Care for the Sick in Shenoute’s Monasteries
SHENOUTE’S WRITINGS PROVIDE a rich store of evidence for the various ways in which the sick were cared for in his monasteries. Care for the sick was a shared value at the heart of the early monastic movement, and certainly this was the case in Shenoute’s monasteries. The theological, social, and ideological reasons for the noteworthy monastic interest in care for the sick are all rich areas for investigation, which I have had opportunity to explore elsewhere. In this chapter, however, I will limit myself to the medical and institutional aspects of care for the sick by outlining the basic contours of this important component of monastic life in Shenoute’s monasteries.
In Shenoute’s monasteries, the infirmary (pma nnrwme et4wne) served the acutely ill. Coenobitic literature from Egypt in general indicates that the infirmary formed an expected and functionally vital component of the coenobitic life. Unlike virtually every other type of ancient medical care, including that provided in many fourth- and fifth-century semi-eremitical monasteries in Egypt and elsewhere, coenobitic monasteries offered inpatient care under the supervision of trained healers, including a nursing staff and doctors. The writings of Shenoute and Besa are important witnesses to this tradition of monastic healing. It is to be noted that while the monasteries of Shenoute provided a range of charitable services for non-monks use of the infirmary was restricted to the monastic sick.
As it stands, only one early monastic infirmary in Egypt has been identified as such through excavation: that in the monastery of Apa Jeremias at Saqqara, although the identification of the structure as an infirmary has been treated with some skepticism. Nevertheless, for Shenoute’s monasteries we must make do with the literary record for the time being.
Passing comments in Shenoute’s Canons indicate that the infirmary was architecturally distinct and spatially removed from the rest of the monastic buildings. The reason for the separation was not a need for medical quarantine, since the ancient world lacked modern notions of contagion.
Rather, the spatial separation enforced a social quarantine: whatever activities occurred within the infirmary were to be out of sight of healthy monks. We know also from Shenoute’s own writings that the infirmary had its own storeroom, refectory, and kitchen.
Within the infirmaries’ walls several types of monastic healers cared for the sick monks. These included doctors, nurses, and elders.
Shenoute refers to doctors in the monastery on a number of occasions, and doctors are frequently mentioned in other contemporaneous monastic sources. In Shenoute’s congregations both male and female doctors joined the monastery and continued to practice medicine for the residents therein. Doctors could also be brought in from outside the community, in which case Shenoute orders that they be paid their customary wages.
In Shenoute’s monasteries, as in other coenobitic monasteries in the Pachomian tradition, another class of healers cared for sick monks within the infirmaries. These were “nurses,” or rendered literally, “the servers of the sick” (netdiakonei enet4wne) in Shenoute. Shenoute classifies these “nurses” as among the various professions within his monasteries: bakers, builders, agricultural workers, and so on. As I have argued elsewhere, this occupation, as a defined and distinct specialization, is without precedent in the ancient world; nursing the sick was a duty normally imposed upon lay caregivers and, to the extent that they were present, physicians themselves. In the coenobitic monasteries of Shenoute and his contemporaries we see the emergence of nurses as a profession distinct from both physicians and lay caregivers.
From Shenoute’s writings we know that the job of nurse could be an extremely taxing one: he refers rather graphically to his monks’ hesitancy to care for the sometimes noxious ailments that the sick suffered. Nonetheless, we know from Shenoute that the nurses served the sick according to the individual prescriptions (often dietary) determined by the elder in charge of the infirmary. We may also presume that they performed hygienic duties such as bathing and comforting the sick, tasks that the sick and infirm normally performed for themselves when not confined to the infirmary. Actual numbers of nurses are not reflected in Shenoute’s writings or in other writings of contemporary monasticism, but the nurses must have formed an important part in caring for the sick among the thousands of monks in Shenoute’s monastic federation.
Another role in the health care system, specifically in fourth-century coenobitic monasteries, was that of overseer. In Shenoute’s monasteries much of this practical administration was performed by so-called “elders.” For example, an elder was charged with determining the gravity of illness and whether indeed the monk was “truly” sick, and not just malingering, and then determining whether his or her illness was severe enough to necessitate infirmary care. Then he or she would either give or deny permission to go to the infirmary. They might also allow the monk some special dietary dispensation within the refectory, but of course to be eaten under the elder’s watchful eye.
