Jens Hartz, who trained as a health care professional and nurse (p. 6), begins his study with a detailed review of the current state of research (9–23). He cites preliminary work on the development of ancient nursing and the significance of Christianity in it and notes that comprehensive source-based scholarship on these topics is lacking. Hartz aims to “at least reduce” [“zumindest verkleinern”] this gap with his work (24). Methodologically, he looks for activities that could have been part of professional nursing in antiquity, independent of the varying philosophical frameworks and conceptions of human nature found during that time. Using modern nursing theories by Virginia Henderson and Liliana Juchli as hermeneutic tools enables him to identify and analyze potential nursing practices in a structured manner (25f.).
First, Hartz deals with nursing activities and personnel in the Corpus Hippocraticum, written around 430-350 BC (28–57). Following a presentation on the complex questions of authorship and dating (28–32), he examines evidence related to nursing activities in all the writings. The guiding question here is always whether these activities are explicitly stated or must be inferred from the context, and who, if anyone, performed them: the physician, an assistant, the physician’s students, or the patients’ family members. Hartz takes a similar methodological approach in the next chapter, which covers nursing activities in the works of medical writers of the Roman Empire. In this chapter, he examines the works of Aulus Cornelius Celsus (59–76), Aretaeus the Cappadocian (76–81), Rufus of Ephesus (81–88), Soranus of Ephesus or his translator Caelius Aurelianus (88–113), and Galen (113–128). Using his hermeneutic tool from modern nursing theory, Hartz impressively identifies and analyzes numerous nursing activities. In the footnotes, he debunks research opinions as medically implausible.[1]
In the fourth chapter, Hartz transitions from a work-oriented analysis to a systematic typology: He first explores nursing and its practitioners in households during the Classical Greek period (129–133). Then, he discusses physician assistants as nursing practitioners (133–138), private institutions and their nursing staff in households during the Roman world (138–149), Asclepieia and nursing activities (149–157), and military valetudinaria (‘hospitals’) and their nursing and medical staff (158–166). Thus, he presents a concise overview of the various contexts of ancient nursing, drawing on sources ranging from Greek orators, such as Demosthenes and Isocrates, to Latin authors, such as Columella, Seneca, and Livy, as well as inscriptions, papyri, and imperial legal texts. In the process, he discusses variant readings and demonstrates his solid philological expertise (e.g. 148 n. 108).
The fifth chapter on Christian nursing and social welfare institutions is the most comprehensive in the book. It also covers a wide range of topics (167–227). Here, Hartz traces the institutionalization of Christian nursing throughout antiquity in nine sections. I will outline the most important aspects he highlights in more detail below:
- Intra-congregational nursing during the Roman Empire (167–173): Here, Hartz addresses the frequently expressed research hypothesis that intra-congregational nursing was initially carried out by widows and deacons. He concludes that the sources for this thesis are only of limited significance. Calls to deacons, as seen in the Didascalia Apostolorum [ch. 16] and in a circular letter from Clement of Rome [Clem. de virg. I.12.4–8] imply that deacons required motivation to perform nursing tasks, indicating that nursing was not a matter of course for them until then (168f.). Further evidence (e.g. Tertullian, apol. 39.6f.) suggests that all Christians were responsible for nursing, regardless of their ecclesiastical status. However, the extent to which this responsibility was embraced varied (169–173).
- Care for the poor and the beginnings of Christian care institutions (173–187): Here, Hartz carefully distinguishes between the various welfare institutions by discussing the relationship between xenon, xenodochium, and nosokomeion (175f.) and examining the charitable work of Basil the Great in detail. Basil’s institutions and efforts are best documented in this early period (180–187).
- Competition from Emperor Julian (187–191): Hartz discusses the content and authenticity of a letter from Julian [Soz. hist. eccl. 5.16.5–11]. The emperor ordered the creation of state institutions to compete with Christian welfare institutions and prevent the Christians from monopolizing the care of the poor. Regardless of its authenticity, the document reveals implications for the Christian institutionalization of poor relief, as Hartz convincingly explains.
