Beyond Religion and Medicine: Ministering to the Sick in and Outside of Hospitals

In Le Livre de vie active de l’Hotel Dieu de Paris, Johann Henri—proviseur of the Hôtel Dieu hospital in Paris from 1471 to 1479 and again from 1482 up until his death in 1484—provides an allegorical account of his hospital, its staff, and the treatments undertaken in care of the sick poor. Throughout the text, the river Seine, on which the Hôtel Dieu is situated, could easily be portrayed as a barrier that separates the sick from the city, yet this is not how it is presented. The Seine is invoked in a play on words with health (saine) because it served a vital purpose in the medical and spiritual care of the hospital’s patients. All patients had to pass across the river and on reaching the hospital entrance, their physical state was assessed by one of the nursing canonesses before they were taken to a canon to confess their sins.1 Henri presents this crossing of the river as a penitential act: “Also see how that house of alms is a religious house of hospitality situated on an island surrounded by water of tears and pity, which makes a river of healthy water of grace, over which the person should pass who wants to come into the house of hospitality.”2 That the hospital is labeled a “house of alms” and “hospitality” indicates the institution’s value beyond convalescence and palliative care. The Seine is transformed into a river of tears and pity that becomes the water of healing grace, a process that reflects the journey of each patient. Before they enter the hospital, patients suffer ill health and sin, but once they cross the penitential water, take confession, and are admitted inside, they begin to receive physical and spiritual care.3Yet, the river served as more than a penitential metaphor. Henri’s depiction of the Seine and the “house of alms” and “hospitality” situated on it blends together the practical and allegorical. Not only did the Seine provide a means for the hospital to receive supplies, but it also acted as a tool for maintaining hygiene. Canonesses carried out laundry duties in the Seine, which was vital for cleaning clothes and bedsheets, as well as staving off disease, preventing the buildup of harmful, miasmatic substances.4 This mingling of the religious and medical litters Henri’s work and many other devotional texts of the period that sought to capture the penitential and charitable care provided by such institutions.5Such an overlap between religious and medical themes seems hardly surprising to modern scholars. Nearly a quarter of a century ago, Joseph Ziegler exposed the unsatisfactory nature of medieval medical historical inquiry, where many operated on the assumption that scholastic, academic medicine was “religiously neutral.” He continued that this view was “no longer satisfactory,” as scholars had come to realize that medieval medicine and theology intersected on almost every level.6 Physicians and certain members of the clergy sought to care for both bodies and souls in tandem, and even discourses surrounding disease had religious components. The 2001 volume Religion and Medicine in the Middle Ages, to which Ziegler provided the introduction, sought to expose the interwoven nature of religion and medicine in all aspects of healthcare in the Middle Ages. Of course, even at the time of writing, Ziegler and the other contributors were aware that the religious aspects of medicine had been addressed before.7 Nevertheless, they felt the need to revise the ways in which scholars approached medieval health. Since the publication of the volume, numerous works have been produced that were dedicated to proving this overlap between religion and medicine, so much so that it should no longer be surprising, and perhaps even be expected to find religious elements in works on the history of medicine. Highlighting the interrelation of religion and medicine is no longer sufficient to sustain a monograph, as scholars have turned to probe the depths of the overlap to better define its boundaries, aims, and functions.In 2023, three books were published that demonstrated that joint religious and medical discourses were fundamental for community building, as members of the clergy, often assisted by the laity, worked to provide charitable healthcare in and outside of hospitals. In the past, scholars have described a secularization of hospitals in the late medieval period moving into the early modern, yet two of the three books reviewed here demonstrate quite the opposite. Building on recent trends in the work of the likes of Adam J. Davis and Sethina Watson,8 Lucy C. Barnhouse’s Hospitals in Communities of the Late Medieval Rhineland, Houses of God, Places for the Sick and Nicole R. Rice’s The Medieval Hospital: Literary Culture and Community in England, 1350–1550 illustrate that religion and medicine continued to be inseparable even in the age of Reformation and the so-called professionalization of physic and