Monks who were ill with more specific medical indications, such as a wound, fever, or pain, also had to apply for medical service through the elder in order to receive treatment at the hands of a doctor. In the infirmary, an elder was also responsible for determining the right therapeutic diet for each of the sick monks, to be then administered by nurses. Additionally, the elders were responsible for providing special clothing, medical instruments, and food for monks who were not sick enough to warrant inpatient care. As in all other areas of monastic life, from worship to work to spiritual direction, care for the sick in Shenoute’s monasteries depended upon the system of elders and housemasters to aid monks in distress as well as to regulate access to health care and the special benefits (food, rest, and comfort, for example) provided for the sick.
I should also point out that most care for the sick was provided not through the infirmary, or even by the three classes of healers I have just described, but by lay caregivers, that is to say, the sick’s fellow monks.
Monks were expected to provide basic care for their sick brethren in coenobitic monasteries. Such lay care comprised typical elements of comfort care, but also allowed for minor surgical procedures to be performed on oneself or on fellow monks. Jerome, writing in his introduction to his translation of the Pachomian Rules, describes the compassion that monks showed toward their sick brethren as among the most remarkable features of coenobitic monasticism. The case was no different in Shenoute’s monasteries, as Shenoute frequently exhort his monks to care for the sick among them.
I will now return to the care for the sick as provided by doctors, nurses, and elders through the infirmary. I will focus on three types of care in the present chapter: dietary care, surgery, and pharmacology, with a special focus on pharmacology.
Dietary care in antiquity was not only a source of comfort, but was also the first line of treatment for most internal ailments. This was certainly no less the case in Shenoute’s monasteries. While the standard monastic diet in Shenoute’s monastery was decidedly ascetic, it is clear from Shenoute’s own writings, as well as those of his contemporaries, that sick monks were held to a distinctly different standard of asceticism and were given access to a whole range of food normally forbidden or at the very least severely restricted for reasons of health, including vinegar, fish, eggs, oil, wine, and perhaps meat.
Regulation of access to such foods was of utmost importance in coenobitic health care, particularly with regard to wine. So Shenoute writes:
And those who serve in that place (the infirmary) shall act in accordance with what is appropriate in the measure that the eldest commands them to give, each one according to each type of illness. But neither the housemaster nor anyone at all, whether male or female, shall say to anyone in his sickness, as to persuade him, “Wouldn’t you like some wine to drink?”
To avoid the unnecessary use of wine, requests for it, as for other normally forbidden foodstuffs, had to come from the monks themselves. This safeguard, of course, could not entirely prevent abuse of the special privileges afforded the sick, and Shenoute condemns malingering on a number of occasions.
Beyond the typical provision of special foods to the sick, dietary therapy was also determined by the elder in charge of the infirmary, and served by the nurses, as mentioned previously. The diet for the sick was not uniform, as was the diet for the healthy, but was ‘prescribed’ by the elder according to the type of illness. Shenoute’s writings do not specify what sort of medical training this elder in charge possessed in order to make such determinations, or how treatments were codified, if at all. But in a community in which doctors were a regular feature, both as monks and as visitors from outside, it is more than reasonable to suppose that the elder in charge of the infirmary had some medical training or knowledge, or at the very least had access to it. Monastic sources, furthermore, do not give any indication of how the particular diet was determined for each monk, that is to say, which symptoms called for which types of food, heating or cooling foods, for instance.
Monastic medicine, as attested in Shenoute’s writings and elsewhere, also drew on the range of surgical skills available at the time, techniques that are well attested in other monastic sources from late antiquity. As mentioned previously, minor surgery was regularly performed, often by the monks themselves: thorns were removed, wounds cauterized, and bleedings performed. Furthermore, doctors treated pustules and wounds, pulled teeth, and treated eye disorders.
Coptic monasteries also drew on and transmitted the important pharmacological heritage of Egypt. Coptic pharmacy is documented by at least twenty-seven published Coptic medical manuscripts, most of which are regrettably fragmentary. The Coptic corpus of medical literature provides valuable evidence for the care of the sick in Egyptian monasteries, including Shenoute’s monastery. While Coptic manuscripts of medical content postdate the life of Shenoute by several centuries, late ancient medicine maintained considerable continuity over time, being a highly conservative rather than an innovative tradition. So it is likely that the sorts of treatments preserved therein reflect manuscript exemplars from earlier centuries.
