Healing in Christian Liturgy in Late Antique Egypt: Sources and Perspectives

Introduction

Christian communities in fourth-century Egypt show “a strong and consistent interest in matters of illness, health, and healing”,^[1] as R.J.S. Barrett-Lennard concluded from the prayer book attributed to Sarapion of Thmuis. Indeed, late antique sources from Egypt are replete with testimonies to the importance of healing among Christians and the various healing methods to which they could recur, including charismatic healing by holy men, miraculous recoveries at the tomb of martyrs and in incubation shrines, amulets prepared by monks and the clergy, and substances and blessings administered in the framework of the liturgy. Of all these practices Christians had on offer for the afflicted, this paper will explore the last one, prayers and gestures performed and substances consecrated and distributed in a liturgical context, i. e. in the context of the regular prayer occasions of the church (Eucharist, liturgy of the hours, baptismal rites), that were intended to induce healing in the suffering members of the church with divine help, as well as some related practices. Though a modern reader may find my approach and my wording unusual, here I will discuss these rites as ‘therapeutic’ practices, since this is how they were perceived by contemporaries. In Late Antiquity, such rites were performed in order to (and believed to be able to) bring relief, and they were recommended by church authorities as a therapeutic alternative in the ‘market of healing’.^[2]

This paper will first and foremost present a survey of liturgical prayers and gestures performed for the benefit of the sick in late antique Egypt. Such an overview is a desideratum in liturgical scholarship, which has chiefly discussed Egyptian evidence for the anointing of the sick in the context of the Christian oikumene^[3] but neglected other practices such as the intercessions for the sick and the prayers for the laying on of hands; moreover, new evidence has emerged since the last studies. Due to the diversity of early liturgical practices, such a survey must remain close to the sources,^[4] and statements cannot be generalized for the whole of Egypt. The lacunose and often elliptical nature of the sources present further challenges of interpretation. In spite of these obstacles, from the sources of the fourth and fifth centuries a variety of liturgical prayers and actions benefitting the sick can be deduced, including intercessions, laying on of hands, anointing, and the distribution of oil, bread, or water, many of which disappeared latest by the seventh century.

These practices were all interpersonal therapeutic rituals, enacted in order to bring healing to the afflicted members of the community. As such, they are similar to countless other therapeutic practices, historical and present, that do not include a physiologically effective treatment.^[5] Such practices have been the subject of extensive recent medical and psychological research focusing on the placebo effect. The second objective of my paper is therefore to apply the results from this research on the liturgical healing rites and examine if it can provide useful insights for interpreting late antique liturgy.

Medical and psychological research of the past thirty years has concluded that ‘placebos work’.^[6] In other words, it has recognised a number of interpersonal and contextual stimuli in the framework of both active and inactive therapeutic practices that are capable of eliciting quantifiable changes in the brain with beneficial healing effects.^[7] Most of this research has been clinical and experimental in nature and has focused on the neurobiological processes, devoting less attention to the psychological mechanisms that induce them, or to a complex theory of the placebo effect that integrates cultural aspects or anthropological insight as well.^[8] The two psychological mechanisms that have been best explored are expectations induced through verbal instruction and classical (Pavlovian) conditioning. In the latter case, experimental subjects who had been exposed to active medication replicated the effects of the medicine also after the active substance has been replaced with an inert substance that had corresponding physical characteristics (form, colour, size etc.). There is evidence that classical conditioning is more relevant for unconscious physiological processes such as the hormone system, whereas expectations play a role in the case of conscious processes such as pain reduction. Nevertheless, these two mechanisms seem to interact closely with each other.

Indeed, classical conditioning can be regarded as one of the learning mechanisms on which expectations are based.^[9] Another powerful learning mechanism is personal experience of a treatment’s beneficial effects. It has been shown that the length of exposure to effective treatment is closely connected to the permanence of placebo responses,^[10] while experience of ineffective treatment can reverse previous positive learning effects. Another learning mechanism is social observational learning (i. e., learning about the beneficial effects of the therapy by observing other patients’ relief), which has been demonstrated to produce nearly as strong analgesic effects as first-hand experience.^[11] Finally, learning can happen through verbal suggestion, and not only in the therapeutic situation; previous exposure to such suggestions (e. g. the branding of a drug or communication between the patients) also contributes to raising expectations.^[12] If this information is based on an argument that seems rational in the patient’s system of beliefs and cultural context or is provided by an authoritative person, it has an even more pronounced effect.^[13] Altogether, the role of expectations seems central at least in conscious processes such as pain, as shown by experiments where the patients’ awareness of being given painkillers resulted in a robust placebo response and a reduction in additional painkiller requests compared to the hidden administration of the same dose of painkillers.^[14] Positive expectations are in turn assumed to be responsible for triggering various neurobiological processes by reducing anxiety and/or activating the reward system of the brain.^[15]

Besides learning and expectations, other cognitive processes have also been conjectured to have a role in inducing a placebo response, such as desire for healing or self-reinforcing feedback (a positive loop in which the patient selectively attends to signs of improvement to reinforce the impression that the therapy works).^[16] Moreover, in one of the few attempts to create a coherent explanation for how placebos work, Nicholas Humphrey stressed the central role of hope, generated by beliefs, as the emotional variable that acts on the patient’s immune system.^[17] Others connected placebo with a reduction in negative emotions such as stress and fear and with positive emotional states of the patient.^[18]

The significance of the healer’s role has also been pointed out; a study found that the number of the doctor’s visits was a good predictor of remission in the absence of active treatment.^[19] Other factors of the patient-therapist interaction, such as emphatic listening,^[20] or a clear diagnosis and opportunity for dialogue, have been found important as well.^[21] Furthermore, the healer’s optimism and belief in the success of the therapy apparently also has ‘placebogenic potential’;^[22] in fact, the healer’s conviction seems more important than that of the patient, who does not even have to share her belief system for the therapy to be effective,^[23] a moderate openness to the proposed solutions appears sufficient.^[24] Not only the healer but also significant others (relatives or friends) can contribute to pain reduction by physical contact or by their mere presence.^[25] Finally, the role of the therapeutic ritual as an action loaded with symbolic meaning has also been emphasized.^[26]

As evident from this overview, placebo research is multifaceted and dynamically evolving. Altogether, as of 2020 there are “relatively few comprehensive theories about how beliefs and psychosocial messages are decoded to form a placebo response”,^[27] and none of them has been capable of taking into account all aspects of this complex phenomenon and their relationship to each other. Indeed, it might be futile to try to reduce the placebo effect to one system of mechanisms. Instead, Fabrizio Benedetti, one of the central figures in placebo scholarship, claims that “there are many placebo effects, and many mechanisms can be involved”,^[28] depending on the illness, on the healer, the patient, and their relationship, but also on the cultural context. As meaningful signals presented in a specific context, placebo stimuli are culture-specific.^[29] At the same time, the neurobiological and psychological mechanisms at work seem to be independent of culture. Therefore, in spite of the fundamental differences between late antique and contemporary healthcare, we can look for these psychological mechanisms, such as expectation, learning mechanisms, the role of emotions or of healers also in late antique healing practices and among them in the liturgical rites in particular. Can we catch a glimpse of them at work in the sources? And can we as a consequence suppose that these practices had a potential of beneficial therapeutic effects by eliciting placebo responses? Speculation on these questions will follow the reconstruction of the liturgical rites in each section.