- The first flowering of Christian care institutions (191–196): Hartz once again proves that some supposed sources of institutionalized nursing are unusable. It can only be reliably verified at the beginning of the seventh century in a report by Leontios of Neapolis (Life of John the Merciful VII) (192), as it is often unclear if the buildings were simply guesthouses without specific nursing facilities (194–196).
- Monastic life and nursing by monks (196–203): Although a sickroom with appropriate nursing care is assumed for the monasteries of Pachomius, Hartz questions this assumption for good reason (197–199). Instead, he presents evidence from Palladius’ writings that some monks cared for the sick independently of monastic life (201–203).
- Institutions of bishops and private benefactors (204–212): Sources usually reveal little about nursing activities in institutions run by bishops and private benefactors. Often it is unclear whether nursing was practiced in these institutions or if they were merely guesthouses, as in the case of Melania the Younger (209 n. 169). One exception is the institution of the Roman aristocrat Fabiola, whose nursing activities are highly praised by Jerome in Epist. 77 (207–209). Hartz concludes the section by stating that the development of Christian healthcare institutions mainly occurred in the eastern part of the Roman Empire, analogous to the much earlier and more pronounced development of monasticism and pilgrimage (211).
- Further developments and differentiation (212–215): Hartz notes that, in sources from the sixth century, the term ξενοδοχεῖον was predominant for social welfare institutions (212). Nevertheless, the term νοσοκομεῖον continued to exist as well. He speculates that authors who used the term νοσοκομεῖον wanted to emphasize patient care. However, due to the fluid transitions between institutions providing basic medical care and primary “inns,” there were no significant differences. According to Hartz, this is why Roman jurists in late antiquity did not consider it necessary to differentiate further, instead choosing the presumably more prevalent term xenodochium or xenon as the legal umbrella term (214f.).
- Financing of the institutions and development in late antiquity (215–223): Hartz discusses the legally enshrined support of private foundations in the Codex Iustinianus (216). Despite state support, however, the long-term existence of private institutions was rarely successful. Hartz refers to the ancient Hellenistic ethos of civic pride (216) and Christian agape (217), which also favored imperial donations, as motivations for the use of private foundations. He illustrates this with the commitment of empress Eudokia (217f.) and emperor Justinian (218f.). Hartz then describes the growth of institutions until the early Middle Ages (220–223).
- Concluding remarks on Christian institutions (223–227): Hartz first discusses the activities of various groups associated with nursing (223f.). Then, he addresses how nursing continued in private contexts despite increasing institutionalization (224–225). Finally, he speculates about the motivations of Christians to practice nursing despite the risk of infection (225–227).
In addition to the impressive breadth of sources consulted, Hartz’s efforts to achieve terminological precision in this chapter are particularly noteworthy. The incorporation of ancient medical concepts, such as the miasma theory (172f.), and the thorough examination of financial and legal foundations (215f.) are also strengths. Hartz’s deconstruction of the master narrative of the “utilitarian worldview” transformed by “Christian charity” (10) is convincing as well. Through an examination of sources in the context of the Plague of Cyprian, Hartz reveals that there were non-Christians who helped selflessly (172f.) and Christians who held back for fear of infection (171). In his concluding remarks, Hartz succinctly summarizes his central findings on five pages (228–232).
Despite the remarkable wealth of material and methodological innovation, there are also critical aspects to mention. For example, Hartz’s attempts to identify nursing staff in the sources result in several instances of argumentation chains in which far-reaching conclusions are drawn from the sources’ silence (e.g., regarding Celsus, 61). This is a problem that Hartz acknowledges (114), though he does not always draw the necessary methodological conclusions. The hypotheses developed are entirely plausible, but in some places, they should be more clearly identified as such and compared with alternative interpretations.
