Hospes venit, Christus venit: Hospitality, Healing, and the Opera Misericordiae in the Ospedale di Santa Maria della Scala

Abstract

For almost a thousand years (1090–1990), Santa Maria della Scala in Siena—arguably one of the oldest surviving hospitals in the world—opened its doors to pilgrims, travelers, the sick, the poor, and the gittati (children who were “cast off” and left on its steps). Making manifest the traditional adage of hospitality, all the guests who presented themselves there were to be welcomed as Christ himself. In this paper, I explore this broadening of the Church’s vision of its healing ministry (that is, beyond care for the sick) alongside the increasing dedication of the laity to the opera misericordiae (the works of mercy) in the late and high Middle Ages with the Ospedale di Santa Maria della Scala in Siena as a case in point. I will make reference to the mid-fifteenth century fresco cycle in the Pellegrinaio of the hospital that bears witness to its celebrated functions and speaks to how and by whom these were carried out.

1. Introduction

The late Canadian historian Shirley Jackson Case argued that “in the ancient world it was almost universally believed that the function of religion was to heal disease, and it was in just this world that Christianity took its rise. It need not surprise us, therefore, to find that Christianity is from the start a healing religion” (Case 1923, p. 253).1 In order to meet a certain demand in the Graeco-Roman world that understood “the only sure remedy for the ills to which flesh is heir” to be within the province of religion, Case claimed that, as the reach of nascent Christianity began to expand beyond the Jewish community, emphasis went from Jesus-as-master-teacher to Jesus-as-the-great-physician. The conviction was that Jesus was not simply one among many, but—in fact—the divine healer of his age (and of the ages to come) (Case 1923, pp. 254–55). Significant attention would be given to the healing narratives already central in the Gospels. In particular, by the third and fourth centuries, the ministry of healing itself would become an important mark of the Christian community, which sought to care for—and sometimes cure—in Jesus’ name, those who were sick (Case 1923, pp. 254–55; Ferngren 1992).

Although it is true that this particular ministry fulfilled a sought-out function that, for some, signaled the credibility of the emerging Christian Church and confirmed the messiahship of its founder, the Christian character of healing as philanthropy—that is, as a love for humanity—was primarily rooted in the Church’s theological anthropology and was largely inspired by the parable of the Good Samaritan as a model of care for all (Ferngren 1992, pp. 3, 13–14). Indeed, caring took precedence over curing and the practical expression of agape or caritas—“a self-giving love of one’s fellow human beings which reflected the love of God as revealed in the death of Christ for the redemption of the world” (Ferngren 1992, pp. 3, 13)—did not wane when traditional medical interventions failed.

According to medical historians Gary Ferngren and Henry Sigerist, one of Christianity’s hallmark contributions to healthcare was in the revolutionary way through which it approached the sick person (Christian or not) as one in a preferential position of sorts (Ferngren 1992, pp. 13–14). As an example, Ferngren makes reference to a letter in which Dionysius—the bishop of Alexandria in the third century—reported on the difference between the pagans who, during a plague, abandoned their sick out of fear of contamination and the Christians who organized, on a community-wide basis, care for all (Christian and pagan alike) (Ferngren 1992, p. 14, note 75). Although this record undoubtedly discloses an “us” versus “them” dichotomy that seeks to champion the moral life of one community over another, it is true that the church’s philanthropic activities were far-reaching and extended beyond those who were sick to include care for widows and orphans, visiting prisoners, and showing hospitality to pilgrims and travelers (Ferngren 1992, p. 14, note 78).2 In this paper, I argue that this expanded vision of the Christian healing ministry was further reflected in the increasing dedication of the laity to the opera misericordiae (the works of mercy), especially in the high and late Middle Ages (Botana 2011, pp. 5–6), with the philanthropic outreach of Santa Maria della Scala as a case in point. In particular, I will make reference to the mid-fifteenth century fresco cycle by Domenico di Bartolo in the Pellegrinaio that bears witness to the hospital’s celebrated functions and speaks to how and by whom these were carried out.