Three folios from a medical codex probably from the library of the monastery of Shenoute (parts of which were published separately by Georg Zoega and Urbain Bouriant) provide a valuable complement to literary evidence for medical care in Shenoute’s monasteries. The Coptic medical manuscript enhances and, in fact, complicates our picture of monastic healing that Shenoute himself presents in his disciplinary literature. For example, pages 214 and 215 of this once very large manuscript preserve a variety of prescriptions for ailments that one might not associate with monastic medicine, venereal ailments, and ailments of the breasts.
For breasts that hurt. It is also useful for the man’s “male flesh” (epsoma [for epswma] n6oout mprwme]). Take the plant called cat’s eye, with white lead (noupyimiqion [sic]), litharge, lead, and opium, of equal proportions.
Pound them well. Take a little vinegar for them. Mix them up with juice of female grape. Leave them in a lead vessel, and take them (ng2ou, perhaps for ng`itou?) and smear them on them until they heal. . . .
For a breast that is painful. Take mother’s milk. Smear on it. It is also useful for testicles (n`oeit) and penises (nba6, see Crum, 1939, 47b) that are painful.
The prominent preservation of such remedies in the White Monastery medical manuscript is interesting, especially considering that the treatment of specifically female and male ailments was a topic of some concern for Shenoute himself, who forbade his monks from treating women outsiders and such complaints of men: “All the more, cursed is anyone who treats a woman outsider, or treats the shameful members of a man in the area of the congregation, or anywhere else.”
Other recipes in the White Monastery medical codex are lactagogues, to induce lactation, another area of medical treatment that might be surprising to find in a monastic library. So,
For a woman’s breasts, so that they produce milk. Take some dried garlic. Boil them in unmixed wine. Let them drink . . . .
For breasts, so that they produce milk. Take some fava beans. Boil them and have them drink their water (peumoou) first thing after eating . . . . Another [for breasts, so that they produce milk]. Take some leaf of cucumber. Soak them with salt. Put them on [the breasts,] and they will become full of milk.
These are but a few of the lactagogic recipes in the White Monastery codex. What could such recipes be doing in a monastery? We could argue that they are part of a standard formulary, produced or purchased outside the monastery, and thus they do not necessarily reflect the medical needs or practices of the community in which they were preserved and used.
This is possible. But by placing the Coptic medical papyri within the context of both the literary remains of Shenoute’s life and of other monastic documents, the prominent presence of lactagogic prescriptions within a monastic codex makes a certain sense. We know from Shenoute’s own writings, as well as those of other early coenobitic writers, that orphans were a standard component of the monastic population. Young children were abandoned at the gatehouse or ‘donated’ to the cloister as a thanksgiving for miraculous services provided by the monks, as the famous child donation contracts from Thebes attest.
How then is a group of ostensibly celibate nuns to properly care for orphaned infants? Whether or not such recipes as these were efficacious, in the sense defined by western biomedicine is beside the point, but, the likely and persistent presence of orphaned infants within the monastery does at least provide a plausible pretext for the preservation of such recipes within the monastic codex, even if they were not actually used.
The remainder of the White Monastery medical manuscript (last edited by Zoega in 1810, although translated into German by Till in 1951) is dominated by prescriptions for dermatological ailments. So it begins, “Chapter 136. For mange [tywra] and conditions that itch.” Included in the two folios of Chapter 136 are remedies for mange, scabies, leprosy, running sores, itching over the whole body, lice, and canker sores.
The recipes provide a detailed portrait of the types of medicine used in late antique or medieval monasteries. Interestingly, we know from Shenoute’s own writings that Shenoute suffered from a chronic, disfiguring skin condition for a number of years. During his illness and convalescence, he quarantined himself from the community in a hermit’s cell. He continued to write however, and during this extended period he probably penned many of the works that now make up his Canons 6 and 8, although chronological ordering of Shenoute’s works remains tentative.
I would like to draw attention to a passage from Who But God Is The Witness, in Shenoute’s Canon 8, that may shed some light on the care for the sick in Shenoute’s monasteries. Speaking about a custom-made garment that had become befouled by his running sores and subsequently eaten by moths, he writes that he is “testing” his illness with “all the medicines appropriate to it.” The language Shenoute uses to describe treating his condition, “testing” (wnt, per the Greek dokima/zein, Crum, Coptic Dictionary, 775b), and “medicine” (Coptic pa6re), is the typical terminology of Coptic medical literature.