The reconstruction of the rites and their evaluation through the lens of placebo research both face considerable methodological challenges. For the former enterprise, the scarcity and nature of sources create the most serious obstacle. Liturgy was repetitive and self-evident to the participants, who oftentimes recited it by heart. It was performed but rarely discussed, unless sudden changes were introduced or an authority wanted to lay down a series of rules, which may however reflect wishful thinking of the higher clergy rather than actual practice. These sets of rules, the so-called church canons, could travel from one region to another and were transmitted through the centuries with varying degree of adjustment to local practices. Moreover, they stand in a complicated relationship of dependence on each other. Thus, even if the rites and prayers reported by them were once actually performed and did not remain dead letters, deciding when and where they were in use requires source critical speculations.^[30] Liturgical papyri on the other hand, although they testify for what was actually recited and have a relatively reliable date and provenance,^[31] are obscured by fragmentation. Local differences^[32] and the improvisation of prayers up to the fourth century^[33] present additional difficulties. Moreover, one of late antique Egyptian liturgy’s central sources is in the process of being edited: it is the liturgical section of the so-called Aksumite collection, a canonico-liturgical collection preserved in Ethiopic and discovered in 1999,^[34] which goes back to a Greek compilation from late fifth or early sixth-century Alexandria and contains a Euchologion and a baptismal Ritual.^[35] Its liturgical contents can be accessed for the moment through the overview of Alessandro Bausi,^[36] an article by Emmanuel Fritsch,^[37] and a working edition of the Ritual by Bausi.^[38] In addition, liturgical books oftentimes contain only the texts and presuppose that the accompanying actions were obvious for their users, leaving liturgical scholars in the dark concerning a crucial part of any liturgical rite. All these problems set the limits to the reconstruction of the prayers and actions proposed here.

If considerable methodological obstacles impede reconstructing the liturgy itself, these fade in comparison with the hindrances the researcher faces when the participants’ liturgical experience is to be inferred, which is fundamental for a search for the psychological mechanisms of placebo. Assessing the faithful’s experience depends on answering questions such as do the people attend services regularly?^[39] Do they pay attention to what is being said and done?^[40] Do they understand the prayers?^[41] Were they aware of the meaning of the actions? Did the rites elicit emotions from those present? Liturgical sources, which describe or prescribe what is done or should be done in church, contain no reflections on the participation of the congregation. The only exceptions are the mystagogical catecheses, homilies that instruct the newly initiated about the proper participation and the meaning of the liturgical rites. From Egypt only one such text is preserved in Ethiopic, which can be traced back to fifth-century Alexandria,^[42] but it does not discuss practices related to healing. Literary sources provide occasional glimpses of the congregation’s participation and their emotional response. However, without their systematic survey in search for intimations of the congregation’s liturgical experience, what remains is speculation from the liturgical texts themselves on their possible effects on the faithful. Therefore, in order to circumvent the methodological crux, I will look at the potential of these rites to induce effects in audiences who paid attention to them and understood them, acknowledging that this was not always the case.

Moreover, even those afflicted participants who paid attention and understood the rites did not always become placebo responders. In medical experiments and clinical trials placebo response rates depend on various factors, such as on the patient’s optimism,^[43] on culture,^[44] but most significantly on the nature of illness.^[45] Placebos appear to work on illness (i. e. the subjective experience of detriments to health, including symptoms), but not, or only to a very limited extent, on disease (i. e. the biological dysfunctions of the organism).^[46] Consequently, placebo effects are the strongest in the case of diseases that have distressing symptoms and are either subjective, or chronic with a fluctuating course, or have a conspicuous psychological component.^[47] As it is rightfully pointed out by Hedvig von Ehrenheim in this volume, most diseases in Late Antiquity did not fall into this category and could not be cured by a simple activation of placebo mechanisms. However, patients and doctors in Late Antiquity had little understanding of disease and focused on illness, especially on symptoms, which were measured subjectively in most cases. In such a context, if an activated placebo response brought immediate relief from the most distressing symptoms, patients who experienced this and healed naturally from the disease over time could attribute the recovery to the therapy, even though its (or the placebo effect’s) contribution to the healing process was minimal. And in a world where the majority of treatments were essentially inactive, a therapy that had a greater ‘placebogenic’ potential could be seen as more efficacious than the others. In this sense insight from placebo research may contribute to a better understanding of the late antique ‘market of healing’ by pointing out therapies that could have been perceived as ‘working’ best.

Intercessions for the sick

Let us begin our survey of the liturgical prayers and actions benefitting the sick with the most widely attested practice, the intercession for the sick. The special attention that the early Egyptian church paid to the afflicted is nowhere more evident than in the elevated position assigned to this prayer in sequences of intercessions that appear at various parts of the liturgy, most importantly in the pre-anaphoral part of the Eucharistic liturgy and in morning and evening services. In most Christian rites, both present and historical, the Eucharistic service contains a series of intercessions for various members and concerns of the community within the anaphora and at the end of the liturgy of the word (oratio universalis).^[48] These intercessions cover a wide range of topics including the sick. However, whereas in most Christian traditions the sick are but one item in lists of various afflicted members of the church,^[49] in the Egyptian liturgies the sick are commemorated in a separate intercession, which is positioned at the top of intercessory sequences.

In the fourth-century prayer collection attributed to Sarapion, bishop of Thmuis in the Delta,^[50] the “prayer for the sick” (no. 22) is situated at the beginning of a sequence of intercessory prayers, only preceded by the intercession for the catechumens.^[51] The “prayer for the people” (no. 27) of the same collection also contains a request for the sick among various groups, such as those who travel or the poor; among these groups only the sick have an independent intercession of their own, which also indicates their importance.^[52] In the euchologion of the Aksumite collection (fol. 46 vb–47 ra) the prayer for the sick follows the “first prayer of the morning” and opens a sequence of intercessions.^[53] Also in the various medieval redactions of the liturgy of St. Mark this intercession heads the sequence before the anaphora,^[54] and it has the same position among the intercessions of the morning offering of incense of the Coptic rite;^[55] though the extant sources for these two services date from the second millennium, this order of the intercessions probably goes back to Late Antiquity. Placing the intercession for the sick at the front was nonetheless not universal in late antique Egypt. A sequence of intercessions from mid-fourth-century Hermopolis (P. Würzb. 3^[56]) places the prayer for the sick after another for the virgin and married members of the church.

The Eucharistic prayer reserved a similarly distinguished position for remembering the sick. In the traditional anaphora of the Alexandrian church, the anaphora of St. Mark, it is preceded only by the prayer for the peace. This order can already be observed in its earliest extant complete redaction in the Aksumite collection.^[57] Besides the intercessions, the anaphoras occasionally also included a request to God to grant healing through communion with the consecrated bread and wine. Thus Sarapion’s anaphora includes a request that God shall make the consecrated bread and wine into “a medicine of life for the healing of every illness”,^[58] whereas the anaphora of St. Mark lists “healing” (ἴασις) among other, more spiritual benefits of communion.^[59] “Good health” is furthermore one of the promised effects of the “mystery of Christ” (besides joy, blessing, and life) in the mystagogical catechesis.^[60] However, the textual link between communion and bodily healing was weak in the liturgical texts;^[61] indeed, all other Egyptian anaphoras focus exclusively on the spiritual gains from taking the sacrament.

In the various redactions of independent and anaphoral intercessions four different late antique prayers for the sick are preserved. The most widespread is the wording of the tradition of the anaphora of St. Mark.^[62] The late antique evidence for its text is wanting. Apart from the presence of the opening phrase “Having visited the sick of your people, heal them” in the anaphora of St. Mark in the Aksumite collection,^[63] the earliest redactions are found in a tenth-century Greek fragment from Nubia,^[64] in an otherwise unknown Sahidic anaphora in the Great Euchologion of the White Monastery (copied c. 1000),^[65] and in a Sahidic witness to the morning offering of incense, which corresponds to the medieval Greek and Bohairic redactions of the intercession.^[66] Although its exact late antique form(s) cannot be reconstructed, it is likely that much of its wording hails back to late antique Alexandria, as is the case with most ‘Markan’ intercessions. Indeed, it shares phrases with the equally Alexandrian independent intercession for the sick preserved in the Aksumite collection and the Statutes of the Apostles,^[67] in particular the request to “take away the spirit of sickness” and the invocation of God as “Physician of souls and bodies and overseer of all flesh”.