2. Hospitals and Hospitality

The Church’s uniquely congregational and organized approach to care for the sick, and its preferential option for the poor in the first centuries, would lead to the creation of Christian hospitals, which were charitable institutions open to the public (Ferngren 2014, p. 205). The first of these—established by bishops, monastics, laymen, and laywomen (Fabiola in Rome, for instance)—provided care for the poor, especially those with terminal conditions, “who were prohibited from seeking admittance to the [healing] temples of Asclepius, since death within a temple precinct polluted the sacred space” (Ferngren 2014, p. 92).

In the Middle Ages, the Church continued to be committed to the care of the sick and the poor, and people sought healing services from the Church because of the prominent belief that “God healed sometimes through natural means and sometimes by religious means” (Ferngren 2014, pp. 96–97). Medicine and religious healing existed hand in hand, but the source of said healing was understood to be one and the same: God. In this spirit, the Roman senator Cassiodorus advised monastic caregivers to “learn, therefore, the properties of herbs and perform the compounding of drugs punctiliously; but do not place your hope in herbs and do not trust health to human counsels. For although the art of medicine is found to be established by the Lord, he who without doubt grants life to men makes them sound” (Ferngren 2014, pp. 98–99). Ultimately, as agents of God’s healing, caregivers were to be assiduous, well trained, and competent.

Hospitals in the Middle Ages until the mid-nineteenth century remained “what they had been intended to be in the beginning, institutions for the indigent” (Ferngren 2014, p. 205). That is, they were not meant for those who could afford medical care (such persons often received services in their own homes) but were mostly for the poor who had chronic conditions and were primarily palliative in function, at least until about the eleventh century (Ferngren 2014, p. 105). Indeed, as Saint Benedict makes plain in his Rule, “our very awe of the rich guarantees them special respect” of a kind that is not known by the poor (Benedict 1981, chap. 53). Minimal care, including the provision of food and shelter, which the poor had limited access to, was curative for some (Ferngren 2014, pp. 105–6). Attention was given to the patient as more than just a collection of ailments but as a composite of body and soul. As such, psalmody and music also had restorative value and a role to play in the hospitals of the Latin West (Ferngren 2014, p. 106).

The shared etymology of “hospital” and “hospitality”—words that carry a similar, though oft forgotten, sense of sacred ministry—is not lost on the reader here. The Latin hospes can be translated as “friend” and “stranger” as well as “host” and “guest”. Herein lies the famous Benedictine maxim of hospitality, hospes venit, Christus venit, which signals the host to receive the guest as if Christ himself had come knocking (Benedict 1981, chap. 53). This mandate to welcome the other is found in multiple Biblical texts, including Paul’s letter to the Hebrews, wherein he instructs the faithful to “not neglect to show hospitality to strangers, for by doing that some have entertained angels without knowing it” (Heb. 13.2; Gen. 18; Mt 25.35-46). A number of hospitals, such as the Hôtel Dieu in Paris, drew inspiration from this adage and made it their own (Ferngren 2014, p. 106).

3. Charity and the Works of Mercy

At the close of the Gospel of Matthew, immediately preceding the Passion, Jesus gives one final teaching. In it, he makes plain that caring for others in need, a living out of the commandment to love one’s neighbor (Mt 22.39), is the criterion by which people will be judged at the end of time. Jesus specifically mentions feeding the hungry, giving drink to those who thirst, welcoming strangers, clothing the naked, caring for the sick, and visiting prisoners as the actions of the saved who will inherit eternal life (Mt 25.31-46). These six—to which was added the burying of the dead (derived from Tobit 1.16-22) by the end of the twelfth century (Botana 2011, p. 2)—would become known as the corporal works of mercy. This essence of faith, as it were, is echoed in the Letter of James, wherein the practice of charity is considered to be integral to the author’s understanding of genuine religion: “religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world” (1.27) (Viviano 1990, p. 669; Leahy 1990, pp. 911–12). Indeed, as art historian Federico Botana suggests, “in the Middle Ages, as today, charitable initiatives met real needs, but at the same time they were a matter of religion, and thus assisting the destitute was also a form of ritual” (Botana 2011, p. 1).