Such terminology is used throughout, for example, the Chassinat papyrus roll: “this is tested,” “I have tested this medicine myself,” and so on. Does Shenoute betray here a familiarity with Coptic medicine? Or perhaps does his rhetoric simply reflect certain shared cultural models about suffering? In fact, Shenoute elsewhere displays some considerable familiarity the traditions of Coptic medicine. So from Canon 6:
Observe: when the doctor applies a cooling or cool medicament to the wou[nd at] the moment [or hour] that it nee[ds] it, it [d]estroys (tako) it (the wound) and gathers together a multitude of worms. But if he applies a medicament that penetrates (pet6ot6t) and a solvent (petouwm) on it at the moment and hour that it needs, and then applies that which cools at the moment and hour that it needs, then the growth (prwt) becomes visible, and the one who sees it rejoices because the wound has come out bit by bit.
These are the words of someone with more than a passing familiarity with medicine, of someone who knows a variety of medical treatments for an ailment, classifications of drug types, and perhaps something of the humoral theory underlying the treatments. So when Shenoute draws on the specialized terminology of Coptic medicine, and speaks of “testing this illness with all the medicines that are appropriate to it,” we should take this seriously. Where, for instance, is Shenoute finding “all the medicines appropriate to it”? It is possible that Shenoute had with him in his desert retreat a medical manuscript, perhaps like the one preserved in his monastic library from several centuries later.
Or more likely he had with him some ostraca or a few slips of papyrus bearing the relevant medicines copied from the master text in the library. We find such medical ostraca in a hermit’s cell elsewhere, at the Monastery of Epiphanius in Thebes. As for medicaments, did Shenoute have with him a small collection of materia medica to treat his skin condition? From my reading of Shenoute’s Canons such an arrangement would not have been allowed for regular monks in Shenoute’s monasteries, who would have been required to receive treatment through the official channels I have just outlined. But perhaps in this case, as in others, Shenoute was a living exception to his own rules.
Shenoute’s own illness experience, and the effect that this had on his administration of the monasteries, his theology, and indeed on the care for the sick in his monasteries is a rich area for future study. For now I would like to conclude by noting that the care for the sick was an essential and distinctive aspect of monastic life in Shenoute’s monastery. It is an aspect of life that we will continue to learn more about as Shenoute’s Canons and Discourses are published in the coming decade, and one hopes also as Shenoute’s monastery is scientifically excavated.
 For more details see: Crislip 2005; Crislip 2006a: 179-209.
 For example Peter Grossmann’s comments that monasteries should not have infirmaries, in Atiya 1991b: 773-74. His skepticism is accepted by Cacilia Wietheger, Das Jeremias-Kloster zu Saqqara unter (1992: 21-22). Abundant literary sources show that the situation is more complicated, as I have discussed in more detail than is possible here: Crislip 2005: 9-14.
 Shenoute, Canon 9, DF 16=Vienna K9345 verso; Canon 5, XS 275-6=Mich. 158: 19B. Citations of works of Shenoute are according to bibliographical sigla established by Stephen Emmel (2004b).
 Shenoute, Canon 9, FM 186=L.IV: 160—61, “No physician (saein) among us shall heal an outsider, not only not for wages, but not even free of charge . . . .” And Canon 9, FM 186=L. IV: 161, “Female doctors (s6ime nsaein) in these communities also shall not behave in this way at any time.”
 Canon 5, XS 386-72bis=L.IV: 56.
 Shenoute, Canon 5, XS 326=L.IV: 56.
 Crislip 2005: 15-17.
 Ibid.: 86-90.
 Shenoute, Canon 5, XS 326=L.IV: 56. On diet, see Shenoute, Canon 5, XS 325- 6=L.IV: 55, “And those who serve in that place (the infirmary) shall act according to what is fitting, in the measure that the elder commands unto them, so that they may give to each one according to the type of illness;” also Canon 5, XS 319=L.IV: 53-54, “When people are sick, their allotment shall be determined for them [by the elder 6itmp6llo, (supplied from previous paragraph)].”
 Chamber pots, “[No one] shall urinate in a baukalion or a 4o4ou or in any other similar vessel before having been given permission (empououe6sa6ne na3) by the elder, except for the infirmary only and the elderly (n6llo eaur6a6 nrompe). And as for these others, let them seek permission from the elder (etreu4ine ntoot3 mp6llo),” Shenoute, Canon 3, YA 421=L.IV: 124.