surgery.9 These monographs attest that far from turning away from religion and spirituality, hospitals embraced the stability and community-forming opportunities that religion offered. Thomas M. Izbicki’s Ministry to the Sick and Dying in the Late Medieval Church establishes that the clergy saw to the cura corporum as a key part of their pastoral role, which was typically concerned with the cura animarum. Taken from the authority passed down from the apostles, the clergy treated the health of bodies as an extension of the soul, and in fact they viewed the two as inseparable. The works of Barnhouse, Rice, and Izbicki together further our understanding of the use of religious rites, canon law, and theology in medicine, revealing their significance to establishing and maintaining communities around the sick and dying in the Middle Ages.That Izbicki’s Ministry to the Sick and Dying in the Late Medieval Church is the first dedicated study to such an important topic as providing penance, the Eucharist, extreme unction, and prayers to the sick and dying is surprising. Izbicki presents a comprehensive and erudite rectification of this gap. The work is not aimed at proving any one particular argument but, as the author himself explains, is intended to extend his previous studies on the Eucharist and viaticum, seeking to interrogate the ways in which the clergy attended to the physically ill (vii). While the prime focus of the clergy was to heal the soul, Izbicki illustrates that the clergy saw their ministry to the ill as a form of medical care. In fact, the clergy viewed their role as part of a fundamental system of healing, which in some cases enacted what amounted to physical treatment. For instance, the viaticum was not simply a way to include those that were bedridden in the sacrament but was explicitly treated as a means of providing comfort and even healing for the sick and dying (27–33).In a culture preoccupied with memento mori and ars moriendi, no role could be as important as creating the conditions for a good death. As Izbicki shows, far from animosity toward physicians and the place of medicine in the affairs of the dying, priests were to work alongside physicians in order to comfort and prepare the soul for the afterlife. Even during the Reformation, this dual focus on physical and spiritual health continued. In John Calvin’s Geneva, where there were no longer means for patients to seek out miraculous cures and the mortally ill were advised to visit physicians, prayers for the dying were still valued, deacons oversaw the running of hospitals, and ministers provided spiritual comfort to the terminally ill (211).Across this book, one is struck by the breadth of Izbicki’s sources, which range from around the Fourth Lateran Council (1215) up to the Council of Trent (1545–1563). The sources themselves are diverse in genre and area of composition. He examines pastoral manuals, canon law texts, and more complicated, and at times esoteric, theological works. As Izbicki notes, the limitation of such sources is that they are typically theoretical and do not give much of a hint as to the lived experience of priests as well as the sick and dying. Further difficulty arises from the fact that while “Roman practice influenced the development of instructions for visiting the sick and dying,” there was little unity of practice. Each “diocese had its own variations within a shared framework, and manuscript copies of a diocesan manual might have their own differences” (37). Uniformity was still not accomplished after printed manuals for priests became widespread. Izbicki overcomes these source limitations by incorporating case studies drawn from texts such as visitation records. For instance, the visitation records of the archdeaconry of Josas near Paris reveal that several churches violated diocesan statutes by not having renewing oils readily available and in some cases, supplies had not been renewed for as long as four years (157). Such records give an insight into the type of treatment, or lack thereof, that the sick and dying could expect at specific institutions and the oversight that ecclesiastical authorities provided. At each stage of Izbicki’s work, the local variations and differences are respected by offering a tremendous level of detail. It is this attention to detail and breadth of research that will make this study the essential handbook for ministry to the sick and dying for years to come.Hospitals were perhaps the most obvious sites in which the medical and spiritual united, with the sick poor taking up beds and relying on nursing sisters to provide care. These institutions did not often provide healing or regularly employ medical or surgical practitioners but rather presented themselves as places for convalescence and spiritual care. As Lucy C. Barnhouse’s Hospitals in Communities of the Late Medieval Rhineland, Houses of God, Places for the Sick demonstrates, several hospitals for the sick poor