These acts of charity listed in the Gospel of Matthew were first formally and collectively called the opera misericordiae—the works of mercy—in the Glossa Ordinaria, which was the most extensively used edition of the Bible (with rich commentary) from the late Middle Ages up to the sixteenth century, even though the text was already established by 1140 (McDermott 2013, p. 424). It enjoyed wide distribution in European libraries and monasteries; Thomas Aquinas, Bonaventure, and Martin Luther, among others, made frequent use of the Gloss, which was recognized as “the foremost vehicle for medieval exegesis” (McDermott 2013, p. 424). The seven works of mercy found a prominent place in catechetical programs for the laity at least by the late thirteen century alongside the Creed, the Decalogue, the Great Commandment, the virtues and vices, and the sacraments to provide for a well-rounded knowledge base of Christian faith and practice (Duffy 1992, pp. 53–55). The emphasis here on the Christian moral tradition was, in part, linked to a new religious obligation, i.e., that of annual confession, which was put forward by the Fourth Lateran Council in 1215 (Duffy 1992, pp. 54–55). As a result, the works of mercy became a focal point for a proper examination of conscience that one was to undertake in preparation for the sacrament of penance, and so there was a proliferation of teaching and preaching on the works, especially by friars (Botana 2011, pp. 6–7). Botana reports that artistic representations of the works of mercy, which was an important way through which to teach the laity how to live charitably, blossomed in the Middle Ages, with imagery found in Italy, Catalonia, Basel, Slovakia, Transylvania, Norfolk, and Suffolk (Botana 2011, p. 8; Davis 2014, p. 943).

Thomas Aquinas, in his Summa Theologiae, proclaimed that “the sum total of the Christian religion consists in mercy, as regards external works” (2a2ae Q. 30, art. 4, resp. ad obj. 2). According to Aquinas, all human bodily needs can be reduced to the opera misericordiae, “for blindness and lameness are kinds of sickness, so that to lead the blind, and to support the lame, come to the same as visiting the sick. In like manner to assist a man against any distress that is due to an extrinsic cause comes to the same as the ransom of captives” (2a2ae Q. 32, art. 2, resp. ad obj. 2.). Healing, then, as a response to the suffering body in a condition of need, went beyond the call to care for the sick. In many ways, the healing ministry was intimately tied to the Church’s philanthropy, to its love for the poor, and to its commitment to good deeds writ large. In Matthew’s version of the Beatitudes, for instance, the “poor”, the “mourners”, and the “hungry” refer to the same people, who—like the sick—ultimately belong to the one communion of those in need of God’s salvation (Viviano 1990, p. 640). In other words, poverty, mourning, hunger, oppression, illness, and death are signs of humankind’s shared and inherited condition of frailty that ought to evoke, as Jesus’ aforementioned lesson on judgment makes plain, compassion for all those in need (Catechism of the Catholic Church, n. 2444; 2448). “Truly I tell you”, he says after listing the saving actions (of feeding the hungry, welcoming the stranger, etc.), “just as you did it to one of the least of these my brothers, you did it to me” (Mt 25.40).

There is debate in Biblical scholarship as to whether the reference here to “my brothers” intended to limit the scope of concern to the Christian community alone. Interestingly, this same verse is repeated again in the text moments later (Mt 25.45), but the reference to “my brothers” is left out altogether. The late New Testament scholar Benedict Viviano is convinced that the reach of the mandate to care for others is best understood in the Gospel of Matthew in its broadest sense, seeing “any human being as the object of ethical duty” (Viviano 1990, p. 669). This is in line with theologian Mitchell Reddish’s reading of Matthew as having clear hints of a “more inclusive spirit, ‘good news’ that applies to Jew and gentile alike” (Reddish 1997, p. 128). According to Reddish, restrictions of Christ’s ministry to certain groups, which are mentioned in the Gospel, are thought by Matthew to be only temporary: “the post-resurrection task of the disciples includes proclamation to all people” (Reddish 1997, p. 128).