 The administrative structure is not entirely transparent in the White Monastery, especially due to the imprecision in terminology, Crislip 2005: 153-54; and compare the learned discussions of Shenoute’s administration in the contributions by Bentley Layton and Rebecca Krawiec in this volume.
 Canon 5, XS 61-61=L.IV: 78; Shenoute, Canon 5, XS 275-6=Mich.158: 19B.
 Shenoute, Canon 5, XS 372bis=L.IV: 73.
 Shenoute, Canon 5, XS 319=L.IV: 53-54; Canon 5, XS 326=L.IV: 56.
 “The sick are sustained with wonderful care (miris obsequiis) and a great abundance of food (copia cibis),” Jerome, Preface 5, tr. Veilleux 1980-1982, vol. 2.
 Shenoute, Canon 3, YA 538-9=L.IV: 33-34; Canon 4, BZ 26-27=L.III: 127; Canon 3, YB 108=BnF ms.copte 130.2 folio 42 verso; Canon 3, YB 72=BnF ms.copte 130.2 folio 60 verso; Canon 3, YB 73=BnF ms.copte 130.2 folio 61 recto; Canon 9, DF 178=BL Or. 3581A(28).
 For more details see Crislip 2005: 28-30; and Layton 2002: 25-55.
 Shenoute, Canon 5, XS 326=L.IV: 56. The manuscript breaks off, but we can presume that Shenoute went on to order that the sick must request the wine themselves.
 E.g., “Let us not ask for anything we don’t need, lest the Lord condemn us as sinners,” Shenoute, Canon 3, YB 73=BN ms.copte 130.2 folio 61 recto; “Every one of us, whether man or woman, is despised in the presence of Jesus if they ask for any dishes deceitfully as if they were sick when they are not sick,” Shenoute, Canon 5, 537 XS 61-62=L.IV: 78; “Those who ask naively to eat, when they are not sick, are acceptable in the presence of our savior Jesus,” Canon 5, XS 62=L.IV: 79; “As for the truly ill, who doesn’t know that his stomach rejects all dishes? People are not neglected (nse4aat an) in eating what they need just because they think (eumel- hta mpai), ‘My stomach did not receive it,’ or ‘I did not want to eat it,’ or ‘When I ate them, what did I do (airou)?’ The things you ate, they pleased you. They are your portion (4i). But your stomach did not receive any, because it is diseased,” Canon 9, DF 49-50=L.IV: 85-86. For more on the regulation of the behavior of the sick, see Crislip 2005: 68-99.
 Shenoute, Canon 5, XS 326=L.IV: 56.
 Crislip 2005: 36-38.
 Shenoute, Canon 5, XS 372bis=L.IV: 73.
 Shenoute, Canon 5, XS 386-372bis=L.IV: 72-73; on the prevalence of eye problems in Egyptian medicine, see Nunn 1996: 197-202.
 On the Coptic medical tradition in general, see Krause 1991b: 1886-88; Kolta 1991: 1578-82; Wolfhart Westendorf 1999: 146-56; and Till 1951.
 See Crislip 2006b: 165-68, at 166.
 See in particular Nutton 1984: 1-14.
 Zoega 1973: 626-30; Bouriant 1887: 319-20.
 Canon 9, FM 186=L.IV: 160-61.
 Bouriant 1887: 376. Other lactagogic recipes are preserved on page 215 of the manuscript, but have been omitted here due to difficulties or obscurities in the text.
 Crislip 2005: 232.
 See Wilfong 2002: 99-104.
 Yet the complexity of the issue of pharmacological efficacy should be recognized. Chemical efficacy is by no means the only, or even the most important, factor in drug effectiveness. See the overview in Helman 1994: 194-223.
 Zoega 1810: 627.
 Canon 8, XO 126=IFAO Copte 2, unpublished.
 Chassinat 1921: nos. 26, 56, 80, 109, 123, although in these cases the physician tests the medicine rather than the illness.
 See Garrett 1995: 91-94. I would argue in fact that Shenoute’s illness discourse reflects a familiarity with both medical knowledge and culturally shared models of suffering.
 Canon 6, XM 190=L.III: 195
 Crum 1992: 117, nos. 574-575.