The third late antique intercession for the sick, P. Würzb. 3, is an enumeration of various afflictions, spiritual and bodily, including despair and demonic possession,^[68] that God is asked to remove from the sick. It shares with the Alexandrian prayers the concluding phrase ‘Physician of souls and bodies’. The fourth one, Sarapion’s prayer 22, is a short text invoking God as the creator of soul and body to remove illnesses from the suffering,^[69] which does not have any wording in common with the other three, not even a reference to the demonic causes of disease, which is shared by most liturgical prayers in the context of healing.

Turning to assessing the placebo potential of these prayers, I have to point out in the first place that intercessions did not single out individuals and were not accompanied by a particular ritual action. Instead, they were part of a sequence of various requests of the church, thus the sick listening to them may not have been cognisant that this text is being recited for their personal benefit. In other words, these prayers might not have been conceived of as ‘treatment’, a fact that by itself significantly diminishes or even annuls the potential of any therapy for a placebo effect.^[70] For those who nonetheless related these prayers to their own condition and expected God’s intervention on their basis, the straightforward way in which the texts are phrased could communicate “a confidence about the outcome”^[71] and boost expectations. However, our only interpretation of the liturgy from late antique Egypt, the Alexandrian mystagogical catechesis, does not claim efficacy for eucharistic intercessions. It mentions only the intercessions within the anaphora briefly: “[L]et us then pray our every supplication which is useful to us”,^[72] but it does not suggest that God will fulfil these requests, nor does it mention any preanaphoral sequence of intercessions. The apparent lack of explicit verbal instructions concerning efficacy, either in the texts or in homilies interpreting them, marks a weak potential for these intercessions to create expectations of healing. Moreover, while the repetition of these prayers in every service can create a lasting learning effect,^[73] it can just as well have a detrimental effect on their placebo potential, as repeated experience of inefficiency creates obverse effects.^[74] Taken all together, these factors suggest a limited placebo potential for these intercessions.

However, these intercessions might not have been recited only in this strictly liturgical context and may tentatively be linked to another, non-liturgical, care for the sick, where they might have had a greater potential to give the patient an experience of relief. Two canons from the so-called ‘Canons of Hippolytus’, a mid-fourth-century Lower Egyptian revision of the church order known as the ‘Apostolic Tradition’,^[75] report visits of the sick by the clergy. Both canons were adjusted from the Apostolic Tradition to reflect local customs. Canon 21 prescribes that the clergy should visit daily those who are so ill that they cannot come to church to get the oil and water of healing.^[76] The other one, Canon 24, specifies that the bishop should visit the afflicted in the community and pray over them, and suggests that his prayer is an effective therapy: “He is relieved of his sickness when the bishop goes to him, especially when he prays over him, because the shadow of Peter healed the sick, unless his lifespan is over”.^[77] In this situation the bishop could easily recur to the same prayers he recited in the liturgy, in particular to the intercession for the sick. That these liturgical intercessions might indeed have been used this way may be implied by the opening phrase of the ‘Markan’ intercession: “Having visited (ἐπισκεψάμενος) the sick of your people, heal them”, and the return of the same request (and root) at the end of the intercession “overseer (ἐπίσκοπε) of all flesh, visit (ἐπισκέψαι) us in your salvation”.^[78] The request that God should ‘visit’ the sick also appears in six Byzantine prayers, the text of which presupposes a home visit by the clergyman reciting the prayer.^[79] In a like vein, the insistence on the visit of God in the ‘Markan’ intercession can have a link with the visit of the bishop at the house of the sick and his recital of this prayer. However, the connection is not inevitable, since an image of God as a physician visiting the sick can equally have triggered the choice of the verb ἐπισκέπω; indeed, God is addressed as ‘physician of soul and body’ in three of the intercessions above.

Thus the link between the intercessions for the sick and the episcopal visits remains a highly speculative scenario. If, however, the bishop indeed used this prayer for his visits, such a practice could possibly create a link in the patient between personal experience of relief and the recitation of this prayer. The visit and prayer of the bishop had a considerably greater placebo potential than hearing the intercessions in the liturgy. First, the personal attention of the most important member of the community had the potential to induce positive feelings of importance and care, and thereby to elicit a placebo response and bring relief.^[80] Frequent visits of doctors have been found to enhance the placebo effect,^[81] and in the community behind the Canons of Hippolytus the bishop and the priests were believed to be potent healers by virtue of powers they received through their ordination.^[82] Expectations of the prayer’s efficacy could also be heightened through hearing or reading the canon, or through learning about its contents through personal communication; indeed, the canon might only record or reinforce a general conviction about the beneficial therapeutic effects of the episcopal visits. All these factors increase the possibility that the patients felt actual relief on the occasion of the recital of the intercession during the episcopal visit. Such personal experiences may link the recital of the prayer to a feeling of relief in a conditioning-like mechanism, and the prayer as a conditioned stimulus could develop the potential to induce a placebo effect even upon hearing it among the intercessions during a service.

However, even such speculative mechanisms, if they ever existed, likely faded once the custom of episcopal visits began to disappear. That seems to be the case already in the late fourth or early fifth century in the community that produced Canon 15 of (Pseudo)-Athanasius, where instead of the importance attributed to the episcopal visit in the Canons of Hippolytus, all we find is a warning that “a bishop that does not visit the sick and those in the prisons is without compassion”.^[83] In the largely Christianized society of the turn of the fourth and fifth centuries it likely became impossible for the bishop to give personal attention to all the sick among the faithful.

Laying on of hands

Besides the intercessions, there is another liturgical prayer that is suitable for the visits of the clergy, the prayer of laying on of hands on the sick. Two such prayers have been preserved in the liturgical collections from late antique Egypt, Sarapion’s prayer 30^[84] and P. Monts. Roca fol. 155b.19–156a.5.^[85] The latter is preserved in a miscellaneous codex which was unearthed in Upper Egypt, probably in the Upper Panopolitan nome, but the prayers in it likely originate from Alexandria.^[86] Both Sarapion’s prayer and P. Monts. Roca fol. 155b.19–156a.5 contain requests for sick people in plural, which indicates that they were intended for communal celebration. However, it is difficult to pinpoint where in the liturgical services they were recited. Sarapion’s prayer 30 is the last in a series of prayers for laying on of hands, the other two being for the catechumens and the people in general; after prayer 30 the note “all these prayers are accomplished before the prayer of offering” was appended. If these three prayers were recited in the position where they were copied within the collection, then they served as a series of dismissal prayers at the end of the liturgy of the word or the morning or evening prayer.^[87] However, Sarapion’ collection is composite and does not follow a liturgical sequence strictly, thus it is conceivable that these three hand-laying prayers were used separately as dismissals “to any kind of liturgical assembly”,^[88] and they were grouped together because of their related topic. Johnson suggests that prayer 30 could be a dismissal prayer to a liturgical rite specifically for the sick; he cites the prescription in Canon 21 of Hippolytus that the sick should come for blessed water and oil to the church every day as evidence for such a separate gathering for the sick.^[89] However, this instruction in the canon follows a detailed description of the morning prayer and that suggests that the distribution of the substances could happen in the framework of the daily morning prayer (see below). If this was the case, the prayers of laying on of hands could very well be positioned at the end of that service.

