footnote ¹⁷

Although all these data are still under study and contextualization, both with the historical and archaeological data and with the immense archival heritage of the Ca’ Granda, they prove the substantial amount of information that may be extrapolated from the study of the skeletal remains lying in the sepulchral chambers of the Ca’ Granda crypt.