Conversely, Hartz’s skepticism seems exaggerated when he claims that reliable evidence of medical and nursing care only appears in sources from the beginning of the seventh century (192). Earlier, he thoroughly discusses Basil’s fourth-century institutions (180–187) and convincingly presents their nursing dimension. Here, his methodological caution turns into hyper-skepticism, obscuring rather than illuminating historical developments.
Hartz draws directly from literary and rhetorical texts for historical reconstructions. For example, he describes Aelius Aristides’ Sacred Tales as a “useful descriptive account” [“nützlich-deskriptiver Bericht”] (146), yet he does not sufficiently consider their highly subjective genre and apologetic purpose. (Regarding Aelius Aristides’ self-stylization in his descriptions of his illnesses, see Downie 2013, 89–102.) Hartz also treats the Vita Pachomii as straightforward historical evidence without engaging with the scholarly discussion of its historicity and hagiographic character (199f.). For such a methodological reflection, see Bojowald (2023, 38f.). He does, however, acknowledge these issues for the vita of Basil (180f.). A systematic reflection on how ancient narratives of illness function in literary-theological terms – for example, proof of holiness, miracle motifs, theological interpretations – and the implications this has for their use as sources of medical history is lacking. Such reflection would have greatly enriched the work.
Furthermore, it is notable that references to the central theological concept of caritas are clearly outdated (173 n. 25). Regarding the reliability of Palladius’ information about John Chrysostom’s life, Hartz refers to a 1928 study (202 n. 143). For a more recent and nuanced evaluation, one may consult Hübner 2021, 42f.
In terms of language and form, the work is virtually flawless. The extensive and often highly instructive footnotes provide in-depth discussions of the research literature. However, their abundance makes reading difficult in places. Interim summaries or introductory abstracts would have given readers more guidance. Additionally, an index of terms or sources is missing. This would have been helpful, especially given the large number of sources. Hartz’s extensive reading in ancient medical history is evident in his exhaustive bibliography. Future studies in this field can build on this foundation by exploring gender perspectives, disability studies, or cultural anthropological comparisons in more depth. These topics were not the focus of this study, which is understandable, given its scope of 232 pages.
Overall, despite the problems mentioned at the end of this review, this study can be considered a groundbreaking work in ancient medical history. Hartz’s keen eye for nursing practices, shaped by a professional background uncommon among ancient historians, has enriched the field by offering a neglected perspective that will undoubtedly inspire further studies.
Cited literature
Bojowald, Stefan (ed.). 2023. Die Vita des koptischen Klostergründers Pachom. Synoptische Darstellung, Übersetzung und Analyse. Berlin/Boston: De Gruyter.
Downie, Janet. 2013. At the Limits of Art. A Literary Study of Aelius Aristides’ Hieroi Logoi. New York: Oxford University Press.
Henderson, Virginia. 1997. Basic Principles of Nursing Care. 2nd ed. Washington: International Council of Nurses.
Horden, Peregrine. 1999. “Pain in Hippocratic medicine.” In Religion, Health and Suffering, edited by John R. Hinnells and Roy Porter, 295-315. London/New York: Kegan Paul International.
Hübner, Adelheid. 2021. “Einleitung.” In Palladius von Helenopolis. Dialogus de Vita Joannis Chrysostomi / Dialog über das Leben des Johannes Chrysostomus, edited and translated by Adelheid Hübner, 7–69. Fontes Christiani 90. Freiburg i. Br.: Herder.
Juchli, Liliana. 1983. Krankenpflege. Praxis und Theorie der Gesundheitsförderung und Pflege Kranker. 4th ed. Stuttgart/New York. Thieme.
Notes
[1] See, for example, p. 38 n 54, where he employs his nursing and historical expertise to refute Peregrine Horden’s assumption that Hippocratic physicians were not interested in the causes and alleviation of pain.