Although healing and poverty, for instance, may appear to be disparate categories, Jesus’ healing ministry often involved those who were thought to be poor and deprived in some significant way and, consequently, were considered social outcasts: the widow, the foreigner, the orphan, the afflicted (Lk 7.11-17; Mk 5.25-34; Lk 10.25-37; Lk 17.11-19; Mt 15.21-28). In the Gospels, Jesus is much less interested in the nature of the illness in question and in curing than he is in healing as a way to restore social and personal meaning (Labrecque 2015). This expansion of the scope of healing, beyond a mere tending to the physical ailments of the body, can also be seen in the descriptions of categories of poverty in late medieval and early modern Europe. Here, as John Henderson reports in his Piety and Charity in Late Medieval Florence, the category of “the poor”, to which relief was directed, simultaneously included the elderly, the chronically ill, those who suddenly found themselves struggling to reach a level of minimum subsistence due to, say, an outbreak of epidemic disease, as well as those struggling in “the most potentially vulnerable phases of the life-cycle” (for example, the abandonment of children, the loss of employment, and the challenge of supporting a large family) (Henderson 1994, pp. 245–46). As the historian Charles de la Roncière made plain, the word “poor” was used rather generically by Florentines in the late-thirteenth and early-fourteenth centuries (Henderson 1994, p. 245).

Furthermore, the healing effects of these works were not limited to the intended recipients. As Adam J. Davis and Abigail Firey have discussed, the Church Fathers “popularized the notion that almsgiving had the capacity to erase sin and deliver the almsgiver from death, and this idea of redemptive almsgiving remained a central force underlying charity during the medieval period and beyond” (Davis 2014, p. 936; Firey 1998). Therefore, the practice of the opera misericordiae brought about mutual healing. Furthermore, the medievalist André Vauchez showed that charity, which was becoming a key feature of lay spirituality, was clearly linked to sanctity and that devotion to charitable acts became the mark of a “new category of saint” (Davis 2014, p. 942; Vauchez 1975, 1981).

This commitment to the works of mercy became increasingly important among the laity, particularly in the high and late Middle Ages (Botana 2011, pp. 5–6). A growing number of lay penitents joined confraternities devoted to the practice of the opera misericordiae and would go on to found establishments that broadened the healing ministry for the sick to include provisions for pilgrims, members of religious orders, and the destitute (Botana 2011, pp. 5–6; Henderson 1994); that is, while we traditionally identify seven corporal works of mercy, the vision of what could be counted among these charitable works was extended to a variety of good deeds, such as caring for orphans and transporting the sick (Botana 2011, p. 11).

I turn now to the Ospedale di Santa Maria della Scala in Siena as an example of a place that brings all of this to the fore, integrating the works of mercy into a comprehensive understanding of the Christian imperative to heal.

4. The Founding of Santa Maria della Scala

Santa Maria della Scala in Siena—arguably one of the oldest surviving hospitals in the world—opened its doors to pilgrims, travelers, the sick, the poor, and the gittati3 for almost a thousand years (1090–1990CE), embracing the traditional motto of hospitality described above. Called “Holy Mary of the Staircase”, its entrance was purposely positioned in line with the steps that lead to the great doors of the Cathedral of Siena. One of the first examples in Europe of a xenodochium (Toti 2003, p. 9), Santa Maria della Scala was located along an ancient and important pilgrimage route, the Via Francigena, which ran from Canterbury to Rome and, thus, was a major road passing through England, France, Switzerland, and Italy. Sometimes used as a generic reference to a charitable institution, the word “xenodochium” was, technically, reserved for a place that received xenoi (strangers or foreigners), such as pilgrims, especially as guests (Dey 2008, p. 403). In the fourth century, the emperor Julius ordered the high priest of Galatia to establish xenodochia in every city to provide pagans in need with the same kinds of services that Christians were already offering to others—who would then subsequently go on to join the Church in numbers (Dey 2008, p. 403).

It has been argued that xenodochia did not outright disappear over time, but steadily evolved into “hospitalia”, particularly by the high Middle Ages, as “places where the sick went to be cured, albeit often in the company of healthy beggars who continued to receive other sorts of assistance there” (Dey 2008, p. 410). This seems to have been the case with Santa Maria della Scala. According to legend, it was founded by a lay cobbler named Sorore in the ninth century (Toti 2003, p. 9; Hook 1979, p. 145). At first, he began lodging pilgrims who came through Siena on the way to Rome; then, he started mending their shoes; and, eventually, his scope of care extended to nursing those who were ill (Hook 1979, p. 145). He would go on to establish the order of hospital friars to assure that this ministry continued after his death (Hook 1979, p. 145). Therefore, what was once a xenodochium gradually transformed into a hospital as different services were added to the roster. Historians confirm that, in the eleventh and twelfth centuries, there was no clear demarcation in terms of Santa Maria della Scala’s charitable functions as the need for food, shelter, clothing, and medical care was common to all who came to the hospital (Orlandini 2002, pp. 29–30). As the historian Alessandro Orlandini describes, “children, for example, lived together with the adults, and the sick were not sheltered in separate areas and did not receive particular treatments” (Orlandini 2002, p. 30). It was only by the thirteenth century that we see the emergence of specific and distinct jurisdictions regarding treatment and organization of the hospital’s space (Orlandini 2002, p. 30).