As for P. Monts. Roca fol. 155b.19–156a.5, it is transmitted in a short collection of prayers, after the anaphora and a prayer of thanksgiving after communion and before a prayer for the exorcism of oil for the sick. The ensuing exorcism claims in its title that it is τῷ αὐτῷ τύπῳ, “for the same rite”.^[90] These two prayers might have made up an independent service for the sick;^[91] however, as parallels suggest that in the fourth century the oil for the sick was consecrated within the Eucharist (see below), we can tentatively position also the laying on of hands within the Eucharist. Thus the two hand-laying prayers could either belong to a separate liturgical celebration for the sick, or to the morning prayer and the Eucharist. Whatever their communal use, they could easily be adapted to private contexts as well, as by the Manicheans of Kellis, who adjusted the hand-laying prayer of P. Monts. Roca fol. 155b.19–156a.5 to their purposes by changing the first of the plural references to the singular.^[92]

Before evaluating the placebo potential of these two hand-laying prayers, the question of the accompanying actions needs to be clarified. The issue at stake is whether they were accompanied by an individual laying on of hands by the celebrant or the sick received the blessing collectively. The title of both, χειροθεσία, implies an individual gesture, and evidence from Egeria’s account of the liturgy of Jerusalem as well as the expression προσελθόντων ὑπὸ χειρά of Canon 19 of Laodicea shows that in certain contexts in the second half of the fourth century the people lined up for the final blessing and the bishop laid his hand on the head of each.^[93] However, elsewhere the congregation remained in their place for the blessing, bent their neck, and the celebrant blessed them stretching out his hand towards them.^[94] The choice of action probably depended on the number of those present and the customs of the local congregation.^[95] As for the two prayers under consideration, in the lack of detailed accompanying instructions there is little information about the actual practice. The text of P. Monts. Roca fol. 155b.19–20, which asks God to ‘place upon your strong hand’ (ἐπίθες τὴν χεῖράν σου τὴν κραταιάν), might imply an individual laying on of hands, whereas Sarapion’s prayer, which only speaks of God stretching out (ἔκτεινον) his hand, might suggest the collective solution instead. The wording of the prayers betrays an intention that God’s health-giving gesture requested by the text be mirrored by the celebrant’s action. Thereby the celebrant could render the requested divine healing act present and mediate it toward the sick. However, it is by no means ascertained that a community that used the prayer in fact followed the gestures indicated by its text.

The performative evocation of God’s powers by the celebrant could have a considerable placebo potential by directing attention to him as the supreme healer and creating a mediated link, a sort of therapeutic relationship, between him and the patient. Moreover, the accompanying gestures, individual or collective alike, emphasised the prayer as a therapeutic act benefitting the sick. The confidently worded requests and the image of the healed patient offering thanksgiving, which is evoked at the end of the Barcelona prayer, could moreover act as a verbal suggestion inducing expectations. If these prayers were recited in a liturgical rite in the presence of the entire congregation, people could learn to expect relief from them also by observing others, even when they themselves were not sick.^[96] A congregational setting also encouraged verbal exchange concerning the experiences, which is also a potent way to learn about beneficial effects.^[97] If these mechanisms indeed induced a placebo effect and thereby some relief, repetition could reinforce these (but also counteract them in the case of repeated negative experience).

Consecration of oil and other substances

The rest of this paper looks at the most widespread healing practice, the consecration of oil (and other substances) in various liturgical contexts, which was frequent in Egypt as well as other parts of the Mediterranean world in Late Antiquity.^[98] Oil was used as a common healing material in non-Christian contexts as well,^[99] and its neutrality, together with the scriptural recommendations of James 5:14 and Mark 6:13, favoured its adaptation by Christians. Christians consecrated oil in several different ways: through contact with relics, through the prayer of a holy man, or by the clergy, through liturgical or magical prayers; and it could be applied privately (as a drink or self-anointment) or by the person who consecrated it. The various contexts were intertwined and interdependent; holy men and healing shrines endorsed practices from the liturgy and the hierarchy approved of (or contested) their actions. On the other hand, there was a continuous, though not always successful, attempt by influential church leaders to demarcate acceptable Christian consecration from spurious, ‘magical’ ones and prevent the faithful from recurring to the latter.^[100] One of the several possibilities of the Christian use of oil for healing was blessing it (and other substances including bread and water) in the framework of liturgical celebrations, especially the Eucharist and baptism. It is to these instances I will limit my observations here.^[101] Due to the ambiguity of the sources, the reconstruction of the consecration of oil in the liturgy requires a complex liturgiological discussion before I can turn my attention to its placebo potential.

Canon 21 of Hippolytus, cited above for its reference to priestly visits, speaks of the consecration of oil and water:^[102] “The sick also, it is a healing for them to go to the church to receive the water of prayer and oil of prayer”.^[103] This statement follows an instruction concerning the daily morning prayer, which suggests that there was an association between them: either the substances were consecrated during this quotidian celebration or distributed there. The regulation that follows concerning the daily visit of the priests by the sick also points in this direction: they could bring the blessed materials to those who could not come for them in person to the quotidian celebration of the community.

However, other sources imply the weekly Eucharist as the celebration during which oil (and water) for the sick were consecrated. In the Eucharist of Sarapion, oil and water are blessed after the thanksgiving for communion and before the dismissal, through a “prayer for those offering oils and water” (prayer 5).^[104] This is the only unambiguous reference to this practice, but there are other less secure testimonies as well.^[105] First, the Apostolic Tradition and the church orders derived from it also contain a prayer for the consecration of oil after the anaphora.^[106] The Apostolic Tradition is traditionally attributed to Hippolytus, bishop of Rome in the early third century. This attribution has been challenged,^[107] and it has been suggested that the text is a mere aggregate of prayers and prescriptions from different times and places, “a piece of ‘living literature’”, of which no original can be restored.^[108] However, a recently discovered Ethiopic version in the Aksumite collection, which corresponds closely to a fifth-century Latin translation, seems to presuppose that a Greek redaction with a relatively stable text circulated latest by the fourth century.^[109]

In the Latin redaction the oil prayer is placed immediately after the anaphora, introduced with the instruction “if anyone offers oil” and it reports a short prayer that refers explicitly to the “health (sanitatem) of all using it” (Ap. Trad. 5). The prayer is followed by another one for the offering of cheese and olives (Ap. Trad. 6). Both prayers were to be used as models rather than recited verbatim and were possibly inserted in the anaphora or in a similar thanksgiving format.^[110] Phrases from these two texts recur in a number of prayers, Eastern and Western, which were probably part of a common early Christian prayer tradition for the consecration of oil, both for the catechumens and for the sick.^[111]

The Egyptian derivatives of the Apostolic Tradition contain the two prayers with modifications, or references to them. Canon 3 of Hippolytus mentions the consecration of oil and the blessing of firstfruits after the anaphora and refers to the corresponding prayers as well, but the prayers themselves were removed.^[112] The Apostolic Tradition in the redaction of the Ethiopic Statutes of the Apostles keeps the oil prayer after the anaphora but deletes the prayer for the cheese and olives. It also modifies the text of the oil prayer, removing the first reference to health and changing the second to sanctification, thereby annulling the connection with healing.^[113] By contrast, the redaction of the Aksumite collection places the oil and cheese prayers after the teaching on confessors.^[114] The text of the oil prayer retains the first reference to health, as in the Latin text, but follows the redaction of the Statues of the Apostles in changing the second to ‘sanctify’.^[115]

These church orders witness the consecration of oil within the Eucharist after the anaphora. However, due to the nature of these collections it is difficult to see where and when this was actually practiced and where it was retained only out of respect for the source from which the compiler worked. In the Canons of Hippolytus, the presence of the rubric but the disappearance of the prayer have been interpreted thus that the community behind the Canons consecrated oil after the anaphora but used a different prayer than the one reported in the Apostolic Tradition.^[116] By contrast, the absence of an oil prayer in the post-anaphoral part of the Euchologion in the Aksumite collection implies that in late fifth or early sixth-century Alexandria oil was no longer consecrated within the Eucharist.^[117] If the Greek original of the redaction of the Apostolic Tradition in the Aksumite collection was compiled in Alexandria in the same period, this can explain the unusual position of the oil and cheese prayers there: Whereas the compiler perceived the Eucharistic prayer as liturgically relevant, moved it to the end of the Euchologion section and modified it for actual use, he left the oil and cheese prayers, no longer considered useful, in the Apostolic Tradition and moved them inorganically after the instruction on the confessors and before the rite of baptism.