and leprosaria in the Mainz archbishopric portrayed themselves as religious houses in legal frameworks as a means to build communities of support from secular and ecclesiastical sources. As the second chapter explains, their legal status did not differ vastly from monasteries, and in fact hospitals were brought into conflict with such religious houses (63). Yet, it was their mission to care for the sick poor that differentiated hospitals and ensured their independence from other religious institutions. Despite this independence, hospitals were able to forge economic, social, and civic connections and secure support through canon law, which became “an engine of their late medieval development” (1).Nevertheless, this monograph is far from a simple legal history of the hospitals of the Rhineland. The final three chapters consider how significant hospitals were in community building between the clergy and laity. Chapter 4 explores leprosaria in Mainz, Speyer, and Strasbourg, arguing that instead of being segregated from society in an attempt to isolate the diseased, leprosaria were integrated into cities and the civic landscape. In fact, the help of civic communities and local patrons bolstered the efforts of leprosaria in maintaining their religious status and independence (150). The final chapter illustrates this same reliance on community forging in rural hospitals. These supportive communities were multilayered, deep seated, and often multigenerational, with neighbors across society seeking to strengthen the resources of the hospitals (209).Barnhouse concludes that hospitals—from large institutions catering to the sick poor to leprosaria and small rural hospitals—“managed their resources in the service of the sick, and most jealously guarded the economic liberties afforded them by their legal status” (211). It is this administrative independence and guarding of resources that enabled hospitals to persevere through turbulent political and religious events such as the Reformation. In fact, Barnhouse’s argument seeks to revise the “conventional” narrative in which “hospitals passed from archiepiscopal into civic control as pawns of the dominant political interests,” “with site-specific conflicts between civic and ecclesiastical authorities driving events” (66–67). While this narrative is certainly ill fitting to some institutions, there is still wisdom in the “conventional” narrative. It would be difficult to prove beyond doubt that hospitals were not subject to the currents of political discourse in one way or another, as even with their independent status, they so stridently sought the support of civic and ecclesiastical authorities. This small qualification aside, Hospitals in Communities of the Late Medieval Rhineland is an impressive study of hospitals, their communities, and the laws that enabled them to function or, in some instances, got in their way.The Medieval Hospital: Literary Culture and Community in England, 1350–1550 makes a different contribution to the discussion of hospitals and community building, arguing that certain institutions—namely, St. Leonard’s in York, St. Bartholomew’s in London, and St. Mark’s in Bristol—were surprisingly prolific centres of “literary-cultural” production (4). Much as Barnhouse plots the development of hospitals in the Rhineland through their legal status, Rice argues that literary production and the formation of reading communities, through the creation and dissemination of miscellanies, enabled hospitals in England to reinvent themselves in the face of the dissolution of the monasteries. One of the most illustrative examples of this process is presented in chapter 6, which is centered on the dissolution and refoundation of St. Bartholomew’s. During a time in which there was fear of “illicit behavior in London,” the hospital used the 1556 Ordre of the Hospital to present itself as an institution of moral reform, explaining that vulnerable women would be tended to by nurses of the hospital alongside local caregivers who assisted poor unmarried mothers and their children (239). This framing of civic responsibility was not new in the sixteenth century. As the first chapter outlines, in the early fifteenth century, St. Leonard’s sponsored the Purification of the Virgin pageant, part of York’s Corpus Christi cycle. Having a presence every year in the play cycle would not only enable the hospital to gain increased support but also facilitate its further integration into the civic structure of the city. In fact, as Rice suggests, the St. Leonard’s version of text may have had increased roles for women and thus the pageant might have served to emphasize the hospital’s aim in caring for vulnerable women (31–36).Still, these hospitals were not simply concerned with how they were viewed by outsiders but were also focused on directing the spiritual lives of their patients. Rice illustrates that some hospital residents created reading communities that drew from Augustinian