Most historians point to the record of a deed of gift dated 1090 and attribute the foundation of Santa Maria della Scala to the cathedral canons: who were required to give part of their revenue to relief of the poor (Toti 2003, p. 9; Hook 1979, p. 146). After 1195, the running of the hospital passed from the hands of the cathedral to friars, called oblates, often laypersons who, without making a formal profession of solemn vows in a monastic community, nevertheless left behind their lives of comfort to serve others in the way of a particular Order (Toti 2003, p. 9). The friars, by that time, greatly outnumbered the clergy in carrying out the everyday functions of Santa Maria della Scala, and so they petitioned for ownership of the hospital (Orlandini 2002, p. 23).

The oblates living at Santa Maria della Scala wore habits, were prohibited from marrying, participated in communal prayer, had to avoid familiarity with patients, and promised “never to take action” to recover their donated possessions (Toti 2003, p. 42). Up until the fifteenth century, they elected a rector who headed the establishment and who was required to donate all of his assets to the hospital (Toti 2003, p. 9). It was perhaps not peculiar, then, that most rectors came from some of the wealthiest noble families in Siena. This notably increased the patrimony of Santa Maria della Scala, along with a considerable number of bequests, alms, and land donations (the Commune canceled the taxes of those who donated real estate) (Orlandini 2002, p. 26) pouring into the hospital, making it an important—if not the most important—economic and agricultural center of Siena. In 1460, Pope Pius II issued a bull that lifted the rector’s obligation to swear an oath to the canons of the cathedral, and reaffirmed the Commune, or municipality, of Siena’s full right of election; this also made the rector a city officer and councilor (Toti 2003, p. 9). But even before then, as means to stop a rising conflict between clerics and the increasing number of lay caregivers—tensions that would ultimately never subside—over the administration of one of the wealthiest establishments in Siena, Pope Celestine III, in 1193, released a papal bull that removed the hospital from the cathedral’s jurisdiction and made it an independent lay organization (Baron 1990, p. 1449).

5. The Pellegrinaio and the Works of Mercy

Many of the great Sienese artists (Simone Martini, Pietro and Ambrogio Lorenzetti, and Bartolomeo Bulgarini) were commissioned to beautify the hospital, making it also one of the most important artistic hubs in the area (Toti 2003, p. 11).4 With the prestige and power of Santa Maria della Scala on the rise, two master painters, in particular, were invited to capture—with the budding Renaissance styles of the day—the life, history, and functions of the hospital. It is primarily the works of Lorenzo Vecchietta (1410–1480) and Domenico di Bartolo (c. 1400/1404–1445/1447) that adorn the Pellegrinaio, the ward specifically dedicated to pilgrims, travelers, and the ill (Toti 2003, p. 29).5

The rector, Giovanni Buzzichelli, who commissioned the artwork in the Pellegrinaio, was deeply devout but also attracted to the contributions of humanism. He first ordered the ceilings of the space to bear frescoes of a religious nature: saints and familiar figures from the Old Testament were painted there (Orlandini 2002, pp. 13–14). For the walls, the rector originally wanted to highlight the virtue of obedience to God and so chose the story of the biblical Tobias, but, as the work progressed, he had a change of heart and commanded instead that the walls underline the humanitarian activities of the hospital and the ultimate commitment to the common good that public institutes, such as said hospital, were called to pursue (Orlandini 2002, pp. 14–16).

Even though there was no explicit mandate to portray the opera misericordiae there, the hospital’s major functions were unquestionably in line with them, and so the cycle of frescoes very much appeared to be a representation of the steadfast devotion of both the religious and laypersons to the works of mercy. For centuries, the two groups clashed over the administration of the hospital, but they nonetheless were joined in a common pledge to the disposable of society who, in a “throwaway” culture whose historical roots run deep, were often seen as replaceable, transient, or easily cast aside. In the end, Buzzichelli was of the mind that the decision to go with a depiction of what seemed to be the “secular” activities of everyday life at Santa Maria della Scala—in place of the biblical themes he had originally envisaged—was a fitting compromise given that Christian charity clearly remained front and center (Orlandini 2002, p. 16).