The last potential witness to the consecration of oil in the Eucharist is the prayer for the exorcism of oil in P. Monts. Roca fol. 156a.6–156b.3.^[118] It follows a Eucharistic prayer, a prayer of thanksgiving after communion, and a prayer for the laying on of hands on the sick. These four prayers of the euchological section of the codex could possibly have made up a concise Eucharistic service. However, this collection is an individual selection from a prayer book coming perhaps from the patriarchal court, and the prayers in it do not necessarily belong to the same service, thus the two prayers for the sick can possibly have made up an independent rite as well.^[119]

To sum up the evidence, the cumulative argument suggests that in fourth-century Egypt oil (and in Sarapion’s community water) was consecrated within the Eucharist for the sick in various places. This is evidenced for Sarapion’s community perhaps in the Delta and can be assumed for the Lower Egyptian community behind the Canons of Hippolytus as well as in the Upper Panopolitan nome in the south of the country that copied P. Monts. Roca (and potentially for Alexandria, from where the contents of the codex may stem). In the communities of Sarapion and the Canons these substances were offered by the faithful. There are no hints concerning how the oil (and water) was distributed beyond the instruction of the Canons of Hippolytus that the sick should come to the church to receive it, and if they cannot come, the priests should visit them; the combination implies that the priests could bring along the consecrated materials and apply them to those seriously afflicted. In church the sick could either line up to be anointed or receive a quantity, or they could go to fetch their own blessed offerings after the ceremony. The texts themselves contain hints only concerning the administration of the oil, suggesting that it could either be eaten^[120] or anointed,^[121] although they do not indicate whether the sick were anointed by the clergy or took some of the substances to anoint themselves or their beloved. Altogether, the presence of the consecration of oil in the Eucharist is certain for fourth-century Egypt, but its contents are fuzzy, the liturgical actions accompanying it are unsure and its geographical spread is unknown.

Besides the Eucharist, baptism and catechumenal instruction were the other liturgical celebration in the context of which oil for the sick was consecrated. The association of catechetical and baptismal rites with the consecration of oil might be the explanation behind a curious expression in the title of the Montserrat prayer for the oil, which states that it is an ἐξορκισμὸς ἐλαίου καθημένων, literally, “an exorcism for the oil of the sitting” (P. Monts. Roca fol. 156a.6–7). While sitting might be an unusual term for the sick,^[122] it is easier to interpret the word as a corruption from κατηχουμένων ‘of the catechumens’, from which a syllable was dropped and the τ aspirated in order to make sense of the word.^[123]

This interpretation is supported by a series of evidence for the consecration of oils (and other substances) with healing association in the context of catechumenate and baptism. Fortunately for this study, a detailed study of baptism in Egypt was undertaken by Heinzgerd Brakmann in 2020. He also incorporated the Ritual section of the Aksumite collection into his analysis (though not the Euchologion section, which remains unpublished).^[124] Since much of the evidence for the consecration of oils in baptismal context comes from this source (and its redaction in the Ethiopic Statutes of the Apostles, which contains the same texts but in a different order),^[125] I will also incorporate the baptismal material from the Euchologion, which is currently accessible through its text in the Statutes of the Apostles (Sinodos),^[126] compared with Bausi’s summary.^[127]

In the Aksumite collection there are three prayers for the consecration of oil that explicitly refer to healing. Two of them are in the Ritual section. I will refer to them by their sigla assigned by Salles (and adopted by Bausi), N^[128] and X.^[129] As evident from the arrangement of the Ritual, N is the prebaptismal anointment of the rite.^[130] Its title implies that it was recited in the chamber reserved for the full-body prebaptismal anointment. This prayer is baptismal in focus, but it has an exorcistic element as well. It asks God to prepare the catechumens for baptism and exorcises the oil to become effective against magic and demonic possession, to which it adds the request that the oil should become “oil of healing and safety”.^[131] We find the same associative, corollary reference to healing in the context of repudiating sin and demonic forces in the prayer for the prebaptismal oil (no. 15) in the collection of Sarapion, which asks that “our Lord Christ Jesus may work in it and reveal healing and strength-producing power (ἰατικὴν καὶ ἰσχυροποιητικὴν δύναμιν) through this oil and may heal their soul, body, spirit from every sign of sin and lawlessness or satanic taint” in a context that focuses on the sacramental effects of baptism.^[132] These two prayers for the prebaptismal oil are not a healing rite per se, as the oils consecrated thus were only used as prebaptismal anointment and not distributed to the sick. Instead, they witness a close association of baptism, and especially of its exorcistic elements, with healing. The association is based on an evolving exorcistic understanding of the prebaptismal anointment^[133] and the belief that illnesses were caused by demonic forces; such ideas induced the inclusion of healing among the benefits received from the prebaptismal anointment.

It is more difficult to determine the liturgical function of the other oil prayer of the Ritual, X. It is inserted inorganically after a rubric concerning postbaptismal anointment and before instructions for the baptismal Eucharist. It is headed by the title “the unction of oil that the Chief Priest consecrates for those who receive the washing and for sick believers”.^[134] Its text is almost identical to that of another oil prayer in the collection, K,^[135] which belongs to Euchologion section and is placed at the end of the baptismal sequence (fol. 53vb–54ra) before an “exorcism of water” and the ensuing anaphora. Its title in the Statutes of the Apostles reads “prayer of the holy oil of chrism with which the catechumens are anointed, and for full Christians who are sick”.^[136] The double focus on baptism and healing is evident in both texts. Both rely on wording from the oil and firstfruit prayers of the Apostolic Tradition (5 and 6) and are thus part of an ancient pool of wording for prayers over oil for baptism and for the sick, which according to Segelberg was originally baptismal in focus.^[137] However, the central request of both K and X is healing. The request for grace for those who receive baptism is added only as a secondary element; it is made more explicit in X than in K. Both of these prayers appear to be inorganic additions to the baptismal sequences where they are placed, since baptismal sequences are not expected to contain any other anointments after the postbaptismal one. In fact, X is framed by the clauses “and then comes the order of the prosphora” and “Before the prospora”,^[138] which may indicate that it intruded into instructions concerning the baptismal Eucharist.

A telling indication of these prayers’ origin may be spotted in the fact that K is followed by an “exorcism of water” (G)^[139] in the sequence of the Aksumite collection. This exorcism requests God to sanctify the water and make it effective against “all that opposes”, “against all divination and potions, both those which are drunk, and those which are sprinkled, or used in any other way, cause it to be healing and life for him who shall receive of it”.^[140] Though the redactor of the Statutes of the Apostles placed this text among the consecration prayers for baptismal water, the reference to distributing the blessed substance^[141] and the complete absence of baptismal themes make it evident that it had a different function.

The closest parallel can in fact be found in prayer no. 5 of Sarapion’s collection, which consecrates oil and water for the sick through a single text during the Eucharist. Thus, on analogy, it is possible that in the community that produced the original of the Euchologion section the combination of K and G was used as the prayers consecrating oil and water for the sick, and that they were recited in the course of the post-anaphora. However, at a later point these prayers were placed between the baptismal sequence and the anaphora, maybe because in the community where the Aksumite collection was compiled, oil and water were no longer consecrated within the Eucharist, as I have speculated above also in connection with the Apostolic Tradition. Instead, they linked the water and oil blessings with baptism and moved the two prayers at the end of that rite ‒ though it does not necessarily mean that they actually performed them in this sequence, they might also have kept them out of respect for the source. Similarly, X might have been moved to its current location from the description of the baptismal Eucharist, where also a formula for the milk and honey is provided (and its performance in its eventual position in the Ritual is equally uncertain). If this speculative reconstruction holds water, X, K, and G may provide further evidence for the eucharistic consecration of oil (and water) for the sick, likely for Alexandria, as well as for its disappearance by the late fifth or early sixth centuries. In addition, if the rubrics mentioning the catechumens and “those who receive the washing” is original to the source of the Aksumite collection, this may be another instance of a possible link between the catechumenate, the oil of the sick, and its eucharistic consecration that I have already tentatively observed in connection with P. Monts. Roca fol. 156a.6–156b.3. However, to fully evaluate this hypothesis a thorough study of both baptismal sequences of the Aksumite collection will be needed, which cannot be attempted here.

