Lucy C. Barnhouse’s Hospitals in Communities of the Late Medieval Rhineland: Houses of God, Places for the Sick examines the development of several types of hospitals in the Rhineland in the later Middle Ages arguing that while scholarship on medieval hospitals has expanded recently, there is still significant work to be done. Barnhouse’s answer to the existing lacuna is to a focus on hospital religious legal status to better fill the gap. According to Barnhouse, legal status affected hospital organization and its external relationships, and as such, legal status was debated and used by hospital communities, ecclesiastical authorities, civic figures, and the laity to justify and advance the institutions (16). By using legal status as the lens through which to view large, small, rural, urban, and leper hospitals in the archdiocese of Mainz, Barnhouse identifies “patterns of institutional development” (211) that denote medieval hospitals as religious institutions situated intimately in the economic and religious networks of Europe.

According to Barnhouse, hospitals were affected by the development of canon law. They were certainly considered within promulgations of it—as early as Third Lateran Council and culminating in the Council of Vienne. As a result, legal religious status became important for hospitals, especially during the thirteenth and fourteenth centuries, and methods for obtaining such status came to be better defined.

Using council legislation, local charters, and even papal privileges, Barnhouse demonstrates that hospitals were “agents” of law and of the legal process (37). Tantamount to this argument is consideration of the hospital as a religious institution: it did not differ largely from other religious institutions, e.g. monasteries, with the exception of their explicit mission to care for the sick-poor.

Chapter two provides an examination of hospitals in the archdiocese of Mainz—center of ecclesiastical, religious, and synodal activity (45)—and of civic involvement in hospital administration; it was in Rhineland that hospitals negotiated their religious status to achieve institutional independence (63).

The goal in this chapter is to shift the traditional argument away from invocations of lay piety as an impetus for hospital foundation, which Barnhouse defines as “simplified narratives of lay elites asserting their newfound social power against ecclesiastical control” (64). Barnhouse wishes to consider hospitals not “as pawns of the dominant political interests” (65) but as attempting “to protect the privileges of the hospital as a religious institution” (66-67). Hospitals treated the ill, performed liturgies, and administered the sacraments (87), and these activities often brought them into conflict with other religious institutions providing similar services. Legitimate legal and religious status were thus necessary in hospital development and in continued existence. In turn, legal and religious status entrenched the hospital in the community. Barnhouse posits that the role of hospital sisters (chapter three), for example, was central to a sense of communal purpose for such institutions. Such evidence can be found in the sisters who were forced to leave Mainz's oldest hospital in 1259: the women forged institutional identity for communal survival (101) by interacting with the laity and civic and ecclesiastical authorities to form relationships that in turn assured their religious status (123).

The next chapters narrow their focus: chapter four to medieval leper hospitals, which were affected primarily by the law that defined them, and chapter five to small hospitals in Rhineland, both inside and outside of city walls. Traditionally, the formation of leprosaria has been seen as an attempt to segregate the sick from the healthy. Barnhouse, however, argues that hospitals for the leprous in Mainz, Speyer, and Strasbourg were integrated and visible. In addition, and in the face of the traditional argument that medieval attitudes about lepers led to a proliferation of the institutions, Barnhouse offers an alternative approach: legal status influenced social, religious, and economic networks (150) and these same networks helped to maintain legal status of leprosaria. As for rural hospitals, Barnhouse argues that they too were integrated into their communities; functioned similarly; were affected by intervention efforts of the bishops to reform (religious status being the impetus—legal status might lead to parochial or civic conflict); and had ties to neighbors and other institutions.

The final chapter turns to neighbors and donors and maintains that hospitals were firmly situated in networks and within personal relationships (177): the networks of Mainz's hospitals were often multilayered and intimate, multigeneration, and multifaceted. Yet, while imbedded in communities, hospitals also maintained a distinct identity made clear by growing definitions of legal and religious status (209). Barnhouse promptly concludes.

The strengths of this book are many, which include a passionately-argued monograph that is clearly well researched. Readers will appreciate the author's desire to create a new narrative regarding hospitals and the many attempts to shift historiographical arguments, such as in the chapter on leper hospitals.

Indeed, Barnhouse convincingly demonstrates that leper care was not segregated and not determined by medieval fear, but rather that care was central, integrated, and shaped by legal definitions and legal status. Readers can also appreciate some of the highlights that come out of this work about hospitals in general: relationships to hospitals were multigenerational and multifaceted (33).

Barnhouse’s plea to see the hospital as a religious institution is not unreasonable. It is perfectly justified. Barnhouse’s survey of the variety of means by which hospitals sought such identity, shaped such identity, and worked within multiple networks to preserve this identity, is perceptive. There are some arguments, however, that merit tempering. Barnhouse claims to move away from “simplified narratives of lay elites asserting their newfound social power against ecclesiastical control” (64). Barnhouse also maintains that “struggles between ecclesiastical and civic authorities have often been taken as an explanation for conflictions of hospital administration” (19). Rather than taking such a hard line against these ideas, this book would benefit from a complimentary, perhaps parallel, view that touts hospitals as actors in their own right rather than as passive players. Nothing is ever that black and white, especially in a society where religion was inextricably linked to every other aspect of life.