The first of the frescoes, by Lorenzo Vecchietta, called Episodes from the Life of the Blessed Sorore (ca. 1441), brings to the forefront the idea that the hospital was established by an inspired layperson and shows that the hospital was, from its inception, concerned about the marginalized. In the center of the painting, we see Sorore kneeling before the bishop and recounting his mother’s prophetic dream in which she saw a ladder reaching up to the Heavens, where the Virgin Mary waited with arms outstretched to receive abandoned children eagerly climbing toward her (Toti 2003, p. 32). Elsewhere, we see the mythical founder being entrusted with his first foundling, or gettatello, as well as another child tugging on the bishop’s alb, while the bishop, in turn, offers a small sum to Sorore to take care of him.

This hallmark piece highlighted an important part of the hospital’s charitable function. Indeed, the number of children left in the care of Santa Maria della Scala was not negligible; one record indicates that, in 1298, there were more than 300 boys and girls at the hospital (Baron 1990, p. 1449). These little ones were typically left at night in the hospital square or, from the fourteenth century, in a stone basin near the hospital’s entrance, which was made for this purpose (Toti 2003, p. 32). Many bore some token of identification (sometimes notes explaining the reason for their abandonment) so that the parents did not lose hope in the possibility that they could be reunited if economic or social conditions allowed for it, although this did not happen all that frequently (Toti 2003, p. 32). Like the oblates and others who worked at the hospital, the gettatelli wore a uniform bearing the insignia of Santa Maria della Scala: a yellow ladder. They were sheltered, fed, educated, and received well-organized care. Girls were provided with dowries and learned weaving and domestic work, and boys were committed to learning trades, often of their choosing, and would go on to leave the hospital at about twenty years old or so with whatever earnings that were kept for them in a special account from work already done to that point and/or with a small sum, clothing, and certain furnishings provided by the hospital itself (Toti 2003, p. 32; Baron 1990, p. 1449).6

Other frescoes depict the Almsgiving of the Bishop (di Bartolo, 1442–1443), the Investiture of a Rector (Priamo della Quercia, 1442), and another marking the 1193 bill of Pope Celestine III Conceding Privileges of Autonomy to the Hospital (di Bartolo, 1442), which ostensibly settled discord between the cathedral and the friars over the governance of Santa Maria della Scala (Toti 2003, p. 37). There is yet another pair of frescoes, created in the second half of the sixteenth century, showing payment of the wet nurses of the gettatelli (Orlandini 2002, p. 16). Interestingly, the statutes of the hospital (sanctioned in the early 1300s) make some mention of needing to be on guard of the “strategic” mother who would leave her child on the hospital’s doorstep only to arrange to be employed as a wet nurse for said child, therefore being paid to feed her own (Orlandini 2002, p. 38).

But the most well known (Toti 2003, p. 38; Botana 2011, pp. 133–4) of the frescoes is Domenico di Bartolo’s Care and Healing of the Sick (1440–1441), which captures the busyness of the hospital in full function. If any serve as the promotional manifesto of the hospital, it is this one (Toti 2003, p. 38). The rector, the oblates, a surgeon, and the patient are front and center. To the left, an assistant carefully, and tenderly, helps a clearly distraught patient to lie down or sit up; the embrace between the two is particularly important (Baron 1990, p. 1450). In the background, two doctors consult each other over a urine sample in a glass matula; urinoscopy was a mainstay diagnostic practice in the Middle Ages (Bynum and Bynum 2016, p. 638). On the right, a rather corpulent monk (a not-so-subtle commentary by the painter perhaps) firmly encourages confession before the start of whatever physical healing activities are required (Toti 2003, p. 38). The statutes of the hospital describe that patients admitted to Santa Maria della Scala were first washed, their personal effects stored, were dressed, and then put to bed to wait for the physician (Toti 2003, p. 38). As the statutes of 1318 indicate, “in aid of the infirm […] this Hospital must have at its expense two doctors, that is one physician and the other surgeon and one spezieri (pharmacist), who are friars of said Hospital […] and if not they must have […] appropriate salaries, so that they doctor gladly and graciously […]” (Orlandini 2002, pp. 34–35). This was a truly innovative aspect of medical care at Santa Maria della Scala.