In yet another practice we can find the conflation of baptismal and healing practices, in the consecration of oil, water, and bread for the sick. In the Ritual of the Aksumite collection, there is a “prayer for those who bring bread, water, or oil in the holy Lenten period, after the examination of those who are to be baptized”,^[142] but the text stresses only healing and contains no reference to baptism or catechumenate. The closest parallel to this text is Sarapion’s prayer 17,^[143] which is a “prayer for oil of the sick and for bread or for water” according to its title (although the text mentions only oil). This does not contain any reference to baptism either, but it is placed after two other consecratory prayers for oils, which are baptismal and derive from the same source.^[144] This raises the possibility that “in origin, [Sarapion’s prayer 17] was also related to both baptismal preparation and the healing of the sick”.^[145] Further support for a catechumenal rite involving bread comes from Canon 20 of Hippolytus, which prescribes that the bishop should send “bread purified by prayer” to the catechumens.^[146] Clement of Alexandria moreover mentions bread and oil that is sanctified through the name of Jesus and water that becomes exorcized water and baptism in a context where he discusses baptism.^[147] The Life of Pachomius, where the saint is described as sending bread and oil to the possessed, is on the other hand a testimony to the use of these substances for exorcism outside the baptismal context.^[148]

Thus in the case of consecrating oil, bread, and water, baptismal and healing practices were again conflated. The common denominator was exorcism, which is the focus of Sarapion’s prayer 17 and is explicit in the title of the Ethiopic prayer (though not in the text). The context in which these substances were used apparently varied. The title of the Ethiopic prayer and the ensuing rubrics imply that bread, water, and oil were brought during the forty days of catechetical instructions and blessed in the early morning, then the catechumens were anointed with the oil^[149] (if they also ate the bread and drank the water remains unstated).^[150] In the community behind the Canons of Hippolytus the bread was sent to the catechumens, perhaps to their prebaptismal catechetical instruction during Lent. However, the contents of the Ethiopic prayer suggest that these substances were also distributed or sent to sick people, which is the use Sarapion and Pachomius made of the exorcised bread, oil and water.

One final, potentially related prayer has to be discussed, though its liturgical role is impossible to determine due to the fragmentary state of its text. On the mutilated fol. 1r of a sixth or seventh-century codex, P. Bala’izah^[151] the lacunose text of a prayer is preserved. The beginning of the text is lost but the extant wording sets in with references to oil and wheat (?) (ἐλα̣ί̣ου καὶ σ̣ί̣τ̣ου, l. 3), then after a lengthy invocation of God (ll. 5–10), which echoes wording from the ‘Markan’ intercession for the sick and the two healing prayers of P. Monts. Roca, it goes on to ask God for safety from all “dangers of the adversary”, salvation and healing from “all sickness and all infirmity”, including “sicknesses of body and soul” (ll. 10–20). The prayer closes with the request “so that we could serve you through your beloved child Jesus Christ” and a doxology. This structure (‘heal them so that healed they can serve you’) recurs in a number of prayers related to healing: the two prayers in P. Monts. Roca, a Sahidic prayer for healing (Stud. Pal. XVIII 276 l. 1–11), a sixth-century amulet PGM P9, and liturgical prayers from other traditions as well.^[152]

The parallels with healing prayers in structure and wording as well as the explicit, though mutilated, reference to bodily and spiritual healing suggest that this was a prayer related to healing. However, in the lack of a title or rubric its precise liturgical function is unclear. Its combination of the reference to oil and wheat (the unsurely read σ̣ί̣τ̣ου) with requests for healing can point in the direction of the above-mentioned consecration of bread, oil and water for the sick.^[153] The general requests for salvation in ll. 11–14 sit well in a baptismal context. Nonetheless, this does not mean that the prayer was still recited in the framework of catechumenal rites in the Middle Egyptian monastery of Bala’izah in the sixth or seventh century; the baptismal connection could easily have been lost by this time.

All the sources discussed above reveal various, though interrelated, liturgical contexts for the consecration and distribution of oil and other substances (water or bread and water) for the sick: during the Eucharist, during the catechumenal rites, during the rite of baptism, and potentially in independent services for the sick (which has been conjectured by scholars^[154] but is not mentioned explicitly by any sources of the fourth and fifth centuries^[155]). Whereas the contexts vary, the oil prayers surveyed above share a number of topics and some of the wording as well. First and foremost, they have in common an exorcistic character, which can be central to the prayer, as in Sarapion’s prayer 17, or marginal, as in the Ethiopic bread-water-oil prayer (C), where it is limited to the title. Second, there is an emphasis on Jesus’ name, usually as the power through which the exorcism is effected. Already Clement of Alexandria argues that sanctification of bread and oil happens “by the power of the Name of God”, and the same idea is reflected in six of our prayers (Sarapion’s prayer 5, P. Monts. Roca fol. 156a.8, C, K, N and X), while Sarapion’s prayer 17 contains a praise of Jesus’ name. In three prayers (P. Monts. Roca fol. 156a.6–156b.3 and Sarapion’s prayer 5 and 17) the mention of the divine name is linked to creedal material taken from Jesus’ life.^[156] At its most concise, in prayer 5, it contains only the short sequence “who suffered, who was crucified and raised up, and who is seated at the right hand of the uncreated”. At the other end of the scale, the elaborate list of P. Monts. Roca fol. 156a.6–156b.3 contains an unusual reference to Jesus being wrapped in swaddling clothes and placed in a manger. A fourth common point is the insistence on God’s healing power (δύναμις), which is linked with the holy name in C, K and X. Finally, these prayers, except for C, enumerate a number of potential evils and diseases from which they request healing and protection. At the most concise these ‘catalogues of evil’ can be as simple as the “every fever and every demon and every disease” of prayer 5, but Sarapion’s prayer 17 contains two long catalogues of this kind. The first introduces each item with the preposition εἰς (e. g., εἰς ἀποβολὴν πάσης νόσου καὶ πάσης μαλακίας), whereas the second is headed by the imperative φοβηθήτω and lists various evils that should flee; the two lists together make up the bulk of the prayer. In two of the prayers the list includes the phrase πᾶσα νόσος καὶ πᾶσα μαλακία from Matthew 4:23, and the clause appears in P. Bala’izah fol. 1r.19–20 as well.

These topics are not unknown from other parts of the Christian world either. The exorcistic pattern with an invocation of Jesus’ name and enumeration of events from his life, mentioned already by the second-century church father, Justin Martyr (dial. 85:2), had enduring success in magical exorcisms,^[157] but it was apparently not so widespread among liturgical prayers of other rites.^[158] Lists of potential evils are also well known from both magical texts^[159] and liturgical texts from various rites.^[160] Matthew 4:23 was furthermore widely referenced as a summary of Jesus’ healing ministry in patristic writings, liturgical texts, and amulets alike.^[161] The frequent combination of these elements in the Egyptian prayers shows that there was an established set of topics such prayers had to treat, even though their order or wording was not fixed and not all items appeared in all prayers. These topics apparently marked a tradition of exorcistic and healing prayers in Egypt and beyond.

After this long discussion of the various forms of liturgical anointing of the sick, let us turn to evaluating the ‘placebogenic’ potential of these practices. The most immediate difficulty of this enterprise is that the precise liturgical function and the accompanying actions of several prayers cannot be determined, although much of the ‘placebogenic’ potential depended on the context and the actions rather than on the texts. Nonetheless, there were a few non context-specific elements of these rites that can be linked to the psychological mechanisms eliciting a placebo response. One of these is the use of oil as a healing material, which through its frequent application in other therapeutic contexts could associate the substance with healing. Thus oil was arguably a meaningful signal, from which patients had learned to expect relief (as pills are for a patient of our days). The efficacy attributed to oil through culturally learned association could perhaps be further boosted by the authoritative recommendation of James 5:14.^[162] Water was also employed in medical practices,^[163] thus its use could equally evoke therapeutic associations in a liturgical context as well.