practices in which the laity were increasingly encouraged to engage with devotional texts. Chapters 3 and 4 examine compilations produced for those living in the close of St. Bartholomew’s. John Shirley, a fifteenth-century scribe, produced Oxford, Bodleian Library, MS Ashmole 59, which contains works from John Lydgate alongside devotional texts. This anthology was not dissimilar to those produced by later scribes such as John Cok—in fact, John Shirley left marginal notes in one of Cok’s compilations (Cambridge, Gonville and Caius College, MS 669/646). Rice contends that Shirley and Cok, as well as scribes associated with other hospitals, produced collections for “a virtuous, disciplined, and generous community of readers, connected by affective ties both familial and spiritual” (139). This reading project not only facilitated the creation of a close, devotional community but also encouraged increased interaction between the laity and the clergy.Covering an impressive array of sources, The Medieval Hospital is an innovative work that proves that hospitals were not simply sites of convalescence and palliative care but could be active contributors to devotional, literary culture. The production, collection, and dissemination of texts established a community of scribes and readers, which was essential for the self-fashioning of these institutions in political and religious contexts, ensuring their continued survival into the sixteenth century. Much like Barnhouse and Izbicki, Rice emphasizes the collaborative work of the clergy and laity in health care. Medical and religious frameworks became inseparable and the role of scribes and readers further blurred the boundaries between professional and lay perspectives. Still, there are limitations to the literary and devotional influences of hospital communities. As Carole Rawcliffe has demonstrated, late medieval England faced a crisis in the administration of hospitals, as a number of institutions were chronically underfunded and accused of mismanagement.10 Rice demonstrates that St. Leonard’s, St. Bartholomew’s, and St. Mark’s did not face such a crisis and were in fact singled out as examples of particularly well-run institutions (203–4). The extraordinary nature of these examples limits the scope of some of Rice’s findings, as clearly not all English hospitals benefited from the same construction of literary culture. Nevertheless, St. Leonard’s, St. Bartholomew’s, St. Mark’s, and the other examples that Rice examines prove that certain institutions were able to thrive in a culture in which hospitals were suffering from maladministration and a lack of In fact, through community building, they could not only these but the provided by Izbicki, Barnhouse, and Rice, make more of the from Le Livre de vie active with which Henri’s text and its with the Hôtel Dieu at the of Paris beyond a between religion and medicine, the physical and For a the hospital was by Augustinian and canonesses like the institutions that Barnhouse on its status as “a religious house of In fact, the to the river Seine and crossing the tears of pity to the Hôtel as part of a The tears not simply from and as well as the patients and of the hospital, but from all who the Hôtel The hospital was on the de and was thus on the Seine, a that for the of and This institution charitable healing to the vulnerable and even provided opportunities for and to treatment, as the were to some of their time to patients at such the Hôtel Dieu was not an institution that the sick poor from but rather the hospital was integrated into the the and the text as a for that a of literary This was no much like the hospitals that Rice Henri sought to the mission of the hospital, its staff, and the community in a devotional As Izbicki demonstrates, the role of the clergy in to the sick was a prime responsibility of the cura and Henri this spiritual care to the sick poor as a fundamental of a charitable Throughout the text, to the health of souls over yet that physical care was a of the nursing canonesses and that spiritual care had physical the frameworks of by Izbicki, Barnhouse, and Rice, beyond a simple of the overlap between religion and the state of the is The of religion and medicine has to a of our understanding of those who treated the sick in medieval Hospitals and members of the clergy who to the sick and dying were vital in community forging and in ecclesiastical and civic authorities. This of building communities of support to in canon law, a of the legal status of the hospital, and even served as a means of literary see these in the of the Hôtel Dieu and Le Livre de vie from a institution that sought to isolate the sick and dying, the Hôtel Dieu and Le Livre de vie active presented its healing mission as a means to engage the community around Henri treated the of Paris as to both the survival of the institution and the health of patients. the of in healing bodies and souls could not be but only through