At the center of the painting, a young man with a leg wound is being washed by an attendant before the surgeon gets to work. The guest is almost naked; his body language gives us pause. His crossed arms are a recognizable gesture of verecundia (from the Latin verecundus for the “feeling of shame”), which Aquinas identified as a prerequisite for the virtue of temperance (2a2ae Q. 143, art. 1, resp.). Here, the verecundus person demonstrates a kind of “strategic fear” that gauges his standing relative to the other person and, accordingly, shapes his behavior in any given social interaction, all the while affirming the social bond that exists between the self and other (Kaster 2005, p. 15). This is opposed to the “shameless” or “underserving” poor to whom I will refer later in the text.

Admittedly, this gesture may have been familiar to observers because of its place in liturgical practice (Wilberding 1989, p. 4). As art historian Erick Wilberding explains, the gesture of crossing one’s arms over the chest can be seen in a number of depictions of the Annunciation in the fourteenth and fifteenth centuries, connoting Mary’s humility and acquiescence to divine will upon learning from the archangel Gabriel that she would conceive and give birth to the Son of the Most High (Wilberding 1989, p. 4; Lk 1.26-38). This gesture—linked to the suffering of Jesus on the Cross—was included in the rubrics of the Mass (prior to the revisions of the Council of Trent in the sixteenth century) as an expression, shown after the consecration, of submission and a plea for grace (Wilberding 1989, pp. 1–3). In secular artistic renderings, the gesture was often meant to suggest shamefacedness or submission to another, but its theological references were not lost on those who knew the Mass (Wilberding 1989, p. 4).

Behind the wounded verecundus person stands another attendant with a blanket at the ready. On the surface, the painting reveals activity that was commonplace at the hospital. However, the biblical imagery associated with the act of washing here is unambiguous; in many ways, it is the ultimate rendering of Christian hospitality. While the patient’s thigh is bleeding heavily, the action that is given primacy by the artist is not the binding of, or tending to, the wound (at least not primarily), but to the washing of the guest’s feet.

Although the antiseptic benefits of washing the body were already known by the time Domenico di Bartolo created this piece (Botana 2011, p. 134), the action clearly recalls the central scene in John’s account of the Last Supper (Jn 13.1-20), in which Jesus kneels, with a basin filled with water, to wash the feet of his disciples. As it is usually the master’s servants—and not the master himself—who wash the feet of the guests, the image is meant to underscore the shared humility of the verecundus man being tended to and the caregiving friar. Jesus’ call to serve, which is rooted foremost in love for the other, is being modeled in the relationship portrayed here (Reddish 1997, p. 206).

It is immediately after Jesus washes his disciples’ feet that he delivers his new commandment, which encapsulates the whole of Christian moral theology: “Just as I have loved you, you also should love one another. By this everyone will know that you are my disciples, if you have love for one another” (Jn 13.34-35). Therefore, loving service becomes the foundation of Christian identity. Healing, then, as we see in the fresco, is more than technique and bandages, but is to start with the recognition of the image of God in the other: hospes venit, Christus venit.

In another fresco, di Bartolo brings to light the distribution of alms. This is mostly in the form of clothing and bread; full loaves are given to families and the fragments of bread leftover from hospital use are apportioned among the poor, mendicants, and pilgrims. To note, also, is a record of a double portion of alms that was to be allotted to pregnant women (Baron 1990, p. 1450). This depicts yet another important element of the charitable mission of the hospital. In the center of this painting, the nakedness of the main figure is an obvious emblem of need. He is being cloaked by a hospital attendant, a clear commitment to yet another of the corporal works of mercy.7 Elsewhere, we see an oblate removing his hat in the presence of some esteemed figure (perhaps a benefactor or at least a potential one) and, beside the man being dressed, we see a group of people—the ill, the hungry, the widow, the child, and the poor—being served in various ways by the hospital staff. One can just make out that the bread that is being offered by a friar to a woman and child bears the insignia of the hospital, a peculiar means of branding or publicity (Orlandini 2002, p. 53).