A similar mechanism might be activated by the established exorcistic phraseology of the prayers. In the belief system shared by the healers (i. e. the clergy) and by the faithful, exorcism was a rationalized and meaningful procedure to counter demons, the commonly held causes of sickness,^[164] and as such it could create expectations of successful riddance from the illness.^[165] Adherence to an established, much-recited phraseology can earmark the prayer as a ‘legitimate’, effective exorcism and provide the cultural clues that can elicit the placebo response.^[166] A beneficial ‘side effect’ of an exorcistic approach to illness implied by the exorcisms is that it provides a sensible ‘diagnosis’, assuring the patients that their distress is caused by the malignant actions of demons and that their removal from their body amounts to a successful cure.^[167] The recapitulation of Jesus’ life as the ultimate victory over evil carries a promise that such a victory and thereby the removal of demons are imminent also in this case. Another verbal clue with a potential to increase expectations is the structure ‘heal the sick so that healed they can serve you’ observed in the two Montserrat prayers and in P. Bala’izah, which directs the attention to the anticipated healed state of the patient.

Much of the placebo-inducing potential of the consecration of oil relies on the liturgical context and the accompanying actions. While the precise context remains oftentimes unclear, oil appears to have been consecrated and applied most frequently in a communal rite, which enables social observational learning even for healthy subjects, as it has been discussed above. However, if there was a special rite for the sick attended only by them, such effects are restricted to the fellow sick, and in the case of private application of publicly consecrated oil an even more limited group of family members and neighbours can benefit from it. Another potentially ‘placebogenic’ practice was the offering of the substances by the sick people or their relatives, which appears in Sarapion’s prayer 5 and in the Ethiopic prayer C, since therapies that “require effort and involvement by the patient” appear to have the best results.^[168] The weekly or daily administration of oil (and water) in the framework of the Eucharist or in the morning service may have had the potential to reinforce positive experience and/or observations, though the frequent recurrence to this measure could easily have had an opposite effect as well, as I have discussed above.

In the prayers linked to baptismal context different mechanisms could be at work. Once baptismal rites received an exorcistic interpretation, the baptismal connection could have the potential of raising expectations concerning the enhanced exorcistic and hence healing efficacy of the associated prayers and substances. The exorcistic powers of baptism were emphasized in the prayers as well as sermons, and exorcisms linked with it were envisioned as particularly powerful, cleansing both soul and body.^[169] A telling testimony to such beliefs is an early sixth-century papyrus with the text of the exorcistic acclamation that accompanied the prebaptismal anointing;^[170] apparently its goal was to perpetuate the effect of the prebaptismal exorcism. The verbal instruction process concerning the efficacy of baptismal exorcisms in the course of baptismal preparation could lead to pre-existing expectations of extraordinary exorcistic and hence healing powers of anything associated with baptism, and greater expectations induce greater placebo response.^[171] These pre-existing expectations could be activated through the verbal clues concerning healing that even prayers related to the prebaptismal anointing (N and Sarapion’s prayer 15) contained.^[172] Supported by the strong positive emotional effect baptism was meant to induce^[173] these great expectations could have an increased potential to make the catechumens experience a general enhanced well-being, including physical well-being. This could be especially relevant if the catechumen, as many people in the fourth and fifth centuries did, delayed baptism until old age or serious illness in order to make the most of its one-time remission of the sins,^[174] although such effects certainly dwindled with the spread of infant baptism, a common practice already by the early fifth century.^[175] On the other hand, despite the references to the cleansing of the body the focus of the baptismal experience was not therapeutic, leaving the possibility open that many catechumens were not aware of being ‘treated’, which reduces the ‘placebogenic’ potential.

Conclusion

To summarise, a number of liturgical practices for the sick can be reconstructed for fourth and fifth century Egypt. Most of them recur in more than one source and are attested in more than one place, implying that they were not mere local particularities. The liturgical attention to the sick included commemorating them as the first in the series of intercessions in the Eucharist. The afflicted were also blessed by the celebrant with a prayer of laying on of hands, for which they either queued up to receive it individually or bowed their heads to receive it together. Oil (and in some congregations also water) was consecrated during the Eucharist after the anaphora and was distributed, weekly or in the community behind the Canons of Hippolytus perhaps daily, to be anointed or consumed. Bread, water and oil consecrated in catechetical and baptismal context were equally used to relieve ailments, and the prebaptismal anointment also had therapeutic associations. In the community behind the Canons of Hippolytus the sick were visited regularly by the bishop or the priests, who prayed over them. A special service for the sick has also been hypothesized by liturgical scholars; P. Monts. Roca may offer a possible example of this consisting of a prayer for the laying on of hands and an exorcism of oil. The liturgical healing prayers, especially the exorcisms of oil and other substances, share topics, structure, and phrases, indicating an established euchological phraseology.

For these different practices I have speculated varying potential to activate placebo mechanisms. Whereas a liturgical intercession for the sick had little potential to bring relief, as patients might not have been aware of being ‘treated’, an exorcism of oil in the framework of baptismal rites, which were believed to be particularly powerful against demons, could create great expectations of successful healing and accordingly induce a strong placebo effect. While the ‘placebogenic’ potential of these rites diverge, some elements are common to most of them. Repetition could have a potential for strengthening the learning effect of positive personal experiences, but in the absence of such it could just as well have an opposite effect. Social observational learning can easily happen in the communal setting of liturgy, and the same setting facilitates exchange of experiences. Moreover, placebo research has emphasized the ritual of the therapeutic act, which is loaded with culturally defined symbols, as a key factor in eliciting the placebo effect. Liturgical healing rites, which meaningfully address the culturally accepted cause of the disease, such as demons, qualify as such therapeutic rituals. The removal language used in most of the prayers has psychological benefits by itself; externalization of negative experiences or emotions has been described as a common defence mechanism of the self, which reduces fear and anxiety,^[176] with corresponding beneficial therapeutic and analgesic effects.^[177]

On the other hand, liturgical rites lack the potential to tap into a number of other placebo mechanisms identified by medical and psychological research. Since they were easily available in the framework of everyday church services such as the Eucharist and the morning prayer, they required little effort beyond perhaps bringing along everyday substances. The only exception to this is baptism, which involved a forty-day catechumenate with instructions and hence involved considerable effort on the side of the baptizand. However, baptism was not a healing rite, and while it is not impossible that some undertook baptism for its expected health benefits rather than for the spiritual gain, this is not what church authorities encouraged and I have not found evidence for such behaviour in the sources either. Moreover, everyday liturgical services or the church setting cannot be considered a setting with particular therapeutic associations as a modern clinic or an ancient incubation shrine were, therefore the environment probably contained few clues beyond the prayers and the oil that could be associated with healing and elicit placebo effects.^[178]

Liturgical prayers also contain relatively few verbal clues that could raise expectations. They are phrased as a request to God, and though the Father’s omnipotence and Jesus’ victory over demons are emphasized and the requests are straightforward and confident, with occasional evocation of the anticipated positive outcome, these verbal clues are less potent than claims of the kind ‘do this and you will get better/feel less pain’, the likes of which patients received in a dream in incubation temples or via oracular tickets in healing shrines, or the confident statements “he will recover” at the end of medical recipes discussed by Anne Grons in this volume. Liturgical healing rites are also rarely praised for their effectiveness by the church authorities. I am not aware of any homilies advertising them as particularly effective; the only scattered references in Egyptian context come from church orders.^[179] The potential of such scarce recommendations to induce expectations diminishes compared to the corresponding potential of publicly recited miracle stories^[180] and martyrdom accounts, where God promises the martyrs to heal everyone in their shrine,^[181] or to the potential of direct communication of therapies by the saint through oracular tickets or in a dream.^[182]

Finally, the person of the healer and his therapeutic relationship with the afflicted, which has been pointed out as an important component of placebo mechanisms,^[183] was also little emphasized in liturgical rituals. Only in the case of the episcopal visit did the person of the earthly healer have any significance, where the bishop’s role as a potent healer was underpinned by beliefs in his therapeutic powers gained at ordination. However, in the other rites the bishop or priest who recited the prayer or administered the substance stepped in the background. In the prayers an omnipotent and remote God was requested to deliver the healing. Though his healing power was rendered present either by the celebrant’s actions mirroring his curative gesture, or through a substance on which his power was asked to descend, and his therapeutic omnipotence was emphasized through the evocation of his supremacy over flesh and of his divine Son’s victory over demons, he was nonetheless an absentee healer with no direct relationship with the patient.

The image of liturgical care for the sick, which has been sketched above in its outlines, starts to fade after the fifth century. The scarcity of sources impedes a detailed reconstruction of what happened, but general tendencies can be noted. By the late fifth or sixth century, prayers for the laying on of hands on the sick already disappeared in Alexandria, as they are not present in the Ethiopic euchological material. After this period, the sick were only occasionally mentioned in final blessings among other groups of the church, such as in a fragmentary blessing preserved in a parchment euchologion from the sixth century (P. Bal. I 30 fol. 8a r.6–8). The blessing of oil (and water) in the Eucharist is not present in the euchologion of the Aksumite collection either (though K and G may be displaced vestiges of it), thus it is also likely to have disappeared, at least in Alexandria, by the late fifth or sixth century. Later sources do not mention it either.^[184] On the other hand, the consecration of bread, water and oil might have been practiced still in the late fifth or sixth century, and the even later, sixth or seventh-century P. Bala’izah may contain a prayer originally related to the same rite. After this the consecration of oil, bread, and water disappears completely. In baptismal context, only rare and passing references to healing persist in the prayers for the prebaptismal oil.^[185] The episcopal visits are already in the process of ceasing in the late fourth or early fifth-century Canons of Athanasius, and by the early seventh century, when we can follow the activity of two bishops in the Thebaid thanks to their documents preserved on hundreds of ostraca,^[186] nothing indicates that they visited the sick in their diocese.

By the sixth-seventh century only the intercessions for the sick and passing references to bodily healing in baptismal context remained in place, retaining their position of honour in the increasingly solidifying sequences of intercessions. Besides, there is evidence for the anointing of the sick, apparently in a separate rite. However, our sources for this rite in the early medieval period are scarce. The most detailed description is given in the homily On Christian Behaviour by Pseudo-Shenoute (XXIII, 2), where priests are warned not to anoint a sick woman with their own hands for reasons of decency, instead, they shall consecrate the oil and to let the woman apply it to herself or neighbouring women do the job if she is unable.^[187] This passage thus evidences a private rite with a home visit of the priest, the consecration of oil, and its default application by the priest (which the homilist contested in the case of women); the relevant prayers are not cited. By contrast, instead of priestly home visits the Sahidic homily by Pseudo-Athanasius recommends going to the church for healing instead of recurring to traditional practices (though he might mean churches specialized in healing, martyr shrines, which he mentions explicitly).^[188] In the Martyrdom of Panesew the saint apologizes for not being a priest when he blesses oil for therapeutic purposes; this implies that the author knew a practice of consecrating oil by a priest, which he considered legitimate instead of anointments by holy men.^[189] It is furthermore recorded of the patriarch Mark II (799‒819) that “he anointed many of the sick with oil in the name of the Lord Christ, and prayed over them, and they quickly recovered their health”.^[190]

There are two Coptic prayers as well for the consecration of the oil for the sick, which are preserved in two manuscripts from ca. the tenth or eleventh centuries, one from the Fayum (P. Lond. Copt. 511 br.19–bv.15) and one from the White Monastery (Stud. Pal. XVIII 276 l.1–11). However, none of these texts inform us about the structure of the rite of the anointment of the sick. Stud. Pal. XVIII 276 ll. 1–11 follows a blessing of Epiphany waters^[191] and is part of a miscellaneous codex of texts useful for monks;^[192] the prayers might reflect the collecting interest of a monk rather than the actual rite of anointing in the tenth/eleventh century. The prayer on P. Lond. Copt. 511 is preceded by two prayers of laying on of hands and a prayer of absolution and is followed by a mutilated prayer of unknown content. These prayers could in theory be part of a sequence for the anointment of the sick with laying on of hands, absolution (in the vein of James 5:15‒16), and the consecration of oil for the sick. However, as none of the prayers for laying on of the hands contain any reference to sickness and speak of the congregation in general, they are rather dismissal prayers for other rites. Furthermore, nothing indicates a connection between the absolution and the prayer for the sick either. The purpose of the collection remains to be uncovered.^[193] Altogether these sources do not allow us to reconstruct the rite of the anointment of the sick. Nor do the Bohairic manuscripts help with parallels. The complex and lengthy ritual of the unction of the sick practiced currently by the Coptic church, which involves seven priests and seven lamps, is an adaptation from the Byzantine rite.^[194] Thus little can be said about the anointment of the sick as practiced in early medieval Egypt. Apparently, the rite attracted little attention in the literary sources, especially when compared with other forms of Christian healing, such as visiting tombs of martyrs or healing shrines, or resorting to the services of monks. And the meagre evidence in the papyri for liturgically phrased prayers for healing is in stark contrast with the abundance of contemporaneous magical prayers for the same purpose.^[195] This may imply that the anointment of the sick, while it was available continuously, had little relevance compared to other forms of Christian healing.^[196] And altogether this single rite fades in comparison with the rich array of liturgical practices benefitting the sick in the fourth and fifth centuries.

It can be asked if the limited placebo potential of the liturgical practices vis-à-vis that of the other practices could have contributed to the decline and transformation of the former. Obviously, it cannot be the sole explanation. For some practices other reasons were operative, such as the decline of adult baptism, and with it the catechumenate which brought about the demise of the consecration of bread, water, and oil in a catechetical context, or the practical problems of individual visits in a larger community that impeded bishops in the task considered so important earlier. However, for the dwindling of other practices, such as the consecration of oil in the Eucharist or prayers for laying on of the hand of the sick, no evident theological or practical reasons can be pointed out, and it is in such cases that one can ask if the limited ‘placebogenic’ potential of these rites can have contributed to their disappearance. As I have speculated above, the ‘placebogenic’ potential of most liturgical healing rites may fall victim to excessive repetition, and the ones for which I speculated most potential (adult baptism and episcopal visits) declined in the period for independent causes. Moreover, liturgical healing rites fail to tap into several placebo mechanisms (verbal communication of efficacy in the ‘therapeutic’ situation or through ‘propaganda works’; the requirement of an effort; the focus on a healer figure and on the therapeutic relationship; or a specialized therapeutic environment with learned placebo stimuli). Other Christian forms of healing, such as incubation in healing shrines, magical cures or therapies offered by holy monks, could in fact have been more efficient in exploiting multiple aspects of the psychological mechanisms of the placebo effect. Olympia Panagiotidou explores in this volume the complex ways in which incubation in the Asclepius sanctuaries ‘worked’ efficiently through the actors, setting, and plot of the ‘placebo drama’, and Hedvig von Ehrenheim shows that several, if not all, of these mechanisms were at work in Christian incubation as well. A similar evaluation of charismatic healing by holy men or healing shrines with oracular tickets such as the shrine of St. Kollouthos in Antinoopolis is still lacking, but compared to liturgical rites these had the advantage of a central healer figure (the holy man or the martyr), of a specific therapeutic setting, of the effort needed to travel there, and of an extensive literary propaganda. Even the personalized rite involving a priestly visit and anointment attested in the homily On Christian Behaviour taps into the healer-patient relationship, which might have been among the motivations behind moving the consecration of the oil of the sick in a private context rather than the Eucharist.

Altogether, it seems that liturgical rites tapped into fewer psychological mechanisms of the placebo effect than other forms of Christian healing. Still, it would be imprudent to infer from these speculations that inferior ‘placebogenic’ potentials had a decisive role in the decline of several liturgical forms of healing. Liturgy in Late Antiquity was in formation, celebrations could change because of influence from other regions, because of the insistence of a church authority, or for theological and dogmatic reasons. The motivations behind the changes in liturgical practice are difficult to grasp for liturgical scholarship, since the sources rarely comment on them. All I would like to suggest here is to consider the ‘placebogenic’ potential as one of the possible motivations behind the formation, popularity, and disappearance of healing rites, liturgical and other, because the sick, then just as now, were looking for solutions that seemed to ‘work’ best.