The last of the large frescoes in the Pellegrinaio is di Bartolo’s Welcoming, Education and Matrimony of a Daughter of the Hospital (1441–1442). Here, we see, again, hospitality in action, but this time the narrative is told from start to finish. In the center of the painting is the pila, or raised basin, which stood outside of Santa Maria della Scala for parents to leave their children in if they could no longer care for them. In the image, the rector has just removed a recently laid newborn from it (Orlandini 2002, p. 54). He entrusts the newborn to wet nurses. On the left in the background, we can see the wet nurses taking care of the children, washing and rocking babies, baking cookies, and keeping the fire going. In the foreground, the children have been weaned and have now moved on to play, to formal education, and, as our eyes move across the fresco, eventually to marriage. It is meaningful that, I think, the artist painted the marriage scene right beside the pila. The daughter of the hospital, as she is called in order to revoke her former status as one who was “cast aside”, is portrayed in refined dress. The rector, in very much a parental role, holds her dowry in one hand and supports her wrist with the other as the groom slips a ring onto her finger (Orlandini 2002, pp. 54–55). The narrative reveals that, while the young woman may have started out as a getattella, her time at the hospital brought her certain privilege and dignity.

The final scene of the frescoes in the cycle is di Bartolo’s Paupers’ Supper (1443–1444) or Banquet of the Poor, highlighting the dinners that were offered to the poor three times a week (Orlandini 2002, p. 55).

6. Conclusions

The art, the history, and the statutes of Santa Maria della Scala reveal that this was not a place that provided rudimentary services and accommodations. The “grooms and servants to serve the infirm and the poor”, the statutes instruct, must “be the best and the most useful and the most merciful and benign, that can be had; in order that to the infirm of said Hospital be done and given the necessary services by the said grooms and servants in praise of God, and in honor of their house, and to the merit of those persons” (statute 1318, chap. XVII; Orlandini 2002, p. 31). As mentioned previously, the charitable activities of the hospital were also carried out by a number of affiliated confraternities—lay communities given to the Church’s works of mercy—which gathered in the underground chambers of Santa Maria della Scala, namely those of Saint Catherine of the Night, Saint Mary Below the Vaults (both are reputedly still active), and St Jerome (Toti 2003, p. 45; Hook 1979; Henderson 1994).

Some chroniclers of the hospital have noted that, leading up to and by the sixteenth century, a social re-visioning of the poor was unraveling. The poor increasingly came to be thought of (not in one fell swoop to be sure) as dangerous social subjects in need of control if not outright ostracizing (Orlandini 2002, p. 61). Adam Davis describes the fourteenth and fifteenth centuries, marked by famine and plague, as having been a period of high mortality, warfare, and economic decline; accordingly, images of the poor were ever more negative, and there was growing suspicion about the “shameful”, “false”, or “undeserving” poor. As a result, charity became progressively more discriminate (Davis 2014, p. 938).8 Santa Maria della Scala was not entirely immune to this. In the shadow of recurring financial crises and various changes in regulations, care for the poor gradually diminished afterward, but the hospital continued to dedicate its services to the ill and to abandoned children and to provide shelter for travelers over the next few centuries (Orlandini 2002, pp. 61–62). At the same time, and perhaps because of this shift, voices in the Church for the poor rose up. Saint Vincent de Paul (1581–1660), for instance, in his contact with the Sisters of Charity, famously said “Let us acknowledge before God that (the poor) are our lords and masters and that we are unworthy of rendering them our little services” (de Paul and Coste 2008, p. 349). Indeed, this echoes the philosophy of Santa Maria della Scala in its prime.

An ideal European model of caregiving over the course of its eventful thousand-year history (Baron 1990, pp. 1449–51), the xenodochium-turned-hospital embraced its mission of hospitality by expanding its healing ministry beyond the treatment of illness. Santa Maria della Scala’s everyday functions, as Domenico di Bartolo captured with such beauty and realism, were deeply rooted, as we have seen, in the opera misericordiae that would come to assume an important place in the spirituality and practice of Christian laypersons everywhere. For this hospital, the Christian healing imperative came to mean caring not only for the sick, but also for the poor, the weary, the disenfranchised, the hungry, the naked, and the “cast aside”.